Nursing home documentation
You received seven banker’s boxes crammed full of unorganized medical records from a long-term care facility.
They hold the documentation of the final four years of the life of a deceased nursing home resident.
The resident’s family is concerned that their loved one was not properly cared for by the facility staff.
The family believes that lack of care by the nursing home staff led to an accident which resulted in the death of their loved one.
You now have the medical records and it is up to you to review them in search of some failure by the nursing home relating to the resident’s accident and death.
You are experienced in reviewing medical records from hospitals and physician’s offices, but have not reviewed medical records from a nursing home. You begin the task of organizing the resident’s records (we’ll call him Mr. Hansen). Soon you become concerned about the various types and quantities of unfamiliar records there are in the nursing home records. You note several pages titled Minimum Data Set, and wonder if you can safely bypass them in your search for the truth in Mr. Hansen’s records.
From my experience in long-term care, I would encourage you review the Minimum Data Set (MDS) in Mr. Hansen’s records. The MDS is an assessment tool utilized by Medicare-certified nursing homes for residents who participate in Medicare or Medicaid.
The MDS form can be found online click here to view a blank MDS
What’s the purpose of the Minimum Data Set?
The MDS assessment is required not only once, but at prescribed periods throughout a resident’s stay in the facility. The assessments documented in the MDS are performed by different departments in the facility over a specified period of time. The MDS is then forwarded electronically to CMS (Centers for Medicare and Medicaid Services). The data in the MDS is then used by CMS to determine the facility’s reimbursement for the resident’s care.
The Minimum Data Set is divided into sections that follow the alphabet in Sections A through Q and Sections V though Z. (Section GG was added near the end of 2016).
The sections in the MDS are identified by alphabet and title, which will make your review easier as you compare the most recent MDS with those recorded in prior months. A comprehensive MDS will usually have about 45 pages.
What details will I find in the MDS?
Following is an overview of the information you can learn about Mr. Hansen by reviewing his MDS. You will see:
Section A records the identifying information about Mr. Hansen, including his birthdate, the date of assessment and the reason for the assessment. You may also be relieved to see the resident’s name is printed in the upper left hand corner of each page, and the date of the assessment is printed in the upper right-hand corner of each page.
Section B shows information about Mr. Hansen’s hearing, speech and vision and any limitations therein. Section B also details Mr. Hansen’s level of communication and comprehension.
Section C relates to Mr. Hansen’s cognition. This section can be key in your case, as it details Mr. Hansen’s mental status by coding his answers with numerical scores, and provides a total score. Fifteen is the highest possible score. Lower scores denote levels of cognitive impairment. If the resident is unable to participate in the assessment due to cognition, the staff member enters a score using the criteria provided. Signs and symptoms of delirium, if any, are also coded in Section C.
Section D documents Mr. Hansen’s mood via the PHQ-9 scale. This is the same scale used in other areas of healthcare. If Mr. Hansen was unable to participate in the assessment, the staff member would answer the questions using criteria provided on the assessment form.
Section E behaviors, provides documentation of potential indicators of psychosis, behavioral symptoms, and their types and frequency. The impact of the behaviors on the resident and others is also coded. Section E documents whether Mr. Hansen rejected care, and if so, how often. If Mr. Hansen was a wanderer (or not) this this would be recorded in section E. Changes in Mr. Hansen’s behavior would also be documented in Section E.
Section F is a record of Mr. Hansen’s preferences for his daily routines and activities. If the resident wasn’t able to participate in this assessment, his family would be asked to provide this information.
How does the MDS relate to my case review?
As you can see there is quite a bit of information available so far in Sections A through F about Mr. Hansen. You may choose to compare the MDS assessments with details and staff care practices documented elsewhere his medical record.
Did the nursing home provide Mr. Hansen’s care in relation to the information you read in his MSA assessments? Did the nursing home individualize Mr. Hansen’s care according to this and other assessments in his medical record?
In our next blog post, we’ll discuss what additional information would be available in Mr. Hansen’s Minimum Data Set.
If you have a nursing home case with medical records you don’t understand, I can help you. Click here to Contact me anytime. Call 815-263-0572