Ask Proactive – I conducted the pain interview with a resident recently and they stated that they have ‘almost constant’ pain and rated it as ‘moderate’. I reviewed the chart and the resident has PRN analgesic available, but never requests it, and the Q shift Pain monitoring on the MAR indicates no pain during the look back period. How should I address this on the MDS?

by | May 11, 2022 | MDS, Q&A, RAI Manual

Q: I conducted the pain interview with a resident recently and they stated that they have ‘almost constant’ pain and rated it as ‘moderate’. I reviewed the chart and the resident has PRN analgesic available, but never requests it, and the Q shift Pain monitoring on...

Ask Proactive – A resident was admitted with a pressure injury (PI) that was unstageable because it was covered with slough and eschar. I coded it on the admission MDS under M0300F(Unstageable Pressure Ulcers Related to Slough and/or Eschar). I’m now doing a quarterly and the slough has been debrided, but there is still a lot of eschar. Do I still code it as unstageable on the MDS?

by | Feb 23, 2022 | MDS, Q&A, RAI Manual

Q: A resident was admitted with a pressure injury (PI) that was unstageable because it was covered with slough and eschar. I coded it on the admission MDS under M0300F(Unstageable Pressure Ulcers Related to Slough and/or Eschar). I’m now doing a quarterly and the...

PDPM Coding Question – We have isolated new admissions in our facility during the Coronavirus pandemic. Can we report and get “credit” for this precautionary isolation or does the resident have to have an active infection?

by | Aug 10, 2020 | blog, PDPM, Q&A, RAI Manual

Q: We have isolated new admissions in our facility during the Coronavirus pandemic.  Can we report and get “credit” for this precautionary isolation or does the resident have to have an active infection?   A: Precautionary isolation should not be reported in the...

Q & A – When interviewing the resident using the questions in the PHQ-9, what do you do when they answer them all as “no”, but in the charting and documentation, you see they had episodes of crying or tearfulness, pain, insomnia, etc.? Is this information to be incorporated into the PHQ-9 or must we code using only the resident’s actual responses?

by | Jun 8, 2020 | MDS, PHQ-9, RAI Manual

Q: When interviewing the resident using the questions in the PHQ-9, what do you do when they answer them all as “no”, but in the charting and documentation, you see they had episodes of crying or tearfulness, pain, insomnia, etc.? Is this information to be...

PDPM Coding Questions – I have NPO resident on tube feeding. He coughed during trials of nectar thick liquids per speech therapy. Should the MDS be coded for swallow problems?

by | Jan 23, 2020 | Coding, MDS, PDPM, Q&A, RAI Manual

Q: I have NPO resident on tube feeding. He coughed during trials of nectar thick liquids per speech therapy. Should the MDS be coded for swallow problems? The RD says directions on the MDS RAI manual say “do not code if interventions are successful in treating...