Surveyor thinks I miscoded section E

[KingDom]

We're having our annual survey. Surveyor is questioning me on why I coded a lady on anxiousness about health issues and insomnia (I coded less than daily on these 2 items).

On the lady's first couple of days at our facility, she confided in the social worker a few times how worried she was that she can get back to prior level of function after her bilateral knee replacement. The social worker charted about this in her notes. However, the nurses notes said nothing about any anxiousness. The MAR showed 2 entries where she was given PRN Ambien for insomnia. The insomnia didn't appear anywhere in narrative form in the nurses notes either, though.

I explained to the surveyor that I observed her anxiousness and so did the social worker the first few days. The surveyor replied "well, I'd be anxious, too--wouldn't anybody?" I then told the surveyor that we had to code things we see on section E regardless of the reason. She again stated she could'nt understand why I coded anxiousness and insomnia when it didn't appear in the chart (..."just that little blurb in the social service notes".."and maybe the MAR", in her words)

Now I'm questioning myself for coding these things... Do you all think this is worthy of a deficency?

[BRemus]

It is probably not worthy of a deficiency however surveyors will find deficient practice where they want to. The social worker made a note in the chart about her concerns. You witnessed these complaints (did you make a note). I would also get out the section from the rai manual and show the surveyors also did you interview the nars (as typically they dont chart in the chart) on your mar did the nurse giving the med for insomnia write why they gave it? I would not particularly worry too much if you have any documentation to back up your charting I would however reiterate to the nursing staff how important it is to make nursing notes for all prns and for any resident health concerns

[Talino]

The surveyor replied "well, I'd be anxious, too--wouldn't anybody?"

And my answer to him/her, "If the MDS was about you, I'd code it exactly the same way!" Albeit, I'll be a little discreet

• RAI p1-19, bullets 2-5, clearly specify "Communication with..."
  
• Same page, last paragraph --- "... Starting with the resident's record, however, does not indicate that it is the most critical source of information, but only a convenient source."

So, whose convenience? In your case, that of the surveyor's!

Yours is but a minor hassle. Remember, the MDS is a legal document itself. You witnessed the event. The SW corroborated. By entering your signature in the MDS, you attested to the accuracy of the info you entered in that MDS.

And, if the PRN med for insomnia given on two occasions is not satisfactory to support the MDS coding, the facility may well be cited of dispensing medications without a need.

Most surveyors are not experts in the MDS as they purport to be. But they sure can raise havoc with their own interpretation or an uneducated opinion.