Top Three Crucial Data Points from the MDS About Pressure Injuries
Are you missing key data on pressure injuries? Discover the top three crucial MDS data points that could change everything! In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Amy Swinehart to talk about these essential data points, helping families ensure their loved ones receive the best care.
Schenk: Critical data points on the MDS as they relate to pressure injuries. Stick around.
Hey out there, welcome back to the nursing home abuse podcast. My name is Rob. I will be your host for this episode. We’re going to be talking about not just the MDS assessment, which we’ve talked about before, but the specific portions of the MDS that have to do with pressure injury development and pressure injury treatment, but we’re not doing that alone. We have the fantastic Amy Swinehart legal nurse consultant extraordinaire with us today.
Now let’s get into the meat and potatoes of the episode. I have absolutely nothing bad to say about Amy Swinehart. She is a lifesaver. She is my go to legal nurse consultant. If you follow her on LinkedIn, her LinkedIn is amazing. It’s very educational. She is nursing home regulations through and through.
So I’m so happy that she’s on today to talk with us. Okay. Enough of that. Amy Swinehart’s journey in nursing home care started 20 years ago as a CNA while attending nursing school throughout college. She worked in various roles, including CNA, restorative aid, and medication tech. But post-graduation, she progressed from a floor nurse to director of nursing and nursing homes.
Since 2018, Amy collaborates with attorneys nationwide, reviewing medical records, crafting work product reports, and offering litigation support. Amy, welcome to the show.
Swinehart:
Nice to be here.
What is the MDS?
Schenk:
I’m so happy that you’re on the show. Like, I can’t speak more highly of you. You are the best you actually are, and again, like I typically try not to do commercials, but you are my go to legal nurse consultant.
Anybody out there, Amy is the best. Okay. Let’s get that out of the way. All right. Today I wanted to talk to you specifically because you’re one of the few people that I know that has read the entire REI manual from cover to cover as well as a watermelon book from cover to cover, which you have in the background like I do.
So you’re the best person that I know to talk about the specific subject, which is to say how, what is the MDS, meaning the minimum data sets? And what can we learn about what the nursing home knows about the resident’s skin integrity? So with that being said let’s hop into it. The first thing is can you tell us just from a 40,000 foot view, what is MDS?
Swinehart:
So it’s a way for the facility to collect data, to get a bird’s eye view of the patient’s overall status. It actually qualifies as a comprehensive assessment and it’s one of the many assessments that are used in the nursing home.
Schenk:
And you’re not fooling around, like the MDS in my experience is, it seems like a bear, but It’s very, you can approach it cause it’s computerized and every, it’s always the same.
Like it looks the same from every nursing home. So it can be easy in that respect. So I recommend, I’m not saying everybody go out and be an Amy, but if you have a loved one in a nursing home and you request records, the MDS shouldn’t be something that completely scares you off. So if I hear you correctly, the MDS is essentially a part of an overall comprehensive assessment of the resident.
Okay. And that, that would be everything from the residents cognitive capacity to all the way down to their plans. When they’re going to get out of the nursing home if they ever get out of the nursing home.
Swinehart:
Yes. Yes. There’s a number of different care areas that are investigated with it. Skin cognition, toileting, nutrition, basically everything that could possibly prompt the development of a care plan.
How is information on the MDS obtained?
Schenk:
So the MDS, in a way, is the process of assessment and then the actual assessment itself. So talk to me about it. That process of how the nursing home actually gets the data that goes into the MDS.
Swinehart:
What’s important to remember with the MDS is that every section has a look back period. When you’re looking at the results of the assessment, the look back period will tell you what information that person has.
We’re what time frame that information represents. So for instance, if it’s a seven day look back, then the answers to those questions are going to be for the last seven days. What is the answer to this question? And the assessment itself fits into the overall picture. In nursing homes the most fundamental concept or standard when it comes to care is the nursing process.
And it’s also called ADPI the assessment, the, the MDS is the A, it’s the start of that process.
Schenk:
So then tell me then, so we have for the most part, we have typically, although there are some that are shorter, a seven day period in which the resident is observed. But is it possible?
Again, let me make this question better. Like, how is the information received for the MDS, is the person doing the MDS looking at medical records, looking at the resident, looking at both. Tell us about that.
Swinehart:
So I think all the sections on the MDS with the exception of cognition and pain are things that involve a look back period things that are gathered from the medical record.
In fact, there’s certain criteria on the MDS, if you don’t see this in the record, you can’t capture that. So the large majority of things are involved in a record review and then the MDS nurse themselves will usually do a pain interview and then the cognition interview. Social services might do it, but that’s done at the time of the assessment.
Schenk:
So in short, it’s possible that in some of the sections, and when we say sections, it’s like a section, a certain section might be cognitive capacity. Another section might be hydration and nutrition. Another section might be skin integrity. It’s possible then that the individual that is conducting the coronal cord assessment, the MDS assessment that actually fills out these, this individual’s diagnosis what’s going on with them, it’s possible that they’ve never laid eyes on that person. Just looking at the records.
Swinehart:
Yeah, I guess in theory, yeah. Yeah,
Schenk:
But I can see by your face that’s probably not recommended.
Swinehart:
I’ve never met an MDS nurse that didn’t, wasn’t hands on with it. And at the very least, the MDS nurse is the person the resident will associate with the bit. We’ll get to that when we talk about the different sections, but I have had the experience where MDS nurses will be walking down the hall and the residents will just start shouting “sock blue bed” because they know that’s the lady who always does their cognitive interview.
Top Data Points about pressure injuries
Schenk:
Right? That’s, yeah it’s the BIMS lady. Yeah. Sock. I gotcha. Okay. Primarily the data hopefully is being gathered by not just records, but observation. So now let’s talk about that. You mentioned that. So let’s talk about what are some of the different sections of the MDS that are important.
Swinehart:
Particularly when talking about pressure injuries, is that what we want to?
Schenk:
Yeah, let’s go into that one. That’s great.
Cognition
Swinehart:
Okay. So section C that’s cognition. That is pretty much a no brainer. No matter what case type we’re looking at, you want to get a sense of what the resident’s cognitive status is. The BIMS is a numeric scoring of their cognitive status zero to 15.
And then the values tell you where they stand cognitively. So if you have a result that’s 13 to 15, that would mean that the patient’s cognitively intact. If the BIM score was 8 to 12, that would mean that they’ve got moderate impairment. And then under 8 would be severe cognitive impairment.
And it’s really important when you think about the different elements of a care plan. You don’t want to have clinically inappropriate interventions on there, like reminding a resident who’s severely cognitively impaired to turn and reposition themselves when their BIMS is three. So starting with that, so you have an idea of what their cognitive status is helps when evaluating whether or not the care plan was appropriate.
Schenk:
And just for the everybody out there when we’re saying BIMS, that’s an acronym for, what is it?
Swinehart:
Brief Interview for Mental Status. I had to look.
Schenk:
I always get the brief part right. So it’s brief and that is one that you mentioned earlier. That’s one that you can’t look at records.
That one, that’s one that you have to actually go and somebody has got to look at this person and conduct the interview, which part of the BIMS is to say three different words and see if they can say them back to you essentially.
Swinehart:
Yeah. You give them the words at the beginning of the interview, have them repeat it back.
And then later after you’ve asked them other questions, you go back and see if they could still remember those words.
Schenk:
Okay, so that’s section C. Now, what are some other sections, if any, that might be important or related to skin integrity?
Behaviors and Rejection of Care
Swinehart:
Going just in order of the MDS, the next one that I would stop and look at would be section E, which is where they capture behaviors, but they also capture rejection of care. So that will tell you whether or not in the last seven days the patient had any episodes of rejecting care necessary to achieve their health goals is the verbiage that they use there.
Schenk:
And why is that important? Like, why does it matter whether or not somebody is declining care?
Swinehart:
Yeah first, when you develop the care plan has a goal, and hypothetically for a wound case, the goal might be to prevent wounds from developing, while if the patient is rejecting care necessary to achieve that goal then it would be relevant because the staff can only do so much.
They can’t force the residents to do things that they don’t want to do and if the resident doesn’t want to do the things necessary to maintain their skin integrity, that’s their right, but it triggers some requirements for care planning, physician notification, and things like that, so that’s important to know when you’re looking at a pressure ulcer case, whether or not patient noncompliance is going to be a factor.
Schenk:
Because at the end of the day, we have to assess, we have to understand why the care is being declined. Is it from is it truly a choice or is it something that has to do with an underlying pain, mental issue, privacy issue, that kind of stuff. And then you would think of alternatives to whatever that intervention they’re declining would be.
Okay. Okay, go ahead. Oh, sorry.
Swinehart:
I was going to say that’s a good point because, if they’re rejecting, say the turning and repositioning, say they don’t want to be turned and repositioned at night while they’re sleeping because of sleep preferences the facility could upgrade the air mattress to a really high quality air mattress to help mitigate some of the lack of pressure reduction that would occur because the patient doesn’t want to be disturbed.
And so getting to the root cause of why that rejection is occurring when you can is really necessary for developing a good care plan.
Schenk:
Exactly. All right, so we have non compliance that’s important to understand whether or not we’re dealing with. trying to find alternative interventions.
What’s next? What else do we got? What other sections?
Bed Mobility
Swinehart:
G, that one you got to look at, everyone too. Particularly when pressure ulcer cases knowing their functional status is going to be really important because the care plan interventions that you put into place need to be appropriate for wherever they’re at.
So if the patient is totally dependent on two staff members for bed mobility, then your intervention is going to look a little bit different than somebody who can reposition independently. So in section G there’s a variety of different functional statuses that are assessed bed mobility, transfers, eating, dressing, hygiene.
So knowing just how much of that the patient is able to do for themselves and how much the staff need to pitch in for the development of the care plan is really important.
Schenk:
And I might be completely making this up, but number one, you have an excellent LinkedIn presence. Like everybody, if you’re on LinkedIn, go check out Amy’s LinkedIn’s.
They’re always highly informative. There was one post that you made, and I can’t remember it again, I’m probably getting this wrong. But it has to do with, you’re saying that checking the turning and repositioning, which we’ll get to in section M, is different from bed mobility, which is checked in section G.
Did I get that right? What, can you tell me what do you mean by that? Like, why are those two things different?
Swinehart:
The definition of, if you go to the RAI manual, the definition of bed mobility is how a resident moves in bed, not if or when. Bed mobility is one of the ADLs that is captured on the MDS, but it gives you no information about whether or not the patient was routinely turned and repositioned for pressure reduction.
It just tells you how they perform bed mobility. So going back some years when I first started, I was a CNA and so I was the one doing the ADL documentation, and I could show you. chart, bed mobility on a patient. If I had only gone into that room one time and repositioned them in bed one time, say for a brief change or something like that is enough for you to go and write down bed mobility, but it certainly doesn’t mean that the patient was repositioned, appropriately for pressure reduction.
Schenk:
I see. I see. Okay. So anything else before we leave section G that you think is important other than that bed mobility?
Swinehart:
No, that’s the main one there.
Toileting
Schenk:
Okay. So what do we got next? Is it, are we coming up on, I don’t know, hydration? What do you, what else is next here?
Swinehart:
H would be next, that’s toileting.
So if the person’s incontinent looking to see whether or not the facility has attempted a toileting program, whether or not there was any efforts made to restore continents, that’s great for skin integrity, obviously reducing contamination like that would be. But…
Schenk:
Wait, hang on. Let’s not say obviously.
Why is it that no, you’re good. Why is it that it’s important to manage incontinence of residents as it relates to skin integrity. What, why are these two things together and related?
Swinehart:
Yeah. So a lot of times, particularly when the resident is maybe short term rehab, they’ve got some functional issues that keep them from being able to toilet independently.
Cognitively, they may be aware that they have to go to the bathroom, but functionally they can’t get there unless somebody’s helping them. So being able to identify those residents who need assistance routinely to get to the bathroom to maintain their continents is going to help keep their skin clean.
It’s going to help keep the urine and the feces off of their skin. skin. And if for some reason they did end up having an open area, that would be really critical because it could lead to wound infections and deterioration of the wound.
Schenk:
I see. Okay. All so leaving incontinent care, what’s next on our list?
Nutrition
Swinehart:
That’s section K, which is nutrition. Primarily looking at weight. CMS has some parameters for what qualifies as significant weight variances. So if the person were to lose more than 5 percent of their body weight in 30 days, they would have to check that there was a significant weight loss, and then that would trigger the care plan.
And then it also just gives you an idea of what their weight was said on admission or at various points in time throughout their residency. So you can look at yourself to see whether or not there were weight changes.
Schenk:
Okay. So let’s bridge that gap again. What does weight have to do with skin integrity?
How are these two things related?
Swinehart:
Sure. The body needs certain nutrients to be able to maintain skin status and heal like small insults to the skin protein, different nutrients. So weight is an indicator of whether or not the patient is getting all of the nutrients that they need to be able to maintain their skin integrity.
Schenk:
Yeah, I see. Okay. Now we’re going past K where are we at now?
Skin Integrity
Swinehart:
We should be to M now, that’s the big one. And…
Schenk:
M is the one, M is skin integrity. M is the one. Alright, let’s do this, let’s do Section M.
Swinehart:
It starts off by asking whether or not the patient is at risk for skin breakdown. That pulls from the Braden assessment, was it done on admission, quarterly, is the patient at risk for breakdown? For skin breakdown.
And then if they are or then the next question would be whether or not the person has any existing pressure ulcers, and then it gets into what, okay, if they do what types of ulcers are there? Are they unstageable, stage one, stage two? And you have to document the number of those wounds that they have.
Schenk:
You mentioned the risk level for the development of the pressure injury. And then you mentioned the Braden cale briefly. What is the Braden scale and what are some of the characteristics that the Brayden scale is trying to catch?
Swinehart:
The Braden scale looks at a couple of different risk areas or a few different risk areas that will increase a resident’s risk for pressure for skin breakdown.
So it looks at nutrition. It looks at functional status. It looks at their sensation and whether or not they can feel, when something starts to hurt because they haven’t been moved. And then it calculates a score and determines, on a spectrum, how high risk is this person for developing pressure ulcers.
Schenk:
And I don’t want to tell you what to do, but I would love to talk about it, I think it’s M 1400. The interventions, right? Or is it?
Swinehart:
Yeah.
Schenk:
Okay. So there’s a section under M where we talk about if the record reflects it, or if after observation during the look back period, the resident requires different interventions based on the risk of the pressure injury development, or if the resident already has a pressure injury.
So what are some of those things that are listed and what does it mean if they’re checked off?
Swinehart:
Sure. First it looks at pressure reduction devices for chairs or beds. I think that can be a little bit misleading because sometimes when people see a pressure ulcer or pressure reduction device for bed, they automatically think that’s like an air mattress or something when really a standard foam mattress can be pressure reducing.
And I’ve never worked in a facility where every mattress in the entire facility was not pressure reducing. So that box is almost always checked. Same thing with wheelchair cushions. It’s pretty standard to have a cushion in somebody’s chair. There’s different degrees of. of quality in those cushions.
Some are better at offloading, some are not. And then it looks at the application of ointment treatments. And then one of my favorite ones to look at is the turning and repositioning program and whether or not that’s selected on the MDS.
Schenk:
All right. So let’s hone in on that. And again, to paint the picture, maybe I’ll have a graphic up, but on the MDS under section M there’s a section it’s M 1400.
It lists interventions that the record should reflect is in place. One of those is turning and repositioning program. So what does it mean if that is checked off? Meaning that the resident is on a turning and repositioning program. As it relates to the REI Manual in the MDS Assessment.
Swinehart:
Yeah. So an MDS nurse cannot select the turning and repositioning program unless certain elements are in place. One of the elements is that there’s a care plan developed that specifically lays out the strategies that are supposed to be used for the turning and repositioning program. This goes beyond a simple intervention on a care plan that says TMP every two hours.
It’s talking about specifics how you will offload, whether or not you will use a device, you’re using a wedge and offloading pillow. I’m really specific. And then there needs to be documentation that it’s being done. There needs to be a review of the program by a registered nurse. I can’t remember the time frame, but some type of Periodic review by a registered nurse to determine whether or not the program is effective or needs to be revised.
And if all those elements aren’t in place then the MDS nurse can’t select that box. The interesting thing about it is that all of those elements parallel the nursing process, which is ADPAI we talked about at the beginning. So that’s a fundamental standard of care to do all of those things. So when they don’t check the box, the question is, are they meeting the standard of care?
Schenk:
Okay, so you said a couple of interesting things there. It seemed as though you were saying they have to do this, they have to do this, if they want to check this box. Where are you getting that information? How do we know that this is what they need to be doing if they’re going to check that box?
Swinehart:
Yeah, it’s in the RAI manual.
Schenk:
And what’s the RAI manual?
Swinehart:
It is the Bible of the MDS. It tells the MDS nurse exactly how to complete it, what the look back periods are, gives you scenarios. So if you’re not sure how to code something, you can figure it out. Yep. It’s spelled right out.
Schenk:
I see. Yep. Okay. And cool. I feel like there’s probably a lot of nurses out there being like, we turn to repositioning.
It’s every two hours. It’s fundamental. It’s just what we do. We don’t document it. But the MDS again, if you check that box, you need to be doing all the things that you listed. If you want to follow the standard of care, at least if you want to follow the standard set by CMS and get reimbursed.
All right. So what else do we got? What are some other things that we can look at in section M if any, that are important with respect to pressure injury development, or we cover everything.
Swinehart:
I think we covered it all. The different treatments, the foot treatments. Yeah, I think we basically covered all the important ones.
Schenk:
Okay. So if you have a loved one in a nursing home and you have the wherewithal to get the MDS has critical information. And what Amy has been saying is that there’s some sections that relate more to pressure injuries than others. And then there’s the actual section where the nursing home should lay out what they’re doing to either prevent pressure ulcer development or treat the pressure ulcer.
So the MDS can be something that’s critical for you to understand what the nursing home understands about your loved one. Amy, this has been fantastic. I really appreciate you coming on the show. Hopefully we’ll get you on next time. We’ll do something else. Cause You’re awesome. You’re awesome.
So thanks so much.
Swinehart:
Thank you. You’re welcome.
Schenk:
I hope you enjoyed the content of this episode. If you are an attorney out there and you are looking for someone who’s highly capable and highly knowledgeable about nursing home regulations. I would highly recommend that you reach out to Amy Swinehart for your legal nurse consultant needs.
You can reach her at her email, which is amy@nursinghomelegalnurse.com. Again, that is amy@nursinghomelegalnurse.com. New episodes of the nursing home abuse podcast come out every week on Monday. You can get them wherever you get your podcast from, but you can also find us on our website, nursinghomeabusepodcast.com or on the YouTubes.
If you have any suggestions for content that you want to see or any guests that you’d like for me to cover, talk to, please be sure to let me know. And with that folks, we’ll see you next time.
Thanks for tuning in to the Nursing Home Abuse podcast. Nothing said on this podcast either by the host or the guest, should be construed as legal or medical advice, nor is intended to create an attorney-client relationship between the host or their guest and the listener. New episodes for now are available every other Monday on Spotify, Apple Podcasts, or on your favorite podcast app, as well as on YouTube and our website, nursinghomeabusepodcast.com.
Again, that’s nursing home abuse podcast.com. See you next time.