Section K Swallowing / Nutritional Status MDS 3.0 By: Shelly Proctor RN, RAC-CT Valley Vista Care

Objectives: State the intent of Section K. Describe the process for conducting a resident’s nutritional assessment. Calculate a resident’s weight change correctly. Code Section K of MDS 3.0 correctly. Determine Care Area Triggers.

Objectives continued: Describe the Care Area Assessment process. Explain resident centered care plans.

Intent of Section K: To assess conditions that could affect the resident’s ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. Nurse assessors should collaborate with the dietician and dietary staff to ensure that items in this section have been assessed and calculated accurately.

K0100: Swallowing Disorder Rationale: Safe swallowing ability can be affected by functional decline and several different disease processes. An alteration in a resident’s ability to swallow can result in choking &/or aspiration which can in turn, increase their risk for malnutrition, dehydration, and aspiration pneumonia.

Care Planning: Include provisions for monitoring the resident during mealtimes or other occasions when the resident consumes food &/or fluids. Additional evals necessary? Assess for s/s suggesting the swallowing disorder has not been successfully treated. Goal: Assist resident to maintain safe & effective swallow.

Assessment: Ask the resident Observe Interview staff Review the medical record

Coding Instructions: Check all that apply K0100A-Loss of liquids/solids from mouth when eating or drinking. K0100B-Holding food in mouth/cheeks or residual food in mouth after meals. K0100C-Coughing or choking during meals or when swallowing medications. K0100D-Complaints of difficulty or pain with swallowing. K0100Z-None of the above.

Coding Tips: Do not code when interventions have been successful. Do code even if the symptom happened only one time in the 7-day look-back period.

K0200: Height and Weight Rationale: Diminished nutritional and hydration status can lead to debility that can adversely affect a resident’s health and safety as well as their quality of life.

Care Planning: Knowing a resident’s height & weight helps staff to assess their nutrition & hydration status by providing a mechanism for monitoring the stability of their weight over a period of time. Knowing the weight is one guide for determining nutritional status.

Steps for assessment: K0200A-Height -Measure resident upon admission in inches. -Consistent measurements over time. -If last height recorded was > 1 year, re-measure.

Coding Instructions: Record to the nearest whole inch. Use mathematical rounding. -Example: 62.5 inches would be rounded to 63 inches.

Steps for assessment: K0200B-Weight -Weigh resident on admission. -For subsequent assessments, record weight taken w/in 30 days of the ARD. -If >30 days, re-weigh. -Record weight closest to ARD. -Measure consistently.

Coding Instructions: Use mathematical rounding. If weight cannot be obtained, use the standard no-information code (-) and document rationale in the medical record.

K0300: Weight Loss Rationale: Weight loss can result in debility and can adversely affect a resident’s safety, health, & quality of life. For those with morbid obesity, a controlled & careful weight loss plan can improve their mobility and overall health status. For persons with fluid overload, careful and safe diuresis can improve their health.

K0300: Weight Loss 5% 5% weight loss in 30 days: -Determine the resident’s weight closest to 30 days ago & multiply it by 0.95 or 95%. The resulting # represents a 5% loss from the weight 30 days ago. If the resident’s current weight is = to or < than the resulting #, the resident has lost more than 5% of his/her body weight.

K0300: Weight Loss 10% 10 % weight loss in 180 days -Determine the resident’s weight closest to 180 days ago & multiply it by 0.90 or 90%. This # represents a 10% loss from the weight 180 days ago. If the current weight is = to or < than the #, then the resident has lost 10% or more body weight.

Other Definitions: Physician Prescribed Weight Loss Regimen Body Mass Index (BMI)

Steps for assessment: This item compares the resident’s weight in the current observation period to his/her weight at two snapshots in time: -At a point closest to 30 days preceding the current weight. -At a point closest to 180 days preceding the current This item does NOT consider weight fluctuations outside of these two time points. A resident’s weight should still be monitored periodically and fluctuations assessed and care planned prn.

New Admission: Ask the resident or family about weight changes in past 30 days & 180 days. Consult with the MD. Review transfer documentation. If admit wt is < previous wt, calculate the loss. Complete the same process to determine and calculate wt loss comparing admission wt to wt 30 days ago & 180 days ago.

Subsequent Assessments

Coding Instruction Definitions: Mathematically round weights before doing the calculation. Code 0, no or unknown. Code 1, yes on physician-prescribed weight loss regimen. Code 2, yes, not on physician-prescribed weight loss regimen. Code 0: If the resident has not had a wt loss of 5% or > in past 30 days or 10% or > in past 180 days or if info about prior wt is not available. Code 1: If the resident has had a wt loss of 5% or > in past 30 days or 10% or > in past 180 days, & the wt loss was planned & in accordance w/ an MD order. Code 2: If the resident has had a wt loss of 5% in past 30 days or 10% or > in past 180 days & the wt loss was NOT planned &/or in accordance w/ an MD order.

Coding Tips

Example #1: Mrs. J has been on a physician ordered calorie-restricted diet for the past year. She & her physician agreed to a plan of weight reduction. Her current weight is 169#. Her weight 30 days ago was 172# & her weight 180 days ago was 192#. How should you code K0300?

Example #2: Ms. K underwent a BKA. Her preoperative weight 30 days ago was 130#. Her most recent postoperative weight is 102#. The amputated leg weighed 8#. Her weight 180 days ago was 125#. How should you code K0300?

K0500: Nutritional Approaches Rationale: Approaches that vary from the “norm” or that rely on alternative methods can diminish one’s sense of dignity & self-worth. They can also diminish pleasure in eating. A resident’s clinical condition may benefit from approaches included here. It is important to work with the resident/family to establish nutritional support goals that balance preference & overall clinical goals.

K0500 Nutritional Approaches

Care Planning: Alternative approaches should be monitored to validate effectiveness. Include periodic reevaluation.

Definitions: Parenteral/IV Feeding Feeding Tube Mechanically Altered Diet Therapeutic Diet

Steps for Assessment: Review the record to determine if any of the listed nutritional approaches were received by the resident during the 7-day look-back period.

Coding Instructions: K0500A, parenteral/IV feeding K0500B, feeding tube K0500C, mechanically altered diet K0500D, therapeutic diet K0500Z, none of the above

Coding Tips: K0500 includes any & all nutrition & hydration received by the nursing home resident in the last 7 days either at the nursing home, at the hospital as an outpatient or an inpatient, provided they were administered for nutrition or hydration.

Tips continued: Parental/IV feeding-The following fluids may be included when there is supporting documentation that reflects the need for add’l fluid intake specifically addressing a nutrition or hydration need: IV fluids or hyperalimentation, including TPN (continuous or intermittently). IV fluids running at KVO IV fluids contained in IV Piggybacks. Hypodermoclysis & subcutaneous ports in hydration therapy.

Do NOT code in K0500A: IV medications. IVF’s given solely for the purpose of “prevention” of dehydration. IVF’s given as a routine part of an operative or diagnostic procedure or recovery room stay. IVF’s given solely as flushes. Parenteral/IVF’s given in conjunction with chemo or dialysis.

Enteral Feeding Formulas: Should not be coded as a mechanically altered diet. Should only be coded as K0400D, Therapeutic Diet when the enteral formula is to manage problematic health conditions, (i.e.: enteral formulas specific to diabetics).

Examples

K0700: Percent Intake by Artificial Route Complete only if K0500A or K0500B is checked. Otherwise, skip to Section L.

Rationale: Health-related Quality of Life. Care Planning.

Steps for assessment (K0700A): Proportion of Total Calories through Parenteral or TF in last 7 days Review intake records. Determine actual intake through parenteral or tube feeding routes. Calculate proportion of total calories through these routes. If no food/fluids via mouth or only sips, stop here & code 3, 51% or >. If resident had more substantial oral intake than this, consult with the RD.

Coding Instructions: 25% or less 26% to 50% 51% or more Select the best response: 25% or less 26% to 50% 51% or more

Calculate Proportion of Total Calories from IV or TF: Dietician reported calories/day below: Oral Tube Sunday 500 2,000 Monday 250 2,250 Tuesday 250 2,250 Wednesday 350 2,250 Thursday 500 2,000 Friday 250 2,250 Saturday 350 2,000

How should you code K0700A? Answer? Review calculation Rationale

K0700B: Average fluid intake/day by IV or TF in the past 7 days. Review intake records. Add up total amt of fluid rec’d each day by IV or TF only. Divide the week’s total fluid intake by 7 to calculate the average fluid intake/day. Divide by 7 even if the resident didn’t receive IVF’s &/or TF on each of the 7 days.

Coding Instructions: Code 1: 500 cc/day or less Code 2: 501 cc/day or more

Example: Ms. A has swallowing difficulties secondary to Huntington’s disease. She is able to take oral fluids by mouth w/ supervision, but not enough to maintain hydration. She received the following daily fluid totals by supplemental tube feedings (including water, prepared nutritional supplements, juices) during the last 7 days.

Example continued: Sunday: 1250cc Monday: 775cc Tuesday: 925cc Wednesday: 1200cc Thursday: 1200cc Friday: 500cc Saturday: 450cc Total: 6,300cc

Calculate her average daily fluid intake for K0700B: Calculation: 6300 / 7 = 900cc/day * Because 900cc is > than 500cc, you should code 2, 501cc/day or more.

Care Area Triggers (CAT’s): Review Nutritional Status triggers. Review CAT Legend.

Care Area Assessments (CAA’s): Refer to Chapter 4 & Appendix C of the RAI Manual. Specific Resources. General Resources.

CAA’s continued: “…nursing homes should ensure that whatever assessment and care planning resources are used are current, evidence-based or expert-endorsed research and clinical practice guidelines/resources.” Appendix C, RAI Manual, 3.0 Version, June 2010

Transitioning MDS 2.0 to MDS 3.0

Questions?

Sources CMS MDS 3.0 Information Site www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage