Maureen Valvo, BSN, RN, RAC-CT Sr Quality Improvement Specialist Activities of Daily Living (ADL) Coding Bed Mobility & Transfer Self Performance My name is Maureen Valvo. I work for IPRO the New York State Health Care Quality Improvement Organization. I am working with your Nursing Home on Pressure Ulcer Quality Improvement. I want to thank you for all the skin care you provide at the bedside: keeping the skin clean, and dry, turning and positioning, and preventing and healing pressure ulcers and all wounds. There is a second factor that effects the High Risk for Pressure Ulcer Quality Measure. That is the number of residents that are high risk for pressure ulcers. This is decide by their coding on the MDS for Bed Mobility and Transfer Self Performance. If a resident can not move out of a chair by themselves and must wait for someone to help them or if a resident can not move out of the position they are laying in, in the bed without some one coming to help them, they are considered high risk for pressure ulcers. Maureen Valvo, BSN, RN, RAC-CT Sr Quality Improvement Specialist

IPRO provides a full spectrum of healthcare assessment and improvement services that foster the efficient use of resources and enhance healthcare quality to achieve better patient outcomes.

Bed Mobility & Transfer Self Performance A resident’s ADL self-performance may vary from day to day, shift to shift, or within shifts. Do NOT record the type of assistance that the resident “should” be receiving according to the written plan of care. The level of assistance actually provided might be very different from what is indicated in the plan. RECORD WHAT ACTUALLY HAPPENED. Bed Mobility & Transfer Self Performance A resident’s ADL self-performance may vary from day to day, shift to shift, or within shifts. Do NOT record the type of assistance that the resident “should” be receiving according to the written plan of care. The level of assistance actually provided might be very different from what is indicated in the plan. RECORD WHAT ACTUALLY HAPPENED.

Bed Mobility & Transfer Self Performance We developed posters with figures to help illustrate the levels of care you provide the resident. The first figure is waving to staff, Level 0, the resident is INDEPENDENT, the resident needed no help from staff. The next figures illustrate Level 1, SUPERVISION, the staff member with the conversation bubble is verbally providing directions to the resident, cueing them on what to do. The next figures illustrate Level 2, LIMITED ASSISTANCE, the resident can do much of the activity but the staff member is guiding the resident, as to what direction to walk or is guiding them in the direction to reach for something, non weight bearing. The next figures illustrate Level 3, EXTENSIVE ASSISTANCE, the staff member is lifting part of the resident’s body, providing weight bearing assistance, to help them complete the activity. And for Level 4, Total Dependence, the staff does the whole activity for the resident.

MDS Rule of 3 The MDS coordinator will code the MDS at the most dependent level if it occurred 3 times in the last 7 days MDS Rule of 3 - The MDS coordinator will code the MDS at the most dependent level if it occurred 3 times in the last 7 days. That is basically why we are having this education again today, to remind you to take credit for the work you do. You may the first person on your shift to document extensive assistance. Monday morning the resident may wake up a little shaky and the resident needed assistance when standing to prevent falling, that moment in time would be coded as extensive assistance. Then Wednesday evening the resident is tired and asks the cna to lift their legs on to the bed. That would be coded as extensive assistance. Thursday night that same resident, who usually sleeps all night, woke up to go to the bathroom. Sometimes it is easier to get out of bed, than it is to get back into bed, especially when you are tired. Thus that resident has to wait for someone to help them to transfer back to bed. That would also be coded extensive assistance. When the MDS is being completed, the nurse would see that the resident needed extensive assistance Monday morning, Wednesday evening and Thursday night. The MDS then would be coded at Extensive for transfers for that week.

Bed Mobility Self Performance BED MOBILITY Self Performance—includes Repositioning in bed, scooting up in bed Level 3= the weight-bearing assistance of pulling up on lift sheet while resident pushes up with their feet. How the resident moves from Lying to sitting & sitting to lying position-Level 3 == weight-bearing assistance of lifting trunk to sitting position and/or lifting legs to put over the edge of bed, legs lifted into bed when resident is laid down

Transfer Self Performance

Transfer Self Performance Sometimes May Need Partial Weight Bearing Assistance Resident use these items, canes + walkers to be independent. How do they get to standing and walking with the cane. Some days they may be totally independent and some days or some times of the day like afternoon or in evenings, or even getting up in the morning, they may need your assistance to stabilize themselves if they are unstable and might fall.

Transfer Self Performance Sometimes May Need Partial Weight Bearing Assistance How does the resident get out of the chair or off the bed. Independently usually or sometimes they may need to hold your hand or you support their elbow.

Bed Mobility & Transfer Self Performance Sometimes May Need Partial Weight Bearing Assistance Lifting resident’s legs –to Transfer back in to bed at night or in afternoon for nap- maybe not everyday but some days and must take credit for the care you provide Lifting Legs – Transfer into or out of bed Or to position legs in bed-Bed Mobility

Transfer Self Performance Sometimes May Need Partial Weight Bearing Assistance Lowering Pivoting

Bed Mobility & Transfer Self Performance Sometimes May Need Partial Weight Bearing Assistance This is how the resident independently turns to sit up and transfer himself out of bed even with one sided weakness as in photo on left number 11. None of your residents actually do a sit up-they usually turn to their side + push up.—Some days they may unstable in this action + at any step in the action, you “catch” them, hold them, support them, so that they do not fall back – that is partial weight bearing assistance, therefore extensive assisitance for your usually independent resident. You must remember to code that day as extensive.

Bed Mobility Self Performance Sometimes May Need Partial Weight Bearing Assistance Some residents can get themselves into bed but may need you to turn them. That may be all you do but if you must turn them, or help them turn, even though they partially move themselves, that is extensive assistance –the 2 photos on the left 17 and 18. Others may get into bed but need or ask you to move them once they are in the bed- that is extensvie assitance even though that is all you did photo 13

Bed Mobility Self Performance Sometimes May Need Partial Weight Bearing Assistance Positioning Pillows Figure 19 — Every resident should at least have pillows under their heels to relieve pressure + prevent or heal heel ulcers. How does that pillow get there. Your resident maybe able to lift his legs, but can they lift them high enough to get the pillow underneath. You may ask them to lift their legs to place the pillow + automatically lift their legs higher to place pillow- thus giving partial weight bearing assistance without even thinking about that. Many of your residents do not have the abdomenal muscle strength to do a leg lift. How do you get the pillow between the resident’s legs to prevent knee on knee pressure? Can your resident lift a leg do a leg lift while on their side for you to place a pillow between? Hey may be able to move their leg but not wide enough for your to place pillow.

Bed Mobility & Transfer Self Performance

Bed Mobility & Transfer Self Performance

Bed Mobility & Transfer Self Performance

Bed Mobility & Transfer Self Performance

Bed Mobility & Transfer Self Performance

Bed Mobility & Transfer Self Performance

Bed Mobility & Transfer Self Performance Why is this so hard to capture? Everyone must understand what actions apply to what words. And staff must Remember to write that you gave additional assistance. Do it right away. Otherwise Day shift get resident up, 2 meals + 2 changes –chart while running out the door, must remember the additional help + not copy the usual per care plan or other staffs charting. Evenings may have the best time to capture accurately if they remember that for that day they lifted the residents legs, which happened so quickly + easily earlier in the evening. Nights ---to be honest– may chart the usual before they actually give their busiest time morning care started by 6 and running out the door at 7am—depending on nursing homes shift—please go back on the few that are different + nights has the best chance of capturing bed mobility issues

Bed Mobility & Transfer Self Performance

Bed Mobility & Transfer Self Performance Think while providing care: I am Cueing= Supervision Guiding= Limited Assistance Partial Weight Bearing Assistance=Extensive AND Take Credit for the Care you Provide DOCUMENT

For more information Maureen Valvo, BSN, RN, RAC-CT (516) 326-7767 ext. 308 (mvalvo@nyqio.sdps.org) CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.ipro.org IPRO Corporate Template 8/18/11