Anyone who works in a long-term care facility knows providing the best resident-centered care involves constant hands-on attention.
Helping a resident dress, brush his teeth, use the bathroom, take a shower, walk to the dining quarters, eat her meal, and perform all the various tasks involved in daily living is paramount.
CNAs constantly have their hands full with these duties. So it’s easy to understand why the more hands-off tasks—such as documentation—might sometimes get pushed to the back burner, and subsequently result in errors in coding activities of daily living (ADLs).
Still, that doesn’t mean you want them happening at your facility. Accuracy in ADL coding is a vital part of resident-centered care, and you don’t want it falling through the cracks. You may have noticed ADL documentation errors occurring at your facility. If so, there are steps you can take to address them. Here are some of the most common errors:
1. Incomplete or inaccurate documentation of ADL subtasks
One of the most common errors that CNAs make when it comes to documenting ADLs is not fully incorporating all of the various subtasks associated with a particular ADL.
When, for instance, the CNA goes into the resident’s room, transfers the resident from the bed to the wheelchair, walks or transports the resident to the bathroom, and helps the resident use the toilet, all of those ADLs need to be fully documented—including the subtasks that fall under each item.
As another example, take the ADL task of bed mobility. You may think of bed mobility as simply whether and how easily the resident can roll from side to side in bed. But in reality this ADL involves far more detail than that. You need to consider all of the subtasks listed in the RAI User’s Manual under that ADL. These include:
How the resident moves from a sitting to a lying position—in other words, if the resident is sitting on the side of the bed, how he lowers his upper body and then lifts his legs into the bed.
How the resident turns from side to side.
Whether the resident slides down the bed and requires assistance in being boosted back up.
How the resident moves from the lying to the sitting position—in other words, how he gets his legs over the side of the bed with his torso upright.
Let’s say, for example, that the resident is able to independently move from side to side in bed. He is also able to get his feet out of bed. But he needs a little extra assistance in getting his torso into the fully upright sitting position. The nurse aide is required to provide extensive weight-bearing assistance to help the resident achieve this component of the ADL.
However, she doesn’t take that into consideration. Instead, she marks the resident as independent with bed mobility, due to her observation of his independent side-to-side motion.
Because she ignored one of the specific subtasks, she has documented the ADL with erroneous data.
“There are a lot of subtasks within bed mobility that might get missed if the nurse aide does not fully understand that definition,” says Jessie McGill, RN, RAC-MT, and curriculum development specialist for AANAC.
Another ADL that contains multiple subtasks is dressing. This includes how the resident puts on, fastens, and takes off all items of clothing—including prosthetics and compression stockings.
As an example, a resident is able to independently dress herself, with one exception. Though she’s able to button her blouse, slide on her pants, and buckle her belt, she can’t get on her compression stockings by herself. The CNA needs to provide additional support by lifting and holding her leg to don the compression stockings.
Despite the fact that the resident was able to complete the majority of the ADL herself, the entire dressing task would need to be coded as “extensive assist,” because the CNA was required to provide weight-bearing assistance for a portion of the activity.
So what can you do to help your CNAs correct this common mistake?
“Education, education, education!” says McGill.
“When we have a new nurse aide and we do the initial ADL training, we are giving them a lot of information at one time. People need to hear that information more than once, and frequently, in order to really understand all the little details of ADL documentation,” she says. “It's so easy for someone to look at the term dressing or bed mobility and apply their own definition to that term, when really, we have to look at how the RAI User's Manual defines those tasks, and how it defines the subtasks that fall under each ADL category.”
For example, one common misunderstanding, says McGill, is cleansing after using the toilet. Often, the CNA will mistakenly believe that cleansing falls under the ADL of personal hygiene. However, the definition for the toileting ADL includes how residents get on and off the toilet, how they use the commode, and how they cleanse themselves after elimination. So that cleansing task is part of toilet use, not part of personal hygiene.
“Unless we have ongoing trainings to reinforce that, it’s very easy for nurse aides to make an incorrect assumption about where the task belongs,” says McGill.
2. The Rule of 3
Once the CNA has documented the ADL, whether through paper or electronic documentation, the nurse assessment coordinator (NAC) must look at all of the ADL information gathered across all shifts for that seven-day look-back period in order to code the MDS.
Section G on the MDS requires coding ADLs that have occurred three or more times.
That’s where the Rule of 3 comes in.
If the ADL has occurred three or more times at any one level, that is the level that is coded. If the ADL has occurred three times at multiple levels, the highest level is coded.
However, it is not just that simple; there are exceptions to the Rule of 3 that must also be applied. On page G-8 of the RAI User’s Manual there is an algorithm that walks the coder through the rule and the exceptions. It clearly instructs you to stop at the first sequence that applies and code that level.
A resident who was independent for an ADL must be independent for every episode that occurred during the entire seven-day look-back period. That also applies if the resident was dependent: the resident must be totally dependent on staff for the entire task, for every episode during that seven-day look-back period.
This is where the errors occur—and it’s why episode charting is so vital to the process.
Let’s say a resident is at the facility for three days. During those three days, the resident has been transferred multiple times with extensive assistance. Yet only two of those episodes were actually documented. Why? Because the nurse aide documented for the entire shift, rather than the singular episode. Now there isn’t enough documentation to support that the resident required that level of assistance on three separate occasions—resulting in an error on the MDS.
Part of the solution for this problem involves revamping your documentation practice.
“You need a documentation practice that supports the nurse aides in documenting multiple episodes per shift. We need to build time and easy access to documenting into their workflow and allow time for them to think about what they are documenting to ensure the accuracy. Especially when the nurse aide’s primary duty is hands-on resident care. We want to reduce that burden of documentation as much as possible, but also capture the frequency and level of care provided,” says McGill.
But the Rule of 3 can be a twofold problem. The other aspect is that NACs are relying on electronic systems that automatically pull the data and calculate the Rule of 3 for them.
If there is even one erroneous charting within that seven-day look-back period that has not yet been corrected, it could change the result of the computer’s calculations. The NAC needs to know how to make those corrections and how to manually calculate the Rule of 3, to ensure that the MDS is coded accurately.
So, for example, say a resident is always totally dependent for bed mobility. However, one charting documentation listed the resident as independent. The NAC would need to manually identify and correct this coding error. While this resident should be coded on the MDS as totally dependent, if the error is left uncorrected the computer software will automatically down-code to extensive assist, resulting in an inaccurate assessment.
“If we don't correct that error, then the computer doesn't know that it’s an error. The NAC has to identify it and manually correct it,” says McGill.
3. Generalizing a resident’s status
Another risk area for incorrect ADL documentation is when someone predetermines how a resident completes a task based on that resident’s history.
For instance, if a resident is typically documented as limited assist for most of her ADLs, the nurse aide might be inclined to simply document her this way out of habit, without considering that specific episode.
“When we’re coding ADLs, we must code based on what actually occurred for that episode. So even if the resident is usually limited assist with bed mobility, dressing, and toileting, we cannot document that. We must document what actually occurred during that episode of care for each ADL task,” says McGill.
One of the best things the NAC or other nurse leader can do, she says, is to go in periodically and observe the ADLs with the nurse aides.
“See how they are documenting those tasks and validate that the documentation is accurate. Actually observing how the nurse aides interpret the care they provide in their documentation is much more effective than other training methods,” she says.
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