1. Rehabilitation services: Medical declines, as well as functional, should be considered when reviewing a resident’s need for a therapy. For example, a resident being treated for pneumonia, IV therapy, and/or general changes medical conditions should be looked at by a therapist to review their overall functional status. Most of the time when there is an acute medical change, direct care staff will also not a decline in the resident’s physical abilities. Nursing staff should document functional changes seen and notify therapy for follow up. Remember, therapy can not be the only discipline documenting on resident’s function.
2. Physician Exams: Document ALL Physical exams; primary, dental, eye, and specialist . 2 physician visits and 2 physician orders, or 1 physician visit and 4 orders all within a 14 day will yield a clinical score.
3. Fevers with vomiting, pneumonia, weight loss, MD diagnosis of dehydration, or tube feeding are crucial to capturing a special care score. A fever is defined by an elevation of the resident’s baseline temp by 2.4 degrees.
4. Wound care: The more specific we can be with skin areas the more accurate the MDS will be. Knowing the origin of the wound will help determined coding and should help determine a proper treatment. This is imperative not only for CMI, but also as CMS continues with the MDS focus audits.
5. Nursing documentation is essential in helping identify declines both medically and functionally. It also helps show the resident’s need for therapy services (something that is being looked for when facilities are being audited). Auditors are looking for the, “story”. Taking this one step further, as resident’s work with therapy services, staff needs to document on how the resident is functioning on the unit. Part of a therapy program is being able to take the skills learned and putting them to use on the units.
6. ADLs: Continuing education and monitoring of direct care staff will help improve your facilities ADL scoring. Staff ten to look at what they know a resident can do vs. what the resident actual does. Consistent reinforcing of scoring rules will help remind them to take credit for the support they provide.
7. Respiratory therapy program: Respiratory therapy can be instrumental in increasing the monitoring and treatment options for our residents who experience an acute respiratory condition. Respiratory therapy is not beneficial for resident’s who truly need it, but it also helps a facility take credit for the time intense care that these resident’s require. Documentation of the program and minutes is essential.
8. Restorative Nursing: This program is great in helping resident’s transition from a skilled therapy program to doing activities on the unit. It has also been put to use for those resident who do not tolerate a full therapy program.
9. Diagnosis: Some diagnoses make a difference in how a resident is scored. Diagnoses like Hemiplegia/hemiparesis, aphasia, Dementia/Alzheimer’s disease should be clearly documented if appropriate. In addition, they should be identified on care plans.