Category: Q&A

Question: What is required if a resident passes away the day after the ARD for a Significant Change in Status Assessment (SCSA) due to hospice initiation? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO:You do not need to complete an SCSA for this situation as the resident …

Question: How does the new CMS memo, QSO-23-05-NH, for the schizophrenia diagnosis apply to OBRA assessments for residents who have been in the facility long-term? Answer from Jeff Taylor: I would say that memo, the errata document, and related State Operations Manual (SOM), Appendix PP changes apply to all MDS …

Question: When a ​resident is admitted with a diagnosis of UTI from the hospital, and has physician documentation and a lab from the hospital in the medical record, do we code UTI at I2300 on the MDS? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: Yes, you …

Question: If the dietitian documents a resident is at risk of malnutrition, can I code this diagnosis on the MDS at item I5600?  Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: I would recommend caution when adding a diagnosis to the medical record. We cannot add a diagnosis based …

Question:Would padded upper bedrails that are raised for a resident who experiences seizures be coded as a restraint? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC:You must assess the effect the padded rails have on the resident’s freedom of movement or normal access to his or her body. If …