Key MDS Data to Identify Fall Risk in Nursing Homes
Understanding these indicators can be life-saving, and the Minimum Data Set (MDS) provides crucial insights. These top five data points are essential for identifying and preventing potential falls among the elderly in care facilities. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Amy Swinehart, RN, to discuss the importance of these MDS metrics and how they can be used to enhance patient safety and reduce fall risks in nursing homes.
Top Five Crucial Data Points from the MDS about Fall Risk
Schenk:
Understanding and reading the MDS as it pertains to fall prevention. Stick around
out there. Welcome back to the nursing abuse podcast. My name is Rob. I will be your host for this episode today. We’re talking about reading and understanding the MDS assessment. As it pertains to the fall prevention in the nursing homes. In other words, what are we looking at in the MDS assessment that might inform us whether or not our loved one is likely to fall?
We’ll get a, we’ll get an understanding as to what the nursing home believes your loved one’s risks are. We’re not doing that alone. We’re going to have the fantastic Amy Swinehart. On the show once again to discuss with us about this. So we’re looking forward to that. Stick around for that.
Again, this week we’re talking about the MDS assessment and it’s and its use in the prevention of falls. And we’re not doing that alone. We have the fantastic registered nurse, Amy Swinehart. 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. Post graduation, she progressed from a floor nurse to director of nursing and nursing homes since 2018. Amy collaborates with attorneys nationwide, including myself. She’s fantastic. Reviewing medical records, crafting work, product reports, and offering litigation support.
For expert legal consultation and analysis on nursing home care, visit Nursing Home Legal Nurse Consultants.
Amy is critical to my own team, and I’m so glad that she could take time away from doing work for me to come on to my podcast. Amy, welcome to the show.
Swinehart:
It’s great to be here. Thank you so much for having me again.
What is the MDS?
Schenk:
Man, I was just telling you off. We were just talking. I guess I could say I was telling you that I loved our last episode.
I don’t know. There’s something about geeking out into the MDS and what it all means that I really enjoy. And you’re, I would say you’re an expert at this. Like you’re an expert at the REI manual, the MDS and all that kind of stuff. So getting your perspective on this stuff, I learned a lot. So I’m happy to have you back.
If anybody’s interested in that last conversation that Amy and I had, that was back in episode 208 and we talked about the MDS as it relates to pressure injuries. And today, as I’ve mentioned a few times already, we’re talking about the MDS and falls. Just a brief primer, Amy, what is the MDS for those that didn’t listen to the previous episodes?
Like just a brief explanation of what the MDS process is, and then we’ll get into the specifics.
Swinehart: Sure. The MDS is basically a standardized assessment that’s used across all nursing homes across the country if you’re Medicare certified. It’s a way for them to collect and synthesize the information from the record and formulate opinions about, care areas and risks and things like that.
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How is information on the MDS obtained?
Schenk:
And typically, how is the information on that MDS, how is it How is it taken from the resident? Like how, like specifically what are they doing to get the information that goes into the MDS?
Swinehart:
Yeah, the large majority of the MDS is information collected from the medical record things that have already been put in by other disciplines and other members of the team.
And then there’s a couple. I think the pain interview, the cognitive interview, those are things that sometimes are done at the time of the MDS by the MDS nurse, but sometimes social services does the cognitive assessment, but for the most part, it’s information that’s already in the medical record being synthesized.
Schenk:
Okay, so the long and short of it is this is a comprehensive head to toe assessment that every nursing home must do for every resident periodically, but specifically at admission quarterly and annually. And then that gets compiled into essentially a document that I would say is probably because it’s computerized is one of the more easier documents in the chart to read.
So now if you’re a family member of somebody that’s, it’s in a nursing home and you’re worried about them falling, perhaps they’ve fallen in the past. Getting the MDS. And specifically going over the portions that Amy and I are going to talk about would be very helpful for you to get an understanding as to what the nursing home knows about your loved one’s risk of falls and what they’re doing about it.
What does Section C tell us about cognition?
All right. So now, and then really quickly, the MDS is essentially as Amy mentioned, it’s broken down in a different area. And that’s alphabetical. So we’re gonna be talking about like in section a and section blah, blah, blah. It’s section eight through Z. Now we’re now without further ado, let’s rock and roll.
So Amy, our loved ones at risk for a fall. Where are we going to first that M. D. S. To learn about that?
Swinehart:
Sure. First section is going to be section C as in CAT. That’s the cognition section. It’s going to tell us whether or not the person is cognitively intact or cognitively impaired and that information is really important for when you develop the care plan to determine what things are most appropriate for the resident.
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Schenk:
I think that this is one of the ones where it’s one of those, when I get a phone call from a family member that like tell me about your loved one in terms of their mental capacity. Like how were they? They say that they had light dementia, I think they were doing just great or whatever.
There’s the, in other words, this is where to me, there’s the most disconnect between the understanding of the loved one, what’s going on with the resident versus the nursing homes, understanding of the residents. And as Amy mentioned, this is very important. And can you talk just quickly about what they’re looking for in Section C?
What’s, what is it that they would need to know?
Swinehart:
Yeah, so it’s a, they call it a BIMS assessment, B I M S. It’s on a 0 to 15 scale with 15 being cognitively intact and the lower end meaning cognitively impaired. Most of the questions are just, questions. For example, one of the things is you say sock blue bed at the beginning of the interview and at the end of the interview, you go back and ask them if they can remember those words.
The day of the week, kind of orientation to time, things like that.
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Schenk:
And so there’s, at the bottom of that page, there’ll be a BIM score, B I M S and if it’s zero to, say, seven, then that’s showing that the nursing home considers your loved one fairly cognitively impaired. And then eight to twelve thereabouts typically is moderate impairment.
Thirteen, yep.
Swinehart:
Yeah.
Schenk:
And then beyond that is, or above that is Oh, you’re right.
Swinehart:
Yep. You’re right. Eight to twelve. Yep.
Why is Section E regarding rejection of care important?
Schenk:
Yep. Is I wrote it down beforehand, Amy, I’m like, I’m not, this is not something that can do off the dome, but no and then 13 to 15 is, is they’re intact, right? So that’s important, right?
Okay. So what’s next? What’s next on the agenda?
Swinehart:
See, then I would go to E. Which is the behavior section and that’s going to let us know whether or not the resident is displaying any kind of behaviors. And also whether or not there’s any rejection of care that’s compromising their progress towards health goals.
Schenk:
And what does what does rejection of care mean and why would that be important in terms of fall risk?
Swinehart:
Say you’ve got a patient who has a BIM score of 15, so they’re cognitively intact, and you’ve said every time you get up, before you get up, I want you to press your call light and call the nurse to come in and help you.
But cognitively they’re intact, and they’re like, I don’t want to ask for help, I’m not going to press that call light. It would be really rude. Really important to capture that because that’s going to enhance their risks of falls if they’re not compliant with requesting assistance.
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Schenk:
I see. And this is the first, this is the first interplay between the cognitive impairment in Section C versus the rest of the MDS and how that, their cognition affects how They’re cared for.
Okay. And what, is there anything else in the behavior section that we would want to look at?
Swinehart:
Yeah. They capture wandering there. That’s always interesting to me, particularly with residents who are, have cognitive impairment. If they’re wandering all over the place in and out of other people’s rooms it’s going to make supervision a little bit more complicated.
So it’s definitely something you’re going to want to consider when you’re developing the fall care plan to make sure that there’s appropriate interventions for all those types of behaviors.
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How does a resident’s functional status relate to fall risk?
Schenk:
And we touched on this, but information that’s put into this section and all the sections, it’s typically done over a certain period of time, which is normally days.
For section E, for example, I believe the look back period is 7 days. So that means that the nursing home has been looking for. and observing for these behaviors. So in the seven days prior to that assessment, if they see your loved one wandering or they see your loved one rejection care, that’s when that would be input in as opposed to six months ago or three weeks ago.
This is a typically a seven day look back period. So it’s recent, like it’s a recent assessment.
Swinehart:
Exactly.
Schenk:
Okay. All right. Behavior rejection of care, where are we going from there?
Swinehart:
Section Section G, prior to October of 2023, and then after that date, you’ll be relying on Section GG to determine functional status.
What is the resident’s ability to perform activities of daily living? things like moving around in bed, how they transfer what are their Like when they’re, you need to use the bathroom. Are they able to do that with staff assistance or without eating, bathing, all the different activities of daily living that section is going to give us some insight about how the resident performs those activities.
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Schenk:
Just as an aside, not to get too wonkish, but do you know whether or not, are we losing any information when G goes away or is all the information to your knowledge that was captured in G being captured in GG?
Swinehart:
I think there’s a. I don’t particularly like the change. I’m really partial to Section G.
Things like bed mobility for pressure ulcer cases, things like that. But I think that Section GG has it, it’s just different verbiage. So instead of saying bed mobility, they’re asking like rolling in bed side to side. So basically the information is there, just not in the usual format that we’re accustomed to.
Schenk:
I know, like I’m the same way, like I fight change sometimes with these things. I’ve been looking at section G for so many years that like it’s gonna be hard to give that up and you’re right, like it’s easier for me to say bed mobility than it is, being able to roll left or roll right. Okay.
And that happens. And that happens in when?
Swinehart:
I think it was the end of October 2023 is when they phased out G.
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Schenk:
I see. Okay. So I guess all my cases are still before that, or they’re just haven’t, or they’re just still collecting the G data. Okay. All oh, that’s I have to look back at my cases for that.
Okay. Anyway, sorry. All right. So the functional status in gg for at least in my experience, and tell me if you agree is where the rubber meets the road in a lot of ways, because this is this is going to be. This is going to determine how the CNAs interact with your loved one and they provide the 90 percent of the care.
If your resident, if your loved one is being cared for, it’s probably the CNA and they are guided by this assessment. So go deep, dig a little bit deeper in that. Like how is what we learn in GG associated with fall risk?
Swinehart:
Yeah. So in order for you to develop a care plan that’s personalized to a particular resident, you need to have a full understanding of all of their functional capacities.
For instance, if the resident needs assistance with transfers There’s a risk for faults there because if they try to transfer without assistance, they’re not going to be able to do it. So having a good understanding of how much staff is needed in the room transfers, ambulation, toileting, all of those things you can’t develop a personalized care plan if you don’t have a good understanding of the functional status.
Learn how to accurately read and interpret MDS assessments in nursing homes with our podcast episode on How to Read MDS Assessments.
Schenk:
And I think that this is a section where again I think as a lay person, the MDS at first can be overwhelming, but if you actually just look at it it’s clean, like it’s just a computer generated document. And if you just spend a little bit of time, you can read it and understand it because trust me, it’s not as though the people that are filling these things out, they, they know 100 percent what’s going on.
But anyway. That’s not a knock. It’s just, everybody’s got a different level of experience with these things, but I guess what I’m trying to say is there’s a lot of numbers. On this. And there’s a lot of, there’s a lot of, um, places to input. Yes. Okay. But the, all the information that you need to read and understand what’s going on in GG is literally on the section.
So there’s going to be like a number that corresponds with the number of people that the, that your loved one needs to assist them to get out of bed, for example. And if you just look at the document, you might say I don’t know what two means. Okay. But I guess what I’m saying is that two is defined on literally the page and you can just read it.
Schenk:
So it’s something that you could understand if you just give yourself a few minutes to read what the definitions are.
Swinehart:
Yeah. Another great thing too about the MDS is that it’s standardized. When they’re asking all of these questions about your loved one in the February, say when they come back and do it, it’s the same questions.
So when you compare the two, you can easily see where there’s been changes in a person’s condition because it’s standardized and always asking the same questions.
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How is toileting related to fall risk?
Schenk:
Exactly. Exactly. Okay, so we’ve got functional status, section GG very important. What, where are we going after that?
Swinehart:
Next, I’d be going to bowel and bladder, the continents.
I think it’s H that’s going to tell us, whether or not the person’s continent of bladder whether or not the facility has ever attempted a toileting program and that relates to falls because a lot of falls in nursing homes happen when the residents responding to unmet toileting needs.
To have a really good understanding of exactly their patterns, their habits. their functional status related to the same. It’s important because there has to be interventions in place.
Gain insights into effective interventions for fall risk prevention in nursing homes through our episode on Interventions for Fall Risk Prevention.
Schenk:
Tell me what a toileting program is just in general and why it would be important for the nursing home to put your loved one on a toileting program or at least trial.
Or attempt to put somebody on one.
Swinehart:
Yeah. And that’s key. The trial, not everybody’s, it’s going to work for, but you at least need to do your due diligence and attempt it. Basically you’re going to do a survey of their toileting habits over the course of a few days, three days look for trends and patterns.
Let’s say, they’re always in continent after lunch or, Oh, they always need to go to the bathroom before dinner. And then once you identify those patterns, you would. Yeah. But incorporate that into the care plan and create a toileting program. That’s just for them. Now, if there’s somebody who’s all over the place and can’t really tell you when they need to use the restroom, sometimes they implement just a standard, every before each meal and before bed or that type of thing prompted waiting.
Understand strategies to prevent falls in elderly care settings in our podcast, How Nursing Homes Can Prevent Falls.
Schenk:
I see. Okay. And then I was going to say that to me, this is another instance in which a lot of times the ball gets dropped, like it’s almost as though it’s, there is no tool to program where does every single person is going to get, we’ll just check them three times a day or two times a day.
And that’s what we’re going to do. And that’s really defeats the point of the program because. The federal regulations are saying that if somebody comes in incontinent, you need to do what you can reasonably do to make them continent again. And just checking them, three times and not doing an assessment of why they’re incontinent.
It’s typically not enough. And this is where I think that the ball gets dropped a lot. Okay. Moving on from section H, that was bowel and bladder where are we going next?
Swinehart:
I think J probably, which is the fall section. It asks whether the resident has had any falls, if there was any injuries, major injury, minor injury, no injury associated with the falls.
So that, speaks directly to the falls.
Schenk:
Okay. And so what are we looking at in that? Is that literally just a history of falls or a top? Tell me a little bit more about that.
Swinehart:
Yeah. I think the questions are whether or not there’s been a fall since the prior assessment and whether or not, and if so, whether there was an injury associated with the fall.
I think that’s about it.
Schenk:
Okay. So very critical section. Because sometimes in my experience, somebody will have multiple falls, but Section J will be blank, basically, with no history of falls. And we’ll get, and we’ll get to why notating these things in the MDS is important, because we’ll get to care planning in a second, but,
Where are we going from J?
Swinehart:
I’m not, I don’t think there’s anything else with falls.
Schenk:
Okay, so let’s, I unless we’re talking about when you get into, and yeah. Maybe medications, but we’ll save that. Yeah. Maybe.
Swinehart:
Okay. Yeah.
Schenk:
Okay. Now. Typically, at least my understanding is how this works is that the nurse is clicking the button.
For example, history of falls in section J. And then what’s gonna happen is that they’re gonna get prompted to dig more deeper into that and carry area assessments going to be generated, which is just it is a more specific assessment. And then, based on all that data, a care plan gets spit out.
Is that more or less how it happens?
Swinehart:
Yeah, basically. So I look at the MDS kind of as the care plan safety net. The standard of care requires that as you identify the risk, you develop the care plans as you go. But in the event that there’s some sort of risk that goes unnoticed they don’t identify it.
There’s not a care plan created by the time you get to the MDS, everything that matters is going to get captured. And so that’s your upper opportunity to reconcile and say, Oh, we need to develop a care plan for this, or Oh, they already did the care plan for this on admission, that type of thing.
Delve into the challenges and solutions for caring for nursing home residents at risk of falls in our episode, Caring for Nursing Home Residents at Risk of Fall.
Schenk:
Okay. So I guess at the end of the day, this is a document that I think would be important for you. So I guess out of the categories of documents that would be important for you to understand as a. A family member of somebody that’s in a nursing home care plan is probably the most important, but the MDS assessment, because for me, at least the ease of being able to read it as opposed to the 15 different assessments that are, that might be documented, that can might be difficult to read.
The MDS assessment is fairly easy to read and you get to understand how the care plan came to be and why the care plan might plan for X, but not for Z, right? Get your hands on the care plan and then get your hands on the MDS to really have a understanding as to what the nursing home understands your loved one’s situation to be.
Any other like broad suggestions or recommendations in terms of, what to get out of the MDS, how to read it, anything like that you can share with us.
Swinehart:
No, I think we covered all the most relevant stuff when it comes to falls.
Schenk:
Very good. Awesome. Amy will again, another awesome golden nugget packed episode.
We really appreciate you coming on and sharing your knowledge with us today.
Swinehart:
Thanks for having me.
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