all right, so section j is, we're going to document health conditions that impact the resident's functional status and quality of life and these are things, number one - and i'm so happy that it's number one on the slide - is pain. often other -- pain is under-reported and under-assessed and especially with our residents who are cognitively-impaired. and we're really going to spend a fair amount of time talking about the pain assessment. we're going to look at dyspnea and the effect of dyspnea, tobacco use. we're going to look at prognosis, we're going to look at problem conditions and then we're going to spend some time on falls.
so, the pain assessment - and it consists of an interview with the resident - and we're going to conduct a staff assessment only if the resident is unable to participate in the interview and we're going to talk through that. so this is, as you see it's been standard. we've done some standardization throughout the whole manual. at all costs, we want you to do the pain interview. it's amazing. even with residents who are cognitively-impaired, more often than not we still can get an accurate pain assessment interview completed. and then for those who we really can't, then we're going to go to a staff assessment. and so, what are the items that we're going to be assessing here when looking
for pain? the first and foremost is: does the resident have pain? now, we use the word "pain," but i want you to think about -- it's not just the word "pain," right? do most of our elders use the word "pain"? no. what kind of words do they use? "ache," "stiffness," "burning," you know, various other kinds of -- "throbbing". they may use a whole host of other words and say that they don't have pain. so, we must be -- it's our responsibility to make sure that we use words that are comfortable for our residents in helping to understand when we're doing a pain assessment. so, some people -- it's amazing, you know i'll be out in facilities and you see, you know, someone who is a fresh post-surgical, let's
say a hip fracture or a knee replacement. i've never had a knee replacement. my mother-in-law did. my sense in talking to her is it was painful. right? it's a painful procedure, and so you go in and you look at the chart and they say, "no pain." why do you think they had no pain? how do you think the person asked the question or assessed the pain? "do you have any pain?" okay? "do you need a pain pill?" all right? they person says, "no." why don't they have any pain? especially, like, our hip fractures. why do they not have any pain? they're fine. they don't have any pain if you don't move them, right? so, right? if they sit there and it's so classic, of not only just our elders, but other people,
"do you have any pain?" "nope. perfectly fine." "all right. well, you know, how about in the last couple hours? how about when you roll side to side? how about when you move your legs?" you know, do you see what i mean? so, we're kind of asking more questions to try to get a sense -- well, of course, if i sit like this [stiffens posture], i have no pain; but, you can only stay like this for so long, alright? so, we want to make sure that we're going above and beyond and not just saying, "you know, the person doesn't have any pain." we would expect there to be some level of discomfort. it's reasonable, right, to think if you've just had surgery or whatever.
what's the other most common cause of pain or discomfort in our elderly population? arthritis. all right? i have a little bit in my thumb. man, i can't imagine what it's like to have it in a variety of other joints. it hurts. you know? but, would i call it pain if someone asked if it was pain? i'd probably say, "no. it aches. i kind of feel it as an ache in my -- in my thumb." people who have told me who have, you know fractured in the past, like, ankles or whatever, and you know, that rain and the weather has come around and they say, "my gosh, you know. it just, you know, it hurts." they don't even really, they just -- it aches. okay? so, that could be equivalent to pain. so, i don't want
to beat a dead horse with that, but i think it's really important that we use the verbiage and the words so that -- some people do this as a quick out. "oh, they don't have any pain." skip the item. that's not what this is about. so, once we determine whatever words - but for this teaching we're going to use the word "pain"; but, we already know that means other things. we can use other words to switch in there. what is the frequency of the pain? what is the effect of that pain upon function for that resident? what is the intensity of that pain or discomfort? how are we managing it and what is the control of that pain? so, we're going to look at j0100, and here we're looking at - pain can cause
suffering and is associated with what? inactivity, and we kind of talked about that. if it hurts to do something, how motivated are we to do it? if it really hurts, we're not going to do it, right? okay? it can cause social withdrawal. it hurts too much to get up and go down to the activity room, so people tent to self-isolate. it can cause depressed mood. if you're in pain constantly, it's hard to be happy, right? i mean if you hurt really bad all the time, would that cause you to be depressed? yeah, of course it could. all right? so, certainly it could cause some depressed mood, and absolutely could cause functional decline. if it hurts too much to move, and then we tend not to move, what do we do? we
could lose function. definitely we could lose endurance, but we could lose function. so, this is really important and pain can interfere with participation in rehabilitation. so, it's critically important that if someone is experiencing pain that - what do we do? maybe we can pre-medicate, right? we can anticipate that the rigors of going through rehabilitation. if you've had surgery, let's say on your hip or a knee replacement or any one of the other things, that it can cause pain. so, let's make sure we anticipate that. pre-medicate so then they can fully function in the rehabilitative process, and we can have the best outcomes. effective pain management interventions can help to avoid all of these
adverse outcomes and we want to determine what, if any, pain management interventions the resident received during the look-back period. so, that's what we're looking at here in j0100. and how - so, what did they actually get? what did the resident actually get? so, we're going to review the medical record, we're going to interview, we're going to talk to direct caregivers and we're going to figure out what the resident had. so, let's look at the look-back period here. it's different. so, when you train on this, please highlight. the look-back period is five days. not seven. it's five days. so, that's a really important piece - both when you do your regular
trainings and, then as we go forward and we start implementing this, it's going to be really important. remind staff: five day look-back. because item-by-item, as generally they say seven days, if on the item set, if the look-back period is different - it's usually right on the item set and it is for these pain items. so, it will prompt and remind them that it's five days; but, sometimes you know, we get in our head - we're so used to that seven-day look-back. we go to sit down and do this, we're used looking at seven days instead of five days. please include information from all disciplines, so make sure you're talking to recreation. make sure you're talking to your therapists, if they're involved
with the resident. let's talk to your nursing staff, your social workers, your nursing assistants and make sure you're involving all of them in helping to do this assessment. and determine all interventions that were provided and answer these items even if the resident denied pain. so, the first question that we're asked here is j0100a: is the resident on a scheduled pain medication regime? all right? so, that's the first question and it's a yes/no answer. so, i think that's a pretty easy question to ask. you have to go back. you have to see what's been ordered. do they have scheduled medication? it could be scheduled tylenol twice a day. it could be a scheduled
fentanyl patch. it could be any one of those, but it's a routine. it's not a prn. it's not given as needed. it is a scheduled medication. so, we go through, we look in the last five days. did the resident have a scheduled pain medication, and we can either answer "yes" or "no" to that question. the second question says, alright, did the resident receive prn pain medication? so, it's not asking - now, this question is a little different. it's not asking you, "was it ordered," because obviously, it would have to be ordered for you to give it; but what it's saying is did the resident receive the prn medication. so, you're going actually have to go in the record, look during that five-day
period of time and see did they receive that prn medication. code "no" if the record does not contain documentation of a prn medication. code "yes," if the record contains documentation that a prn medication was either received or offered, but was declined. so, that's a little different here. so, you have two options here. they actually had an order for something. they -- and they received the medication, or did you have documentation that maybe the nursing staff offered the prn medication and they declined it? some staff, some facilities do a really great job. you'll often see it more so in the nursing notes: "offered prn medication and declined." you know, i assessed them and i
offered it to them and they declined it. so, here you would be able to capture it - that it was offered and declined or that it was offered and received. and then c - this is where we're looking at the resident received non-medication interventions for pain. so, we're going to say code "no" if the medical record does not contain documentation of a non-medication pain intervention or code it "yes," if a medical record contains documentation that a non-medication pain intervention was scheduled as part of the care plan and intervention actually received and assessed for efficacy. things like this could include ice packs, hot packs, you know, other -- other types of interventions that you've done to
help relieve the pain for the resident. so, if it's care planned, and then they actually received it, we're going to go ahead and take credit for it there; and, certainly we want to make sure that we're offering some of these non-medication -- and they can be in place of, or in conjunction with, actual pain medication. so, let's go through a scenario here. so, we have the resident's medical record documents that she received the following pain management in the past five days. she received hydrocodone/acetaminophen 5/501 tablet every six hours and discontinued on day one of the look-back period, and then acetaminophen 500 milligrams every four hours started on the day two of the look-back period. and
they also had cold packs to the left shoulder applied by pt twice a day, and pt notes that the resident reports a significant pain improvement after the cold packs. so, the therapist has said, "you know, this is a really good intervention for this particular resident." so, we would code j0100a as "yes." the medical record indicates that the resident received a scheduled pain medication during the five-day look-back period, even though it had been discontinued. it was scheduled and they received it, and j0100b as "no." there's no documentation was found in the medical record that the resident received, or was offered and declined any prn medications, during the five-day look-back period. and then c
as "yes," because they got an alternative or a non-pharmacological intervention which were the ice packs, and so they received them and it was effective for the resident. that makes sense, right? not a hard thing to do? okay. so, let's look at a practice session here. so, the resident's medical record includes the following pain management documentation. so, they have ms-contin, which is a morphine sulfate control-release medication, 15 milligrams by mouth every 12 hours. and the resident refused every dose of medication during the five-day look-back period and no other pain management interventions were documented. so, what do you think? how would we code j0100a? okay. so, the
correct coding is "no." the medical record documented that the resident did not receive scheduled pain medication during the five-day look-back period. all right? so, they didn't receive any scheduled pain medication. let's see what else we talked about here. so, the medical record -- so the resident may refuse scheduled medications and medications are not considered received if the resident refused the dose. that makes sense, right, if they didn't receive it? okay. well, actually, no, this is wrong. >> audience: it is wrong! >> i'm sorry! i'm reading it -- have they been on a scheduled pain regime? it should be "yes." did they receive any -- you know, it wasn't asking about
received. that's an error in the slides. sorry about that, folks. we'll have to correct that in the training slides. they had been on a scheduled pain medication. all right? how should j0100b be coded? "no." they didn't have any prn, right? they were clearly documenting that they didn't have any prn medications. none were offered. they were documented as offered and they actually were not documented as received or offered and declined. so, during the five-day look-back period. how should j0100c be coded? okay, and here for this particular scenario that they're giving us, the medical record would be "no." the medical record contains
no documentation that the resident received non-medication pain interventions during the five-day period. so, if they had been -- that was the resident who was receiving the ice packs, or whatever, then we would have coded that as "yes." okay. should pain assessment interview be conducted? so, this is one of those -- remember i talked about those gateway questions? so, here's a gateway question. so, most residents are capable, and i talked about this, of communicating and can answer questions about how they feel. we're going to obtain information about pain directly from the resident because it's a more reliable and accurate
than observation alone for identifying pain. and use staff observation for pain behavior only if the resident cannot communicate verbally, with gestures, or in writing. so, it's really important that in any way, shape, or form, that if the resident can communicate with us that we actually go ahead and complete this assessment. so, j0200 - it says conduct the assessment. so, most residents can complete the assessment. we need to determine whether the resident is understood at least sometimes and we should look at whether the resident needs an interpreter to complete this just like any of the other interview sections. so, if we need to
have an interpreter that we have one available to us, and so that we can go ahead and, you know, answer these questions accurately. so, in the assessment, what we're saying here in j -- this slide is wrong too. okay. sorry. this -- oh, what this -- sorry. okay, i see what they're doing. so, what they're doing here is skipping back to say, "is resident comatose," and if so, we're going to skip it -- wouldn't be doing this question. sorry. so, here we have j0200. code "no," if the resident is rarely understood and "yes," if the resident is at least sometimes understood or an interpreter is present. so, i would strongly encourage you to really look at this though. please don't
-- if you go back and you're going to go do the interview and you go back to section b and you say, "is the resident understood," and you see that they're rarely understood, you know, and you think differently, you may want to go and talk to the person who -- if that wasn't you who completed that section of it and talk and see is it, you know -- there will be those people who truly have all -- you know always have nonsensical speech and you really couldn't do the interview and you've coded them appropriately in section b. you may, at this point, then jump right to doing the staff interview; but, we really would like, if there's any level of the person being understood, we want you to try to do
the pain interview. so here - so, let me go back. so, here if it's "no," you're going to skip to complete to j0800, which is staff assessment. otherwise, you're going to continue through and do the pain items. so j0300 through j0600 is the pain assessment interview. so, we're going to - we're going to interview anyone who wasn't screened out by j0200 and it consists of four questions. and we start with j0300 and that's a "pain presence." the interview includes three follow-up items for the resident which says so, if we've got the presence of pain, then we want to know what's that frequency; what's the effect; and, what's the intensity
of that pain. again, the look-back period is five days. we want to conduct the interview as close to the end of the look-back period, as close to the ard as possible. and why is that? well, if you only have -- if your ard is the end point, right? and this is only a five-day look-back, right? so, we only can go back five days. you know, if - if we did this on day, you know, if we did this on day four, or we pushed it back - and we may only have then one day of, really, data to look at. you see what i mean? so, this is one of those -- because it's such a short look-back period, you really want to take this one as close to the ard as possible, and so you can really get a sense about whether
the resident has been taking any medications and then how are they doing in response to those as far as doing the pain interview. so, this is one where i would strongly encourage you to take it as close to the ard as possible. we're going to skip to the staff assessment if the resident is unable to answer the question about the presence of pain. so, if you can't even get the resident to try to -- if they can't even answer whether they have pain or not, then we're going to skip to the staff interview. we're going to stop the interview and skip to the staff assessment if the resident is unable to answer j0400, "pain frequency," also. ask each question in order. so, we want -- so, this is one of
those interviews where we want to go ahead and ask it in order. let's see. we want to use other terms for "pain." we've already talked about that. we want to code 9 if the resident refuses to answer a question, and move on to the next question. so, it's one thing if the resident can't answer the question, like they're giving us goobledygok for an answer, versus someone who refuses to answer the question. so, if they refuse to answer, put a 9 in and continue on. if the resident is unsure about whether pain occurred during the look-back period, see if you can prompt the resident to think about the most recent episode of pain that they had. so, you know, tell me about today or tell me
about yesterday and how did you feel and what did you do and did it affect your ability to move around or go to activities and all of those things. so, trying to help the resident to really think through about recent activities that they had and whether there was pain involved in it; and, then we're going to try, to the best of our ability, to determine if it happened during that look-back period that we're talking about. we're going to conduct the interview. we're going establish a conductive environment, we -- a conducive environment. we already have talked about this. dr. deb saliba spent a lot of time with you guys about this. we're going to use
the interpreter, if needed. we're going to make sure that the resident can hear again. here's - you know, we want to make sure if they have hearing aids or using an amplifier that they're working. we're going to explain the reason for the interview. we're going to explain the response choices. we can -- and i think in your packets some of the pain answers, i think you've got cue cards. so, you can use those. so, you can show the responses in large font, as appropriate, so that people can see it and allow the residents to write a response, if needed. so, this is one of those interviews if they can either point or they can write the answer, if they can't verbalize it to you.
so, go on to the next question, which is j0300, and this is asking the presence of pain. so, we want to make sure that we ask the question as it's written and we're going to code for the presence or absence of pain regardless of pain management efforts during the five-day look-back period. we're going to code "no" for the presence of pain, even if the reason for no pain is that the resident received pain management interventions. and this was one, actually, for the mds 2.0 where people struggled a little bit and i think i talked about this earlier in one of the other sessions that i taught where staff members really felt like it was wrong if they coded, "no pain," if they were receiving pain
management. because they were thinking, like, they had to justify why they were giving the pain medication. but in fact, if someone has no pain, and you have them on the pain regime, what is it telling you? it's working. you're doing a great job, which is-which is the goal. so, but just so you know, that we did see that when we did our dave project. so when you go out and teach, you want to make sure you emphasize that and that's more with the staff nurses who may be filling out part of the mds if they're part of your team. they're thinking they have to justify this. so, and, rates of self-reported pain are higher than observed rates of pain, and the research has been pretty clear about that. and
certainly our response to people's pain. staff say, "you know, gee. they don't appear to be in pain to me because they're smiling or they're interacting with their family." when, of course, they are in pain. so, pain is what the patient or the resident says it is, right? so, we have - we have to take their word for it. so, we must use -- although, some observers have expressed concern that the resident may not complain or deny pain, the regular and objective use of self-reported pain scales enhances residents willingness to report. so, if -- what this basically is saying is if we have a system and a process in our
organization where we are, on a regular basis, are assessing for pain and response to pain management, we have a much greater chance of people feeling open to express their discomfort and whether they're having any - any issues related to pain. so, we're going to code "no." the resident responds "no," to the presence of pain. even if the resident received pain management interventions, it's okay, and the interview is complete and we're going to skip to j1100, "shortness of breath." so, even if the person is getting pain management, and apparently it's working, if you say during the last five days, "have you had any pain," and the resident says, "no, you know what? i'm really
comfortable. i really haven't had any discomfort or pain. i'm doing fine right now." okay. then we answer "no," and we skip out of the rest of the questions and we go to "shortness of breath." if they say "yes," then we need to continue to the pain assessment interview. we can code 9, "unable to answer," if the resident doesn't respond to us or they give a nonsensical response; and, then we're going to skip out to j0800 and we're going to have to do the staff interview at that point. so, a quick scenario: when asked about pain mrs. s. responds, "no, i have been taking the pain medication regularly. so fortunately, i have no pain." that's
exactly what we hope for. so, for this particular resident, we would code j0300 as "0. no," and even though she was receiving pain medication interventions during the look-back period, we code it as "no," and we skip to j1100, "shortness of breath," and we don't worry about the rest of it. okay? so, here we have another scenario: when asked about pain, mr. t. responds, "no pain, but i've had a terrible burning sensation all down my leg." so, how should we code j0300b? yeah, that's right. so, that burning sensation equals pain. so, for this resident we're going to go ahead, it's -- we were able to confirm it's during that look-back period that he's having this burning sensation. so, we're
going to code it as "yes." so, now since we've coded it, "yes," we're going to go ahead and start on j0400 which is "pain frequency." we're going to ask the question exactly as written, "how much of the time have you experienced pain or hurting over the [p]ast 5 days," and staff may present response options on a written sheet or cue card, and this can help the resident to respond to the item. and i would encourage you to do this and i think, again, we have samples of those cards because you're saying to the resident, "all right, so you told me you had some pain over the last five days. how much have you experienced pain or hurting?" so, is it almost constantly? is it frequently? occasionally, rarely,
or they're unable to answer. so, if we have these written out, we can talk. if they narrow it down to two, then we can help work through with the resident and then we're always going to code, if they can, they give you two responses, we code to the higher. all right? so, you're going to code to the higher response. so, make sure that that, again, is something that's written in the manual, but guess what? not everyone's going to read it, especially any of your staff nurses or whatever, doing this. you got to make sure you highlight that to them. we're not going for the lesser amount of pain. we're going to go for the higher amount of reported pain. so, make sure you train on that area.
do not offer definitions of the response options, but if you can help them to narrow it down, you can do that. "so, you said you had pain," and then you can reiterate and then see if they can narrow it down. so, you're not re-defining it for them, but you're helping them to try to narrow it down - the frequency. so, it should be based on the resident's interpretation of the frequency option for themselves. you can certainly -- there was techniques that were talked about both with rena and dr. saliba, and these are the same techniques. you could use echoing to help clarify the preference options, and if the resident does not respond according to the response scale, "so, i hear you saying that you have
pain," whatever they're saying, but it doesn't fit into the scale, "would you say it iså¯," and then bring them back to the scale and try to help them fit their response into one of the responses that we have. stop the interview and skip to j0800 to complete the staff assessment of pain if the resident is unable to respond to this item. so, what you're showing here is you're trying really hard to complete this pain interview but, if the resident can't do it, then we're going to go to the staff assessment. so, we're going to code the response if the resident has difficulty choosing between the two responses -- i just already went through this with you. we're going to help them to echo, and see if
they can come to a definitive response. if not, we're going to code the higher of the two responses. so, we have a scenario here. when asked about pain, the resident responds, "i would say rarely," and then they go on and say, "since i started using the patch, i don't have much pain at all; but, four days ago the pain came back. i think they were a bit overdue in putting on the new patch, so i had some pain for a little while that day." so, in j0400 we would code as, "rarely." so, the "rarely" response would be the option that we put in here. any questions? this make sense to everyone? okay.
so, let's look at a practice scenario. so, when asked about pain, ms. k. responds, "i can't remember. i think i had a headache a few times in the past couple days, but they gave me tylenol and the headache went away." so, the interviewer clarifies by echoing what ms. k. has said, "you had headaches a few times in the past couple days and the headache went away when you were given tylenol. if you had to choose from the answers, would you say you had pain occasionally or rarely?" ms. k. replies, "occasionally." so, by echoing it back to her and giving some of the responses, she was able to narrow it down and say, "occasionally." how should j0400 be coded? "occasionally," yeah. "occasionally."
we gave you the answer right up in the beginning. [laughter] so, she was able to clearly say that she had pain occasionally. so, it took a little bit to get there and help reflect it back to the resident, but they were able to do and tell you that they had it occasionally. all right. so, now we're going to look at -- what is the effect upon function for the pain, and this is item j0500. so again, we're going to ask you to ask each question as written. so, "over the past --" so, this is how the question was written -- "over the past five days, has pain made it hard for you to sleep at night," or b, "over the past five days, have you limited your day-to-day activities because
of pain?" so, we're asking them two questions: has pain -- has pain made it harder for to you sleep or has pain made you limit your daily activities? so, as we move forward here, we want to repeat the responses and try to narrow the focus of the response if the resident response is not clear. so, we want to get a "yes" or "no" answer out of them. so, if they're kind of giving you this vague thing, you want to echo, you want a response, you want to get them down to giving you an answer. so, "over the past five days, has pain made it hard for to you sleep at night," and the resident responds, "well, i always have trouble sleeping." all right.
okay. so, try to help clarify the response by saying, "you always have trouble sleeping. is it your pain that makes it hard for you to sleep?" so -- so, you're acknowledging what they 'vetold you, "i always have trouble sleeping," but now you want to say let me make sure it's pain that is the reason that you can't sleep, and then code the resident's response to each question: "no," "yes," or "unable to answer." so, in that situation, it may be pain that was keeping the resident from sleeping at night or it could be any number of other things. it could be that they have trouble sleeping at night because, for 40 years of their life, they worked night shift and they never slept well at night. so it has
nothing to do with pain, but it has to with a lifestyle that they've had. so, we really -- we just want to make sure that the answers we're getting, we get people to say, "is it related to pain?" so, we have a scenario here. so, mrs. d. responded, "i had a little back pain from being in the wheelchair all day, but it felt so much better when i went to bed and then i slept like a baby." so, how would we code? "no," right? she had no -- she's telling you, "i had pain, but the fact that i was able to get out of the chair and lay and stretch out, i felt so much better and i slept fine." so, she has no problems related to pain in her sleeping.
so mrs. g. responds, "yes, the back pain makes it hard for me to sleep. i have to ask for extra pain medications and i still wake up several times during the night because my back hurts so much." so, what are we going to answer for this question? "yes." okay, and what else who we want to do? so, we've answered this, but she gave us great information. didn't she give us good information? right? what would we want to do with that information? we want to probably investigate a little bit more, right? check the bed, check the mattress, you know, maybe we want to talk to therapists to say, "what else can we do?" do they need a more supportive -- what is it? what we can do for this particular resident to,
hopefully, make her more comfortable at night and so that she can sleep? but yes, we have to answer this mds question. but again, since we're talking to the resident so much, hopefully we're gleaning all kinds of wonderful information that will help inform our care plan and our care processes. all right, so the correct answer is "yes," and she reported pain. so, here we have mrs. n. and she says, "yes, i have been able to play piano because my-" oh, i'm sorry. ms. n. responds, "yes, i haven't been able to play the piano because my shoulder hurts." so, we're looking at j0500b and this is, like, do you change activities of daily living. so we would code "yes," and
because she responded limiting her activities, meaning playing the piano which she enjoys, because she had pain in her shoulder. so, it can be as simple as playing the piano. it could be that they don't go on the out trip. it could be that they don't go to the bingo. it could be that they don't go to a social event because they just don't feel good because of the pain. so, they're limiting. mrs. l. responds, "no, i had some pain on wednesday, but i didn't want to miss this shopping trip. so, i went." so, in this situation, we have a resident who's saying, "yeah, i had pain on wednesday, but, you know what? i pushed through the
pain. i didn't let it limit me and i went ahead and i went on the shopping trip." so, how would we code j0500b? again, you know, did we curtail activities? did she curtail it? no. she went on the activity anyway. okay. so, she was able to kind of push through and she did not change what she would do. so, let's look at item j0600, which is looking at the pain intensity. so, now we've looked at a variety of things. let me kind of -- actually, let me jump back a little bit. when we were talking about the self-reporting pain and whether pain interfered with sleep or whether they curtailed activities of daily living. some of the staff -- some of the people who have come to various
conferences that we've done in april and march shared with us, and plus some q & as that came through, they were really concerned on a couple things. they were concerned if they coded that the resident said they couldn't sleep at night because of pain, or that they didn't curtail activities of daily living, and then you go to the record and the record says either they were up at night because of pain or they slept all night or -- do you know what i mean? there's conflicting information. staff were really concerned about that and they said, "you know, well, what should we do?" well, please remember that these interviews are considered a prime source of information. we have to put down what the
resident tells us in these interviews, and it's okay and it is acceptable in this situation where you might have information that kind of countermands it. we may want to, kind of, talk to the staff that says -- like, for example, if the resident is saying they're not sleeping at night, because of pain and then night staff is charting they're sleeping fine, you know, take it for what it is. but, maybe we want to talk to the night staff and say, "are you sure they're sleeping or is that person --," right? what is that statement, you know, "reclined with eyes closed"? how do we know if they're really sleeping? what we may want to do is talk to the resident and say, "gee, you know what, our staff wasn't aware
you're having so much discomfort at night. what else can we do for you? and maybe we're going to have them check in on you a little more frequently and see if we can help you to be more comfortable and get more time sleeping." so, it's okay that we have some differing information in the chart. all right, so pain intensity. so, we have -- for this item, you are going to answer one or the other of the scales, not both. so, what they've done here is they've given you two options. you have the numeric rating scale or the verbal descriptorscale, and depending on the resident, some do better with the numeric scale and others do better with the verbal descriptorscale. you just need to
know your resident. so, but, you need to answer one or the other. not both. so, we want to read the questions and response options slowly to the resident. we want to ask the resident to rate his or her worst pain and, again, we're looking over the five-day period of time. so, for the numeric scale, we're going to say, "beginning with zero, which is no pain, and 10, which is your worst pain that you can imagine, please rate the intensity of the worst pain over the last five days." so, now you know the resident's told you they have pain, and they may even have described the pain to you. so, now you'd say, "now, from this pain in the last five days, think about the worst pain that you had over the five-day
period." let them get that in their head. all right. "with a scale, if we're going to use a numeric scale, "of 0 to 10, help me to understand what number." now, i can tell you -- again, some residents do really well with this. others, this just frustrates them. my mom was in the hospital, and she had had a bleed in her brain and was having -- was re-absorbing and she was doing well, but she had a lot of pain, a lot of headaches. and the nurses were really great. they were wonderful, but they kept coming in and they'd say, "mary, can you tell us about your pain 0 to 10," and she got so frustrated with them. she turned to me and said, "what the hell are
they -- what are they asking me?" i was like, "mom, you have a headache, right?" "oh, my god, it's killing me." i was like, "is it, like, the worst pain?" she said, "yeah, i feel like my head is going to blow off my, you know, top." "all right. so that's, like, the worst pain you can imagine?" she goes, "it's right up there with the worst pain i can imagine. it's horrible, ann." "all right. that's a 10, ma." you know, and so, but -- what happened in that setting, in this particular hospital setting, they only knew how to do 0 to 10 and they were so rigid in that, they couldn't help her to understand to translate that 0 to 10 into something that she could understand.
so, if it works for your residents, great. if not, you probably want to go to the verbal descriptor scale, and you want to give them some context around how to describe the pain. you can use cue cards to show the response options, if needed. i think it's very helpful. again, you want to keep to the five-day look-back period. you do want to try to use the same scale from the prior assessment, if at all possible. so, once we start using this mds 3.0, if you can go back. let's say i did -- it's october and i'm doing the first mds on mary and i use the verbal descriptor scale and now it's the next -- let's say it's a quarterly assessment. it's the next time i'm going to do this assessment, i want
to go back and look at, and say what scale did this other -- if i'm not the same person doing the assessment -- what scale did they use? and i want to strongly encourage the resident to use that same scale, if at all possible. not mandate it, but we strongly encourage you to try to do that. so, that will take a little bit of extra work - that you're going to have to go and look at that. if the resident is unable to answer using one scale, try the other scale. so, people say to me, "do we always have the numeric scale first and then the verbal descriptor scale?" no, it's just how it's printed on the page. if you try they verbal descriptor scale, and they can't do it, you may want, then, to try the
numeric scale. so, it's not mandated that you do it in any set order. again, once you've done a scale, if you can try to use the same scale that would be best. and, again, please remember and educate your staff that residents can respond verbally, in writing, or both. they may point. like, if you've given them the cue cards and you've put it in front of them, they may point to the word and that's fine. they're responding to you. code is two digit value. use a leading zero for the value less then 10. so here, if someone says, "well, my pain is a 5," this is a common coding methodology that you're going to see if you have a blank first. you're always going to do
the leading zero. so, if they had 5 as their pain, you'd do "05". so, you want to make sure that that happens. i'm sure your software will automatically fill that in for you, if need be. but, and then if you do answer j0600a using the numeric scale, we're just going to leave "b" blank. we're not going to touch it. just leave it blank because you've already answered one of the questions. the same thing if you have to answer j0600b. leave "a" blank. the second scale, which is a verbal descriptor scale, is only one number scale. so, you're going to ahead and put in -- if they said they only have mild pain you're going put in a 1 up to 4, which is very severe or horrible pain, or you're going to put in a
9, that they were unable to answer. so, let's go through a scenario here. so, the nurse asks mrs. t. to rate her pain on a scale of 0 to 10, and mrs. t. states that she's not sure because she has shoulder pain and knee pain; and, sometimes it's really bad and sometimes it's okay. the nurse reminds mrs. t. to think about all the pain she had during that five-day period and select the number and describe her worst pain. so, it could be the pain in the shoulder or the pain in the knee. doesn't matter. "of the last five days, what is the worst pain that you had?" and she reported her pain as a 6. so, we were able to get this resident to get to a number. so, we're
going to go ahead and code this item as "06" because it is a single digit number here and we had to put the leading zero in. here's another scenario. the nurse asks mr. r. to rate his pain using the verbal descriptor scale. he looks at the response options presented using the cue cards and says his pain is severe sometimes, but most of the time it's mild. so, he's saying his pain is severe, but sometimes or most of the time it's mild. so j0600b is coded as, "3. severe." why? we code to the worst. right. okay. very good. so we have -- do we have this activity? i'm sorry. is jennifer back there? do
you guys have an activity? sorry about this. do you have an activity? yeah -- okay, so you should have a sheet in your book that would answer the questions j0300 to j0600. so we're going to, i think, show a video and we want to you answer those questions. so, if you can pull that sheet out in your packet. did they give you a pain section for the mds? yes? okay. they say it's in your packet. so you should have the pain, if you can pull that out. once you find it -- does anyone know which side of the packet they found it on? the right side or the left side? it's on the left side of the pocket, is what most people said. yeah, basically it's the section of the mds. okay. everyone have it? no? yes?
huh? yeah, it's there. so it's your mds, section j. if not, you can just use a piece of paper and jot the answers down or if you have an mds -- a lot of people brought mds's with them. all right. so we're going to go ahead and we're going to do the pain assessment interview video. and so as they're going through this video, if you can code as if you were doing the interview, code your mds. all right? so, this is a practice session for you. so, go ahead and play the video. the pain questions in this interview assess the presence of pain, pain frequency, effect on function, intensity, management and control. the
information about pain that comes directly from the resident provides symptom specific data for individualized care planning. pain can cause suffering and can interfere with rehabilitation and be associated with low mood. most residents who are capable of communicating can answer questions about their pain. testing shows, that they recall moderate or severe pain, even with a 5 day look back. "alright. mrs. white let's move on to a question about physical pain and how you've been feeling in the last 5 days, ok. have you had pain or hurting at any time in the last 5 days?" "no. i don't want to bother anyone. it's not so bad."
"i'm here because i need to know how you're feeling, so we can help you. and, please don't worry that what you're telling me is a bother. have you had pain or hurting at any time in the last 5 days?" "i'm in pain a lot on myå¯ my hip hurts. i had surgery. they said i fell and broke it." "how much of the time have you experienced pain or hurting in the last 5 days? would you say almost constantly, frequently, occasionally or rarely?" "i'm in a lot of pain." "okay. would you say almost constantly or frequently?"
"almost constantly." "alright. alright, i'm going to talk to your doctor in care team about often you're in pain. i just have a few more questions to ask so we can get an accurate picture of how much pain you're in. now, over the past 5 days has pain made it hard for you to sleep at night?" "yes, it hurts too bad to sleep." "okay. over the past 5 days have you limited your day to day activities because of pain?" "yes, it hurts too bad to move. i just want to be still."
"please take a look at this pain scale and rate your worst pain over the last 5 days on a 0 to 10 scale. with 0 being no pain and 10 being the worst pain you can imagine. this will help me give the doctor accurate information. "8." "8, i see. alright, we're going to work with you on that pain, and i'm also going to check to see what medications your doctor has ordered for your pain right now. and, i'm going to share what you just told me with your care team, so we can get started on helping you to feel better right away. is there anything else you want to tell me about your pain?"
"no, thank you." "you're welcome" some observers have expressed concern that residents may not complain and may deny pain. however, the regular and objective use of self-report pain scales enhances residents' willingness to report. in fact, multiple studies have shown that rates of reported pain are often higher than observed rates. this resident had not let anyone know about her pain, and by limiting her activity had avoided frequently demonstrating signs of pain. april could have shown the resident the 0 to 10 scale or the verbal descriptor scale to rate the intensity of the pain.
she used the 0 to 10, or numeric, rating scale to ask mrs. white to rate her worst pain and gave verbal definitions of the 0 and 10 values. april may have used the 0 to 10 scale because the resident had used the scale before, or it is preferred by mrs. white's providers. if mrs. white had had difficulty using the 0 to 10 scale, april would've tried the verbal descriptor scale where the resident would've been asked to rate the intensity of her worst pain as mild, moderate, severe, very severe or horrible. so, i mean, i think that's, you know, about what you probably are going to find when you're dealing with your residents. so, let's go through. how - let's look
at j0300. how would you code that? "1. yes." right. how about j0400? right, constantly, right. j0500a? right, yes. she had issues with sleep. j0500b? right, so she was curtailing activities. and then j0600a, they used a numeric scale, was aå¯? eight, good. "08", very good, as you would put it on the mds. all right, so if you were conducting a staff assessment for pain, consider the following indicators of pain. so, let's say this resident wasn't able to - to communicate as well as she was and we had to do the staff assessment. we would look at some of the things like, you know, was she frowning, rubbing her hip, not moving much, guarding herself. you know, some of those observational things
that would have given us an indication that she has having some pain. so, here we have those questions. all right. so j0700 - "should the staff assessment for pain be conducted?" so again, this is one of those gate questions. so, the resident interview for pain is preferred. we talked about that and we know that a small percentage of residents are unable or unwilling to complete the pain interview, and residents who are unable to complete the pain interview may still have pain. so, we're going to review the resident's responses to j0200-j0400. we're going to determine if a pain assessment was completed. so, either j0300 presence of pain
was coded as "no" or that the presence of pain was coded as "yes," and that the pain frequency is answered. so, in the situation here, we have code "0. no," the resident completed the pain assessment interview. so, that makes sense. so, it's asking should we do the staff interview. well, no. if you just completed the pain interview and the resident was able to engage with you, you don't need to skip out of the staff assessment and we're going to go right to answering questions about shortness of breath - j1100. but, if you say yes, the resident was unable to complete the pain assessment interview, we're going to then continue on to j0800 and complete the pain assessment. so, this is that gateway
question that sets us up for the skip pattern. so, now we're going to look at -- let's say we couldn't do the pain interview and now we have to do the staff assessment. so, this is j0800 through j0850. so, here we have residents who cannot verbally communicate about their pain are at particularly high risk for under-detection and under-treatment of pain. so, we know that severe cognitive impairment may affect ability of residents to communicate verbally and this limits availability of self-reported information about pain and fewer complaints may not mean less pain. an individual is unable to communicate verbally may be more likely to use an alternative method of
expressing or communicating pain. and sometimes we see this with our -- you know, severely cognitively-impaired residents who were acting out, who may have a behavior and it actually may be pain. there was a study done in one of the new york hospitals, i don't even remember what journal it was reported in, but they looked at residents who came in with the hip fractures, you know, certain age, and then they looked at the mini mental scale, which helped divide them into two groups; and, they looked at those who were fairly significantly cognitively-impaired to residents who could communicate and advocate for themselves. and what they found with the hip
fractures - so, these are very similar residents as far as age and everything else, the only thing was their cognitive ability is the residents who had the poor cognition received approximately 50% less pain medication. so, what does that say? do you think they had less pain? no, but they just couldn't ask for the pain medication. so, when someone is cognitively-impaired, those are the residents we really have to pay attention to and say, "are they having pain," and make sure that we are assessing them, monitoring them and treating them appropriately. i want to give you one other example. i was -- heard a speaker at a conference
and there was a nurse practitioner who - a geriatric nurse practitioner working in a long-term care facility -- and we were talking about pain. that was the focus of this particular session, and she was sharing the story about this particular resident who had a lot of arthritis. it's one of those people she's got cognitive impairment and whatnot and one of those residents, you know, when with you go to move their shoulders, it like crunches and creaks and you just kind of like -- you can feel it in your own bones as you go to move them and the resident was quite combative during care and it was really a problem for the staff to provide care for this resident. so, the aprn was looking at the
resident and looking at the -- what was going on with her and her pain medications and whatnot. well, she was getting some pain medication, actually tylenol, for her arthritis and she was getting it twice a day - and they were giving it at 9:00 and 9:00. so, does that sound good? why? why would that not be good? maybe it's not enough? what else? well, what they found is this resident, they tended to do her a.m. care between 6:30 and 7:00 in the morning. she was an early riser. she was up early. so, they were fighting -- you know. so, here's a staff member coming in to try to get her washed up or whatever, and this resident was fighting. she wasn't getting her tylenol until, at best, maybe
earliest, by regulation - 8:00. you know, because you do an hour before and an hour after. more likely than not, she was getting it 9:00/9:30. she was settling down at that point, but when did she have the pain? early. so, what they did is they did a trial for her. they changed her pain medication to 6:00 a.m. and then she wasn't -- they postponed doing any of her a.m. care until the 7:00 to 3:00 shift came in, but she was first to be done, like, right after the staff came in. so, she had some tylenol on board a good hour, hour and 15 minutes or so before any staff member went if to take care of her and, lo and behold, guess what happened? she was a lot more comfortable and she fought a lot less. she
still, obviously, had the cognitive issues, but she wasn't in pain. so, this poor person was fighting staff, not to resist care, but because she hurt. there's been some facilities who are looking at this when we -- on some of the dementia care units of putting, kind of standing, for those who needed standing orders of once, or twice or three times a day tylenol - depending on other things going on. just looking at how it affects behavior and there's been some interesting studies done related to that. so, we must look at some of the behaviors and could pain be one of the things that -- what response we're seeing, is pain part of it. okay. let's see.
so, what are some of the nonverbal sounds that, you know - indicators of pain? again, these are just a list of some. it's not an all inclusive: crying, whining, grasping, moaning, groaning and other audible indications. we could have verbal complaints of, "that hurts," "ouch," "stop." those are, i think, clearer indications that we're probably doing something that is uncomfortable for the particular resident. we may have facial expressions including, but not limited to, the furrowing of the brow, the clenching of the teeth, grimacing, wincing, wrinkled forehead. so, what does that take? you must look at your residents and get a sense about what their normal facial expressions are and
then whether something, upon movement or whatever, that they start showing that they may be uncomfortable. protective body movements or gestures included but are not limited to bracing, guarding, rubbing or massaging. have you ever seen that person walking down the hallway doing this? [rubs hip] you'll see me sometimes do this. i think i'm getting a little bit of a bursitis in my shoulder. you'll see me kind of rubbing my shoulder and moving it because it's sore. clutching or holding a body part during a movement. so, it hurts -- if their shoulder hurts or something, you may see them kind of grabbing. so, when you go to do a particular movement, they may
be guarding that body part. even through their cognitive impairment, they're doing this kind of as a natural defensive mechanism. so, we can then take a look at the resident and try to interpret that as saying maybe they're having some discomfort or pain. we're going to look at the medical record, we're going to confirm the presence or indicators of pain and we can do that, most often, through direct or interview of direct care staff and maybe significant others. and so we want to talk to people who really know these residents and care for them on a regular basis and try to make sure that we can elicit some of these things. so, if we're
relying upon our nursing assistants to give us some of this information, we first have to make sure they understand what we're asking for and what we're looking for. so, we must educate them, have them understand all of these things that we just talked about. we, as the nurse, may have very good knowledge that these can be indicators of pain, but we then have the obligation to make sure the rest of the care team understands this also. and, again, some facilities do a much better job than others related to this. so the look-back period is, again, still five days. some symptoms may be related to pain can include behavior changes; depressed mood; we talked about the
rejection of care; and decreased participation in activities. do not report these symptoms here as pain screening items, but we certainly should be aware of them and look at them in other areas. so, if we have someone who's rejecting care, maybe in section e, one of the other things we might want to do in section j is look at is at the pain part of why they're rejecting care. so for j0800 these are -- should be very familiar to you. we're going to check all of the pain that applies, so this is "check all." and we want to look at, based on the staff observation of an indicator of pain. and then we always have the option for check z if there's no indicators of pain that was observed. and
so, some of these indicators include the nonverbal sounds, the vocal complaints which we talked about, the facial expressions and then protecting those body parts. so, those are some of the indicators that we're going to be looking for. so, we have a couple scenarios here. mr. p. has advanced dementia and is unable to verbally communicate with the staff. a note in his medical record documents that he has been awake during the last night crying and rubbing his elbow. when you go into his room to interview the certified nursing assistant caring for him, you observe that mr. p. is grimacing and clenching his teeth. the cna reports that he has been moaning and saying "ouch," when she tried to move his
arm. so, mr. p. has demonstrated what? nonverbal sounds, right? he was crying and moaning. he gave a verbal complaint because he said, "ouch." you observed some facial grimacing and clenching of his teeth and he protected his body. so for him, what was he telling you? "i'm in pain, you know, by all of these." it was very clear he had all the indicators here for pain. so, we would check all that apply, and then we must look at the frequency of pain. so, that's the next question. so, we say, "all right, well they have these indicators of pain. now, we have to say the frequency. so, that's question j0850. and so we're going to - based on
evaluating treatment needs and response to treatment - we're going to look at information to aid and identify optimum timing of the treatment. we're going to talk to the staff and the direct caregivers, and then we're going to try to determine the number of days the resident either has complained or shown any of these symptoms of pain over that five-day period of time. so, is it a sudden onset with this elbow which it appears in that last 24 hours, in that last example, or is it something that's happening on a daily basis over that five-day period of time? so, what we want to try to do here - and this can be hard - we're going to try
to elicit, based off of our interviews and talking with staff and our own observations and looking at the medical record, did this - did this person have these indicators of pain one to two days; three to four days; or daily? and then we're going to go ahead - not code the number of times the indicators of pain were observed or documented. so again, this is not how many times we observed it but how many days. so, it's a five-day period of time. hopefully, staff will be able to give you the information or you've done a really good job documenting this in your medical record. so, you may want to think about, before i go on to falls history and i close out on pain, for the nonverbal indicators of pain,
some facilities have done a really nice job where they look on a regular basis to assess residents on the numeric scale, 0 to 10, and they do it either once a day or twice a day and they do it on some sort of regular basis. but, then there is no system or process in place to do that same assessment, or an equivalent assessment, for someone who is cognitively-impaired to be able to say how are we observing these people on whatever regular basis that we have so that we make sure capturing the pain and documenting it in the medical record. so, as you look at your systems and processes of care, you maybe want to take that into consideration when you go back to your organizations.
all right. so, we're done with pain and we're transitioning into the fall history on admission. so, this is a whole new section for mds 3.0 and it's a series of questions about falls, as we realize that falls is a major issue for us, and so we really want to make sure that we understand the history. so j1700 - they are the leading cause of injury, falls are; and, they are leading cause for morbidity and mortality in the older adult. we know that those that fall and fracture, let's say a hip, have a much larger -- greater increase of mortality in the older adult. a previous fall are the most important predictors of risk for future falls and injurious or injury from falls. so, the
history of falling in the past can be our best indicator that someone, potentially, could fall in our setting, right? it's the same way that if they've had a pressure ulcer, we learned yesterday, right? if they had a pressure ulcer, no matter what other assessments you've done, the fact they had a pressure ulcer tells what? they're at greater risk, right? kind of the same scenario here because we've had falls in the past, we at least need to know it's an issue or could potentially be an issue for us in our facilities. okay, persons with a history of falling may limit their activities because of the fear of falling and should be evaluated for reversible causes of falling;
and j1700 tracks a history of falls and fractures related to falls in the month prior to admission and the six months prior to admission. so, we really want to say how were they in the last 30 days, or calendar month, before they came in and then all the way back to six months prior to coming in to us. what is their history? and this is so common, and therapists i'm sure can talk to this at length with us, someone who had a fall in the past - man. they can be extremely afraid of moving or transferring or doing, and you have to kind of fight back that fear with them and have them work through it. try to figure out what we can do to put systems and processes in place so that we can say to them, "we are
going to make it as safe as possible for you to transfer, ambulate and prevent falls and you can feel confident and comfortable in that." so, the definition of a fall, because that's always important: it's the unintended change in position, coming to rest on the ground, floor or next to the next lower surface. so bed, chair, or to a bedside mat. it may be witnessed or it may be reported by the resident or identified by finding the resident on the floor or the ground. it may occur in any setting. it may occur in the home; out in the community; it may have happened in the acute care hospital or in the nursing home. and it's not the result of an overwhelming external force and
meaning that the fall -- we're not calling the fall as if someone, like, shoves the resident and they fall. so, we're not counting that - that the resident was pushed by another resident. please remember an intercepted fall occurs when the resident would have fallen if he or she had not caught himself or herself and had not been -- or had not been intercepted by another person. and please, remember that an intercepted fall is still considered a fall. so when we train on this, we need to make sure that staff understand the definition of a fall. so, if that person staggers and grabs the rail in the hallway and, you know, gets -- rights themselves. okay? in that situation, if
they hadn't been able to grab on to something, they probably would have, you know, ended up on the floor. they've intercepted. or if a staff member grabs them and helps right them, that is considered an intercepted fall; but, for our definitions here it is considered a fall. so, we have to make sure that staff understand that and that's defined quite, i think, well in the manual. so, when we're doing this j1700, we're really talking about the history. so, as the resident and family or significant others prior -- a month prior to the admission here had the resident had any falls, and then we're going back to six months prior to admission. we can look at inter-facility transfer information to
find out about that fall. so, hospital information if they're sharing with you. maybe they had a fall and that's what brought them into the emergency room, which then ended up with them being transferred into our nursing facility. so, we're going to review all relevant medical records from facilities where the resident resided in the six months prior to admission, if we have access to them, and we're going to review any other medical records for evidence of a fall. we are going to complete this item only for -- let's see what we started here. for an - alright, so let me fill in what that should say. that's obviously an
error in the slide. so, complete this item only for an admission assessment or the most recent assessment since admission. that's an important point. so, here for this item, please maybe fill this in. write this down. you're only going to complete j1700 if this is the admission assessment or the most recent assessment since admission. j1700a - it documents whether the resident had any falls in the month prior to admission to the facility and j1700b documents whether the resident had any falls in the two to six months prior to admission. so, again, trying to get that sense of the fall history. j1700c documents whether the resident had any fractures related to the falls in
the six months prior to admission. so we're asking did they fall one month prior, two to six months prior, and then, hey, in that whole six-month period did they have any fractures related to a fall? include any documented bone fractures in a problem list from a medical record, an x-ray report or by history from the resident or other caregiver. so, if they're telling you or they've sent you the x-ray results that occurred as a direct result of a fall that was recognized and later attributed to a fall. so, they didn't -- maybe they didn't know what happened initially and then they did further investigation and realized that it was related to a fall. do not include fractures caused by car
crashes, pedestrians versus car accidents or impact of person or objects against the resident. so, what they're trying to say here, if they were in a car crash, it was a trauma, we're not going to consider that a fall, right? so, we're not going to count those fractures here. we also are not going to include if someone pushed someone else and they had a fracture related to that shoving and pushing. it's like if they fell and fractured a wrist, we're not going count that. all right, j1700 we're going to code "no." there's no report of a documentation of a fall or a fracture due to falls. and then code "yes," if there's a report of documented falls with a fracture caused by the fall, or "9. unable to
determine," if a resident, family or significant other cannot provide information and documentation is inadequate. so, here's a situation where you know what? there's a fracture, but you don't have the history behind it and you really -- no one can tell what was related to that, so it's unknown. you can say it's a 9 here. we're unable to determine whether they had this fracture. okay, so here we have a scenario where we're looking at. on admission interview, ms. j. is asked about falls and she says, "well, i've not really fallen." however, she goes on to say that when she went shopping with her daughter about two week ago, her walker got tangled with the shopping cart and she slipped down
to the floor. so again, here's - here's semantics. she didn't consider it a fall, you know. she said, "oh, i slipped to the floor because you know, the walker and the carriage and blah, and yeah and i slipped to the floor. but i didn't fall." so, it's semantics. you really have to work through this to get this information from the resident. so j17a --1700a would be coded 1 as a "yes." the fall caused by slipping meets the definition of a fall, right? so, even though she didn't identify it as a fall, we were able to say based off of our definition and what she described, this would for the mds, be considered a fall, and we would code a 1 there.
all right, j1700. mrs. p. has a history of a colles' fracture of her left wrist about three weeks ago before her nursing home admission. her son recalls that the fracture occurred when mrs. p. tripped on a rug and fell forward on her outstretched hand. so, we would code j1700a -- would be coded as "yes," right? and c, because that's the question about fractures, would also be coded as "yes." and it was one month prior to her coming into the facility. so, let's look at this third scenario. so, mr. o.'s hospital transfer record includes a history of osteoporosis and vertebral compression fractures. the record does not mention falls, and mr. o. denies any history of falls. so, he's
got these compression fractures, but he also has osteoporosis and he's denying to us he's had any falls. so, j1700c would be coded as what? "no." okay? the fractures were not related to a fall, but let's say we didn't know. we were unsure. what else could we have coded this? as a 9, right? unknown. all right. so, that gives us -- those questions were the ones where we're talking about the history of the falls prior to coming into the nursing home and that's going to help inform our care plan and our care processes, and so hopefully we'll be able to put some systems in place to limit or mitigate some of the potential chance of someone falling.
but now we're going to move on to j1800 and j1900 and any falls and the number of falls. and this is looking since admission or prior assessment, whichever is more recent. so, if we're looking at -- since this is looking now -- now they're yours. now, they reside in your facility. so, from admission - we're not looking prior to coming in - from the point that they have entered into your facility to when you're doing the assessment or, if you've already had an assessment done, from when your new assessment back to the last assessment. all right? that's setting the tone for when this section is done. so, falls are the leading cause of -- we talked about that. they can result in serious injury and fear of
falling can limit activities. we already talked about all that. so, determine if any fall occurred during the look-back period and the level of injury for each fall. we're going to review medical record; we're going to review all available sources; and we're going to ask resident, family and significant others and talk to, you know, talk to the staff and figure out whether the resident had any falls. we are going to review the time period from the day after the ard of the last mds assessment to the ard of the current mds assessment. again, once we have that set - so, if the ard from my last assessment was october 10th, this -- now we're onto the next assessment. we're
going to look at october 11th to the current ard and that's going to set our time frame. all right? so, that's going to be hard when you're looking. it may take a little bit of time to figure out did that person have any falls during that time period. so review the time period since admission date and the ard, if this is the admission assessment. again, we already kind of talked about this. if this is the admission, we're going to the ard, we're just looking at that time frame or we do the other way, the day after the ard, if this is subsequent assessment to the most recent ard.
we're going to code falls that occurred in any setting and we're looking at community, nursing home or acute hospital. code falls reported by the resident, the family or significant others even if not documented in the medical record. we're going to code the level of injury for each fall that occurred during look-back period, and if the resident has multiple injuries in a single fall, code for the highest level of the injury. so, if they had a fall and they had some bruising, but they needed stitches or they had a fracture, we want to code for the highest level. looking at j1800, we are going to code whether the resident had any falls during
the look-back period; and if we code "no, the resident has not had any falls since the last assessment, we're going to skip right out of this, right? because there's no more information that we need and we're going to skip right to swallowing disorders, k0100 and your skip pattern is right on your form and it should be built into your software. if you code "yes," the resident has fallen since the last assessment, we're going to continue to looking at the number of falls since the admission of prior assessment, or whichever is more recent. so, here we're looking at j1800. an incident report describes an event in which mr. s. was walking down the hall and appeared to slip on a wet spot on the
floor. he lost his balance, he bumped into the wall, but was able to grab onto the handrail and to steady himself. you got that scenario? okay. so, j1800 we're saying, "any falls since admission or prior assessment, whichever is more recent." so, what would we say here? right? yes. right? because it was an intercepted fall, he helped himself but it was still what we considered an intercepted fall which equals a fall. all right. so the next scenario we have here is -- so, j1900 is, "number of falls since admission or prior assessment" coding instructions. enter a code for each of the items to indicate the number of falls resulting and the level of injury. code
the level of injury for each fall that occurred during the look-back period and code each fall only once. so, if you look at the items we have" a is "no injury"; b is "injury (except for major)"; and, then we have c which is major. and they describe them as major being bone fractures, joint dislocation, closed head injuries and altered consciousness or subdural hematoma. so, really you have the extreme of fractures and major issues, no injury and then everything else falls in between. all right? so, we have a scenario here. so, a nursing note states that mrs. k. slipped out of her wheelchair onto the floor while at the dining room table. before being
assisted back into her chair, an assessment was completed that indicated no injury. so, we would code j1900a as one fall with no injury, correct? so, she didn't have any injuries. so, the second one, you know -- she had no injuries, so it would be zero for the next one which is b, and she had no major injury. so, c would be zero. so, that was an easy one. she had one fall, no injury. so we're coding this there. so, now we have another scenario. a nursing note describes a resident who, while being treated for pneumonia, climbed over his bed rails and fell on to the floor. he had a cut over his left eye and some swelling of his arm. he was sent
to the emergency room where the x-ray revealed a fractured of his arm. neurologic checks revealed no change in his mental status. so, let's look at this. j1900c we're going to code as 1. he had one fall, and it had a major injury. the resident received multiple injuries in the fall, but we are going to code for the highest level of that injury and that was that fracture in his arm. so, code each fall for the highest level of severity and we're only going to code each fall once. so, we want to make sure -- you really don't want to start taking credit for like, you know, 30 falls, right? [laughs] unless they have 30 falls. so, you only want to take credit for each one of these. all right.
so section - section j, i think, the falls section there was -- i will tell you there was a -- an error in one of the versions of the manual that went out that talked about there was confusion with no injury, and injury falls and what happened is the word "non-injurious fall" was missing. so, we've corrected that. i can't remember whether that correction has gone out, but we had received a lot of comments on that and that was just a - a typo for us. but certainly, you know, we read this so much we know what it should say. sometimes we miss these things and, you know, we've had wonderful people like yourselves who have said to us, "no, you know, the manual is not correct." so, we went ahead and
corrected that; but i think this is going to be pretty simple. i think the hardest thing is think about, again, how do you make this work in your organization. if you have to look back 90 days, it could take a lot of review time to -- to do this. so, you may want to think about how do you capture these? it may be it will be easier to look at your a&i reporting system, and can you pull a report off that for your falls? if you have a way that you're doing all of your near -- you know, your intercepted falls are getting captured. think about how are you going to get this information without having to spend 45 minutes reading the medical record to get it. i don't have the answer for you,
but it -- maybe talk with your fellow mds coordinators and corporate people here and think about how other people are capturing this. because even though these are simple questions to answer, they could end up being -- taking a lot of time. so, i encourage you in this time period, between august and our implementation of october 1st, besides all the training that you need to do, this is your opportunity to put some systems and processes in place to make this an efficient system so that we're not wasting time. all right. thank you very much.