section k swallowing / nutritional status mds 3.0 by: shelly proctor rn, rac-ct valley vista care
TRANSCRIPT
Section K
Swallowing / Nutritional Status
MDS 3.0
By: Shelly Proctor RN, RAC-CTValley Vista Care
Objectives: State the intent of Section K. Describe the process for conducting
a resident’s nutritional assessment. Calculate a resident’s weight change
correctly. Code Section K of MDS 3.0 correctly. Determine Care Area Triggers.
Objectives continued: Describe the Care Area
Assessment process.
Explain resident centered care plans.
Intent of Section K:
To assess conditions that could affect the resident’s ability to maintain adequate nutrition and hydration.
K0100: Swallowing Disorder
Rationale: Safe swallowing ability can be affected by functional decline and several different disease processes. An alteration in a resident’s ability to swallow can result in choking &/or aspiration which can in turn, increase their risk for malnutrition, dehydration, and aspiration pneumonia.
Care Planning:
Include provisions for monitoring the resident during mealtimes or other occasions when the resident consumes food &/or fluids.
Additional evals necessary? Assess for s/s suggesting the swallowing
disorder has not been successfully treated.
Goal: Assist resident to maintain safe & effective swallow.
Assessment: Ask the resident
Observe
Interview staff
Review the medical record
Coding Instructions:
Check all that apply K0100A-Loss of liquids/solids from mouth when eating or
drinking.
K0100B-Holding food in mouth/cheeks or residual food in mouth after meals.
K0100C-Coughing or choking during meals or when swallowing medications.
K0100D-Complaints of difficulty or pain with swallowing.
K0100Z-None of the above.
Coding Tips: Do not code when
interventions have been successful.
Do code even if the symptom happened only one time in the 7-day look-back period.
K0200: Height and WeightRationale: Diminished nutritional and hydration status can lead to debility that can adversely affect a resident’s health and safety as well as their quality of life.
Care Planning: Knowing a resident’s height &
weight helps staff to assess their nutrition & hydration status by providing a mechanism for monitoring the stability of their weight over a period of time.
Knowing the weight is one guide for determining nutritional status.
Steps for assessment: K0200A-Height
-Measure resident upon admission in inches.-Consistent measurements over time.-If last height recorded was > 1 year,
re-measure.
Coding Instructions: Record to the nearest whole inch.
Use mathematical rounding.-Example: 62.5 inches would be
rounded to 63 inches.
Steps for assessment:
K0200B-Weight-Weigh resident on admission.-For subsequent assessments, record
weight taken w/in 30 days of the ARD.-If >30 days, re-weigh.-Record weight closest to ARD.-Measure consistently.
Coding Instructions:
Use mathematical rounding.
If weight cannot be obtained, use the standard no-information code (-) and document rationale in the medical record.
K0300: Weight Loss
Rationale: Weight loss can result in debility and can
adversely affect a resident’s safety, health, & quality of life.
For those with morbid obesity, a controlled & careful weight loss plan can improve their mobility and overall health status.
For persons with fluid overload, careful and safe diuresis can improve their health.
K0300: Weight Loss 5%5% weight loss in 30 days:-Determine the resident’s weight closest to 30 days ago & multiply it by 0.95 or 95%. The resulting # represents a 5% loss from the weight 30 days ago. If the resident’s current weight is = to or < than the resulting #, the resident has lost more than 5% of his/her body weight.
K0300: Weight Loss 10%
10 % weight loss in 180 days
-Determine the resident’s weight closest to 180 daysago & multiply it by 0.90 or 90%. This # represents a10% loss from the weight 180 days ago. If the
current weight is = to or < than the #, then the resident has lost 10% or more body weight.
Other Definitions: Physician Prescribed Weight Loss
Regimen
Body Mass Index (BMI)
Steps for assessment: This item compares the resident’s weight in the
current observation period to his/her weight at two snapshots in time:
-At a point closest to 30 days preceding the current
weight.-At a point closest to 180 days preceding the
current weight.
This item does NOT consider weight fluctuationsoutside of these two time points.
New Admission: Ask the resident or family about
weight changes in past 30 days & 180 days.
Consult with the MD. Review transfer documentation. If admit wt is < previous wt, calculate
the loss.
Subsequent Assessments
Coding Instruction Definitions:
Mathematically round weights before doing the
calculation.
Code 0, no or unknown.
Code 1, yes on physician-prescribed weight loss regimen.
Code 2, yes, not on physician-prescribed weight loss regimen.
Coding Tips
Example #1: Mrs. J has been on a physician
ordered calorie-restricted diet for the past year. She & her physician agreed to a plan of weight reduction. Her current weight is 169#. Her weight 30 days ago was 172# & her weight 180 days ago was 192#.
How should you code K0300?
Example #2: Ms. K underwent a BKA. Her
preoperative weight 30 days ago was 130#. Her most recent postoperative weight is 102#. The amputated leg weighed 8#. Her weight 180 days ago was 125#.
How should you code K0300?
K0500: Nutritional Approaches
Rationale:
Approaches that vary from the “norm” or that rely on alternative methods can diminish one’s sense of dignity & self-worth. They can also diminish pleasure in eating. A resident’s clinical condition may benefit from approaches included here. It is important to work with the resident/family to establish nutritional support goals that balance preference & overall clinical goals.
K0500 Nutritional Approaches
Care Planning: Alternative approaches should be
monitored to validate effectiveness.
Include periodic reevaluation.
Definitions: Parenteral/IV Feeding
Feeding Tube
Mechanically Altered Diet
Therapeutic Diet
Steps for Assessment:
Review the record to determine if any of the listed nutritional approaches were received by the resident during the 7-day look-back period.
Coding Instructions:
K0500A, parenteral/IV feeding K0500B, feeding tube K0500C, mechanically altered diet K0500D, therapeutic diet K0500Z, none of the above
Coding Tips:
K0500 includes any & all nutrition & hydration received by the nursing home resident in the last 7 days either at the nursing home, at the hospital as an outpatient or an inpatient, provided they were administered for nutrition or hydration.
Tips continued: Parental/IV feeding-The following fluids may be
included when there is supporting documentation that reflects the need for add’l fluid intake specifically addressing a nutrition or hydration need:
IV fluids or hyperalimentation, including TPN (continuous or intermittently).
IV fluids running at KVO IV fluids contained in IV Piggybacks. Hypodermoclysis & subcutaneous ports in
hydration therapy.
Do NOT code in K0500A: IV medications. IVF’s given solely for the purpose of
“prevention” of dehydration. IVF’s given as a routine part of an
operative or diagnostic procedure or recovery room stay.
IVF’s given solely as flushes. Parenteral/IVF’s given in conjunction
with chemo or dialysis.
Enteral Feeding Formulas: Should not be coded as a
mechanically altered diet.
Should only be coded as K0400D, Therapeutic Diet when the enteral formula is to manage problematic health conditions, (i.e.: enteral formulas specific to diabetics).
Examples
K0700: Percent Intake by Artificial Route
Complete only if K0500A or K0500B is checked. Otherwise, skip to Section L.
Rationale:
Health-related Quality of Life.
Care Planning.
Steps for assessment (K0700A): Proportion of Total Calories through Parenteral or TF in last 7 days
Review intake records. Determine actual intake through
parenteral or tube feeding routes. Calculate proportion of total calories
through these routes. If no food/fluids via mouth or only sips,
stop here & code 3, 51% or >. If resident had more substantial oral
intake than this, consult with the RD.
Coding Instructions: Select the best response:
1. 25% or less2. 26% to 50%3. 51% or more
Calculate Proportion of Total Calories from IV or TF:
Dietician reported calories/day below:
Oral TubeSunday 500 2,000Monday 250 2,250Tuesday 250 2,250Wednesday 350 2,250Thursday 500 2,000Friday 250 2,250Saturday 350 2,000
How should you code K0700A?
Answer? Review calculation Rationale
K0700B: Average fluid intake/day by IV or TF in the past 7 days.
Review intake records. Add up total amt of fluid rec’d each day
by IV or TF only. Divide the week’s total fluid intake by 7
to calculate the average fluid intake/day.
Divide by 7 even if the resident didn’t receive IVF’s &/or TF on each of the 7 days.
Coding Instructions:
Code 1: 500 cc/day or less
Code 2: 501 cc/day or more
Example: Ms. A has swallowing difficulties
secondary to Huntington’s disease. She is able to take oral fluids by mouth w/ supervision, but not enough to maintain hydration. She received the following daily fluid totals by supplemental tube feedings (including water, prepared nutritional supplements, juices) during the last 7 days.
Example continued:
Sunday: 1250ccMonday: 775ccTuesday: 925ccWednesday: 1200ccThursday: 1200ccFriday: 500ccSaturday: 450ccTotal: 6,300cc
Calculate her average daily fluid intake for K0700B: Calculation:
6300 / 7 = 900cc/day
* Because 900cc is > than 500cc, you should code 2, 501cc/day or more.
Care Area Triggers (CAT’s): Review Nutritional Status triggers.
Review CAT Legend.
Care Area Assessments (CAA’s):
Refer to Chapter 4 & Appendix C of the RAI Manual.
Specific Resources.
General Resources.
CAA’s continued: “…nursing homes should ensure
that whatever assessment and care planning resources are used are current, evidence-based or expert-endorsed research and clinical practice guidelines/resources.”
Appendix C, RAI Manual, 3.0 Version, June 2010
Transitioning
MDS 2.0 to MDS 3.0
Questions?
Sources
CMS MDS 3.0 Information Sitewww.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage