C0900B: Staff Assessment of Mental Status: Recall Location of Room, Step-by-Step

Step-by-Step Coding Guide for Item Set C0900B: Staff Assessment of Mental Status: Recall Location of Room

1. Review of Medical Records

• Objective: To determine if the resident can recall the location of their room as part of assessing cognitive function.
• Process:
  • Review care team notes and observations related to the resident’s ability to navigate and orient to their environment.
  • Examine any psychological or cognitive assessments performed that may include observations of the resident’s ability to recall their room location.
  • Consult with staff members who interact regularly with the resident, such as nursing assistants and therapists, for anecdotal evidence of the resident’s recall abilities.

2. Understanding Definitions

• Recall Location of Room: The ability of a resident to remember and correctly identify the location of their own living quarters within the facility. This assessment helps gauge short-term memory and spatial orientation, important components of cognitive health.

3. Coding Instructions

• Code C0900B:
  • 0: No, the resident cannot recall the location of their room.
  • 1: Yes, the resident can recall the location of their room.
• Example: If during observation and routine interactions the resident consistently identifies the location of their room when asked or when navigating independently, code C0900B as '1'.

4. Coding Tips

• Observe the resident’s behavior over multiple instances to make an accurate assessment, rather than relying on a single observation.
• Consider the influence of environmental factors, such as recent changes in room location or similar room settings, which might affect the resident’s ability to recall.

5. Documentation

• Required Documentation:
  • Detailed notes from staff observations indicating whether the resident can identify their room location.
  • Relevant entries in psychological or nursing assessments that document cognitive function related to spatial orientation.
• Documentation should be clear, consistent, and reflect multiple observations to support the coding decision.

6. Common Errors to Avoid

• Coding based on outdated information without considering recent changes in the resident’s cognitive status.
• Failing to document each instance of assessment, leading to potential discrepancies or unsupported coding.
• Misinterpreting the resident’s temporary confusion as an inability to recall room location.

7. Practical Application

• Scenario: A resident who was recently relocated within the facility is observed over several days to assess their ability to recall the new room location. Initially, the resident struggles but within a week, they consistently navigate back to their room without assistance. Staff document these observations, noting the improvement and consistency in recall ability. Based on this documented evidence, the MDS coordinator codes C0900B as '1', indicating that the resident can recall the location of their room.

Please note that the information provided in this guide for MDS 3.0 Item set C0900B was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.