Senin, 31 Juli 2017

osteoporosis reversible

osteoporosis reversible

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 a� 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.

osteoporosis reversal

osteoporosis reversal

hi i'm paula moore the posture doctor talkingtoday about forward head posture and the effects on the ageing process. forward head postureis the leaning of the head relative to our shoulders. it's not the same as a dowager'shump. a dowager's hump is something we see between the shoulder blades and it is a resultof a disease called osteoporosis, where the person has actually fractured some vertebrain their spine giving them a wedged posture. that is a real dowager's hump. the hump thatwe are talking about with forward head posture is the bit of skin that you may have seenon your mother. that is the body's way of protecting the area. as the head comes forward,the body lays down more fat in this area because it perceives more risk to the spinal cord.that is the way i describe it to my posture

pupils. naturally life tends to pull us forward.everything we do-reading books, working on the computer, writing, washing up, runninga bath, washing our hair. always leaning forward. over the decades we see more of this postureif it is not worked on. the more pronounced the forward head leaning, the more devastatingthe health effects. i have seen thousands of patients over a number of years and itis no coincidence that the ones with more pronounced forward head leaning are usuallythe ones on a cocktail of medications. what i like to do with this corrective postureis to hook my hands into a web and anchor them over the belt-line area of your trousers.use them as a lever to help you stand tall. it's not a military posture it's a lengtheningposture. think about a balloon attached to

your chest and head, lengthening you. it feelsgood. see if you can lengthen you head toward the ceiling. feel your posture taller. feelthe weight go back over your big toe, your little toe and your heel. those three pointsshould be holding the weight of your body equally. don't lean back onto your heels orup on your tip toes like you are wearing heels. as you go up into that tall posture, you aregoing to tuck your chin in. not looking down but sliding your chin backwards to bring yourear lobe back over your shoulders. breath in, go tall and tuck in. i'm quite flexibleso you can see that my head goes back a long way. i have been doing these for years. someof you may be so stiff, your head doesn't seem to move at all. if that is the case andyou are older, you will probably find you

have more stiffness and need to use a wallto help you. when you do that, you simply let your head touch the wall. now by the way,if you have to lift your chin to get your head to touch the wall you have already gotfairly advanced forward head leaning and you probably need to see a health professionalto get the joints moving again before you can do this exercise. so for those who area little stiffer you put your head against the wall and tuck the chin right back in andhold. when you relax you will notice your head spring forward. you can use two fingers to tuck in, relax, tuck in, relax. watch myshoulder blades. they go from being a little bit round to really straight and you may evenhear a little 'click' in the spine when the

vertebrae release some gas. do ten in a row,holder each for two or three seconds. do this four times a day. i wouldn't start with thatas you may get a little sore. start with three, four or five in a row, four times a day. youmay need to use the wall when you start out. the downside of using the wall is that youcan only tuck your chin in so far. when you are free-standing you can tuck you chin inbeyond correction so you get more benefit from the exercise. give that a try and letme know how you are getting on. i hope you really enjoy that, it is a great exercisethat i do every day.

osteoporosis research

osteoporosis research

the skeleton is made up of bones, which provide support and shape to the body. they protect soft internal organs, such as the brain, and heart, from injury. together with muscles, strong bones enable the body to move freely. bones have a solid outer surface, called compact bone. the inner bone is called spongy bone, because it is less dense than compact bone, and has many small holes like a sponge. bones contain cells called osteoclasts that break down bone tissue. other cells, called osteoblasts, make new bone tissue using minerals, such as calcium and phosphate, from the blood. hormones, such as estrogen, growth hormone, and testosterone,

help keep the number and activity of osteoblasts higher than osteoclasts so that more bone is made than removed. physical forces and pressure during exercise also help bones to grow stronger and denser. these processes allow bones to grow strong in children and young adults. people have their strongest, most dense bones, called peak bone mass, in their thirties. after this age, osteoclasts gradually remove more bone than the osteoblasts make. osteoporosis is a condition that leads to weakened bones, causing them to break more easily. healthy bone is dense enough to support and protect the body, and to handle the stresses of movement and minor injuries. however, people with osteoporosis have abnormally thin bones with larger holes in the spongy bone. there are two types of osteoporosis.

primary osteoporosis is usually related to older age, as well as a reduced amount of estrogen in women. secondary osteoporosis affects both children and adults. it is related to other diseases or conditions, such as cancer, hormone problems, or use of certain medications. a person has a greater risk for either type of osteoporosis if they don’t develop enough bone mass when they are growing from childhood to adulthood. risk factors that can lead to low peak bone mass include: a family history of osteoporosis, being white or asian, being female,

a poor diet, certain medications, such as steroids or certain seizure medicines, lack of physical activity and weight-bearing exercise, and lifestyle behaviors, such as smoking and drinking too much alcohol. a person also has a greater risk for either type of osteoporosis if they have an abnormal amount of bone loss after age thirty. some bone loss is normal after this age. however, a person with the same risk factors for low peak bone mass can be more likely to get osteoporosis as they age. increased bone loss is also common in women after the time of a woman’s last period, called menopause. after menopause, a woman’s ovaries stop making the hormone estrogen.

with the drop in hormones, bone-removing cells, called osteoclasts, are more active than the bone-making cells, called osteoblasts. bones may break, or fracture, easily because they are unable to withstand the physical strain and pressure from even normal activities. common fracture locations in people with osteoporosis include the wrists, spine, and hips. building strong, healthy bones through a diet rich in calcium and vitamins, and getting regular exercise, can help prevent as well as treat osteoporosis. common medications for osteoporosis include: biophosphonates,

a medication called denosumab, selective estrogen receptor modulators, or serms, and calcitonin. in general, these medications act on bone-removing cells, called osteoclasts. parathyroid hormone acts on bone-making cells, called osteoblasts. food or supplements containing calcium and vitamin d are also recommended for osteoporosis. for more information, talk to a health care professional.

osteoporosis prognosis

osteoporosis prognosis

back surgery for osteoporosis. osteoporosis complications prevention. dr. anton titov, md: osteoporosis is a very big problem, especially in the aging population. in your practice you see effects of osteoporosis, the compression fractures. how should people prevent osteoporosis? how to treat osteoporosis? what advice you give to patients regarding this very common condition? dr. eric woodard: sure. osteoporosis can be a very challenging problem for spine surgery. in general, osteoporosis, as you know, is a complicated process. in osteoporosis the bone loses its mineral contents. the bone loses its calcium content. this can be on a genetic basis individually. it can be on the basis of genetic ancestry. typically the scandinavians and the northern europeans are much more prone to osteoporosis than southern europeans or latin americans. so there's clearly a genetic predisposition toward developing osteoporosis. your bones take on and accumulate calcium and phosphate at approximately constant rate to about age 30. and then you slowly lose mineral at a fixed rate. some of this is hormone-based, as you know. and in women once the hormonal changes at menopause occur, they will have an abrupt increase in the rate of loss of mineral of their bone. since the curves are relatively similar in their shape, clearly the higher the mineral content you can achieve up to age thirty, the higher relative amount of mineral you'll have when your age is 60...70...80. so this is the reason behind a strong recommendations and in children and teens and young adults to maximize their nutrition. especially with regard to taking calcium. typically this is done with dairy milk products, things like that. certainly nutritionally depleted or nutritionally deficient individuals in their youth will have higher risk for osteoporosis later. osteoporosis can be devastating in the elderly population who fall below certain thresholds in the spine especially.

dr. eric woodard, md: and this is most typically at the highest stress points in the spine, the midpoint of the thoracic spine, for instance. the vertebrae nearly collapse due to mechanical failure. and when they collapse obviously there is a tremendous amount of associated pain which can be debilitating. in rare cases the collapse associated with narrowing or cord compression. this can be devastating from a neurological standpoint. in recent years there has been a lot of interest in treating osteoporosis aggressively. treatment includes injection of various types of cement into the fracture. or even reducing or essentially re-inflating the vertebrate with percutaneous or needle-based balloons. the cavity is then filled with some cement. that is called a vertebroplasty procedure or a kyphoplasty procedure. both these have been around for a number of years now. vertebroplasty and kyphoplasty are widely practiced. now, just like any treatment, it's only is good until you study it rigorously. some of the more recent rigorous outcome studies have shown only marginal and transient benefit of both vertebroplasty or kyphoplasty. so that it's more of an option rather than a recommendation for folks who have severe symptomatic osteoporosis related fractures. osteoporosis is a particular challenge in folks that have other spine pathologies. especially in patients who we are considering for surgery. we talked about spine surgery indications for deformity, stenosis, and spondylolisthesis. to do standard surgical procedures on these folks with osteoporosis challenges us. because the typical fixation devices that we use for a standard patient prove inadequate in patients with osteoporosis. screws don't hold, many times we have to spread out the stress and make the constructs stronger or even longer. so that there's a mechanical advantage in this very poor area. it is very thin bone that will not hold screws, for instance. dr. eric woodard, md: so osteoporosis is increasing, it's a challenge, it needs to be prevented ideally, and there are a number of options, both surgical and non surgical treatment of these maladies.

osteoporosis prevention

osteoporosis prevention

today i thought we'd do some exercises specificallyfor the middle part of your back. this region here. you might have heard or been told yourback density has decreased. now these are great exercises to try to help prevent fracturesthrough that middle part of your spine and help to stop that slumping that can actuallyaccompany those types of fractures. so i'm going to show you three great middleback strength exercises that you can do, simply using some dumbbells i'm sitting on a stooltoday you could use a fitball or a bench. whatever is comfortable or whatever you haveaccess to at home. remember that when you're performing osteoporosisexercises it's really important that you don't feel any discomfort during the exercise. youshould feel muscles working and that's all.

if you feel any pain with the exercise youneed to stop straightaway. remember too that if you already have established osteoporosisit's important that you get your doctor's approval before you perform some exercisesand also too it's the same thing the same case applies if you haven't exercised previously.so remember these exercises are also for women who have pelvic floor issues. and when wehave pelvic floor issues, remember (and osteoporosis) we can't perform high-impact exercise, whichis often advocated to address bone density. this is where resistance-training exerciseis ideal to use the muscles that support and attach to that middle part of your spine.those muscles that are supported through here, and your core muscles as well that actuallysupport your spine these are the muscles

that we're after. and doing these exercisesseated in the positions i show you are very safe for your pelvic floor as well as safeexercises for your bones. all right, let's start with posture. postureis very important in order to address, or to prevent that slumped forward posture thatcan occur. you need to start to use those muscles in the middle part of your back. howdo you do that? i think i'll sit side on to demonstrate this best. so, sitting side-onto you, when you sit, have your weight evenly balanced between your sit bones. the actionthen is to lift your chest as if you're being drawn up by a string from your sternum, upat about 45. your shoulders are back and down, so the action to bring your shouldersback isn't correct because you'll use your

neck muscles. bring your shoulders back anddown, draw your chest up. also too, think of a long tall spine as if you're being liftedup by a string from the crown of your head towards the ceiling. so, you're thinking tall,and you're thinking chest is lifted. so that position, front on, looks like this andit's really worth practicing that posture regularly throughout the day whenever you'resitting. shoulders back and down, chest lifted, spine nice and tall. and that way you'll beusing the muscles in the middle of your back also be using your core muscles or yourcore muscles can be used a lot more effectively (those muscles that support your truck.)all right, we're going to use that posture for our first exercise this is called rotatorcuff but it's also a great exercise not only

for the back of your shoulders but also forthe middle part of your back. you'll need two dumbbells or two weights�you could usea couple of tins from out of the cupboard at home. i'm going to use a couple of onekilo dumbbells to start with. make sure when you start your bone density exercise (forthe first couple of weeks while you become accustomed to the exercise) that you're usinga weight that feels comfortable until you can get some really good form. after thatyou can start to increase the weight you're lifting. and remember that research tellsus that for bone health, we should be doing two lots of eight of a heavy weight to reallystimulate that bone growth. so here we go: i'm going to use the weightsabout navel height. my chest is lifted my

shoulders back and down, my spine is niceand tall. here's the action: the action is to take the weights back and bring the weightsback together. can you see i'm keeping my elbows into my waist? i'm not moving them andback. now if you're doing these exercises really well at home, you can look in the mirrorand you can see your shoulders actually move down, now, as the weights go out. so no pressureon my neck and shoulders or upper part of my neck and back together. and slow andsteady i'm going to do three more squeezing my shoulder blades together as if i'm takingmy shoulder blades toward the middle part of my spine. two more slow and steady, andone more time squeezing my shoulder blades together, and down. bring my weights down,give my shoulders a big roll. take any tension

out of my neck and shoulders and if you'reat home, and performing this exercise for your mid-back density, i'd repeat that exerciseagain another lot of eight repetitions for today. remember you should be doing thosetwo to three times a week, on alternative days.all right, next exercise is called a low dumbbell row. this is the way you do this exercise.you might like to use a slightly heavier weight for this exercise. i'm going to use a twokilo weight. so i'm getting my two kilo weight position is, using your bench (or using yourchair, or you could do this on a fitball as well) i'm going to bring a knee up to supportmy back and bring my other hand forward. so i've got my weight in my left hand, and i'vegot my right hand supported on the chair or

the bench. i'm going to put a little bendin that elbow, so that there's no pressure or undue pressure into that right shoulder inmy neck. side-on to you, you can see that i've got an inward curve in my back. my backisn't arched up. my curve is neutral or inward. i bring the weight down along my thing andwhen you do this exercise correctly, you scoop the weight along the line of your thigh andback down. you're really thinking about bringing your shoulder blade in towards your spine,and take it back down; so it's a real scooping action. sometimes you'll see the exercisedone like this, lifting the weight up close. that exercise tends to use your neck and shouldersand often you'll get sore neck and shoulders from doing that exercise incorrectly. to doit really effectively and to do it pain-free

for your neck and shoulders, scoop it alongand down. and if you're checking in a mirror at home, side-on to the mirror so you canjust turn your head and then see what you're doing again, to protect your neck. i thinki'm up to about five repetitions here let's try for three more. skipping up, lifting itand down. and again i'm really bringing that shoulder blade in towards my spine, and down.and one last time, and down. let's try that again on the other side.coming up slowly, move 'round to the other side so you can see what i'm doing andagain check my position, my opposite knee this time my left knee's up. my left hand's onmy chair on my stool. weight in my right hand and again i'm going to do that scoopingaction. again i've got a bend in that left

elbow. here we go: so, scooping the weightalong my thigh, and down, slow and steady, breathing out as i lift the weight. againthat's protecting my pelvic floor (breathing out as i lift the weight.) and i'm in a greatposition for my pelvic floor; no strain in that area while i'm doing this exercise. thisis number five i think it will be four or five and down. we'll call that six, hey?lifting up and sliding down. two to go, full range of movement bringing your elbow back,and down. and one last time and down and again. just taking some pressure off my neck andshoulders. do some shoulder circles. no pressure through neck and shoulders. and once againif you're doing that at home, repeat the exercise again both sides.all right, the final exercise we're going

to do for our mid-part of our back is calleda push-back exercise. terrific exercise for posture, terrific exercise for middle partof your back. now, this exercise you probably want to use a lighter set of weights. i'mgoing to use a couple of sets of or, a set of 500 grams. so, two 500 gram weights. i'lldo this in kneeling so you can see what i'm doing. this exercise can be done in kneelingand lying down on your tummy. some of us don't like to lie on our tummy. if you feel comfortablelying on your tummy, i'll show you this same exercise next time in that position. firstof all, let's start this exercise in kneeling. so i've got my two 500 gram weights. againyou could use some 500 gram tins, or even bags of sugar or flour (whatever you'd liketo use.) one leg comes forward. chest comes

over that thigh so my back is supported. takethe weights, take your palms towards the ceiling. make your arms really long. in that position,tuck your chin in and you're ready to press back and the press back action is to takeyour hands back, push your chest out as you lift and slowly down. so i'm really squeezingmy shoulder blades together towards the spine. lifting up squeezing it, and down. and againsqueeze and lift. again if you're doing this at home, wise to be side-on to a mirror tocheck what you're doing. and turn your head sidewards if you need to to have a look.lifting up, and down. let's do two more. lift and squeeze, and down and one more time,and down, and take a break.