Category: MDS 3.0 and the RAI Process

Question: A resident discharged to the hospital with an unstageable pressure ulcer due to eschar (occurred in house). The wound was debrided in the hospital and then the resident returned with it being a Stage 3 pressure ulcer. Would this be presented upon reentry since it’s now a Stage 3? …

Question: A resident had a chest tube placed in the hospital and removed prior to re-admission. In the 5-Day look-back period, we have orders for an ointment and dressing to the area daily until resolved. Would I capture this under surgical wound and surgical wound care? Answer from Jennifer LaBay …

Question: Is an OBRA Discharge assessment required when a non-skilled resident has an unplanned transfer to the hospital, was not admitted, but was there for 30 hours? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC:Yes, OBRA Discharge assessments are required when residents transfer to the hospital, emergency department, or …

Question: On admission, our infection control nurse asks about the COVID-19 vaccine and documents the resident’s vaccine status and acceptance or refusal of the vaccine. Since we are no longer providing the vaccine in the facility, should I be dashing this item?    Answer from Jessie McGill, RN, BSN, RAC-MTA, …

Question: Do the medications gabapentin/Neurontin get coded in section J, Scheduled pain medication regimen, if the doctor noted they are for pain management, and are they also coded as anticonvulsants in section N? Answer from Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: Yes. Part of the confusion can …