C1000: Cognitive Skills for Daily Decision Making

Item Rationale

Health-related Quality of Life

• An observed “difficulty with daily decision making” may indicate:

— underlying cognitive impairment and the need for additional coaching and support or

— possible anxiety or depression.

Planning for Care

• An observed “difficulty with daily decision making” may indicate the need for:

— a more structured plan for daily activities and support in decisions about daily activities,

— encouragement to participate in structured activities, or

— an assessment for underlying delirium and medical evaluation.

Steps for Assessment

1. Review the medical record. Consult family and direct care staff across all shifts. Observe the resident.

2. Observations should be made by staff across all shifts and departments and others with close contact with the resident.

3. The intent of this item is to record what the resident is doing (performance). Focus on whether or not the resident is actively making these decisions and not whether staff believes the resident might be capable of doing so.

4. Focus on the resident’s actual performance. Where a staff member takes decision-making responsibility away from the resident regarding tasks of everyday living, or the resident does not participate in decision making, whatever their level of capability may be, the resident should be coded as impaired performance in decision making.

Coding Instructions

Record the resident’s actual performance in making everyday decisions about tasks or activities of daily living. Enter one number that corresponds to the most correct response.

• Code 0, independent: if the resident’s decisions in organizing daily routine and making decisions were consistent, reasonable and organized reflecting lifestyle, culture, values.

• Code 1, modified independence: if the resident organized daily routine and made safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations.

• Code 2, moderately impaired: if the resident’s decisions were poor; the resident required reminders, cues, and supervision in planning, organizing, and correcting daily routines.

• Code 3, severely impaired: if the resident’s decision making was severely impaired; the resident never (or rarely) made decisions.

Coding Tips

• If the resident “rarely or never” made decisions, despite being provided with opportunities and appropriate cues, Item C1000 would be coded 3, severely impaired. If the resident makes decisions, although poorly, code 2, moderately impaired.

• A resident’s considered decision to exercise their right to decline treatment or recommendations by interdisciplinary team members should not be captured as impaired decision making in Item C1000, Cognitive Skills for Daily Decision Making.

Examples

1. Resident B seems to have severe cognitive impairment and is non-verbal. They usually clamp their mouth shut when offered a bite of food.

2. Resident C does not generally make conversation or make their needs known, but replies “yes” when asked if they would like to take a nap.

Coding: For the above examples, Item C1000 would be coded 3, severe impairment.

Rationale: In both examples, the residents are primarily non-verbal and do not make their needs known, but they do give basic verbal or non-verbal responses to simple gestures or questions regarding care routines. More information about how the residents function in the environment is needed to definitively answer the questions. From the limited information provided it appears that their communication of choices is limited to very particular circumstances, which would be regarded as “rarely/never” in the relative number of decisions a person could make during the course of a week on the MDS. If such decisions are more frequent or involved more activities, the resident may be only moderately impaired or better.

3. A resident makes their own decisions throughout the day and is consistent and reasonable in their decision-making except that they constantly walk away from the walker they have been using for nearly 2 years. Asked why they don’t use their walker, they reply, “I don’t like it. It gets in my way, and I don’t want to use it even though I know all of you think I should.”

Coding: C1000 would be coded 0, independent.

Rationale: This resident is making and expressing understanding of their own decisions, and their decision is to decline the recommended course of action – using the walker. Other decisions they made throughout the look-back period were consistent and reasonable.

4. A resident routinely participates in coffee hour on Wednesday mornings, and often does not need a reminder. Due to renovations, however, the meeting place was moved to another location in the facility. The resident was informed of this change and was accompanied to the new location by the activities director. Staff noticed that the resident was uncharacteristically agitated and unwilling to engage with other residents or the staff. They eventually left and were found sitting in the original coffee hour room. Asked why they came back to this location, they responded, “the aide brought me to the wrong room, I’ll wait here until they serve the coffee.”

Coding: C1000 would be coded 1, modified independent.

Rationale: The resident is independent under routine circumstances. However, when the situation was new or different, they had difficulty adjusting.

5. Resident G enjoys congregate meals in the dining room and is friendly with the other residents at their table. Recently, they have started to lose weight. They appear to have little appetite, rarely eat without reminders and willingly give their food to other residents at the table. Resident G requires frequent cueing from staff to eat and supervision to prevent them from sharing their food.

Coding: C1000 would be coded 2, moderately impaired.

Rationale: The resident is making poor decisions by giving their food away. They require cueing to eat and supervision to be sure that they are eating the food on their plate.

DEFINITION

DAILY DECISION MAKING

Includes: choosing clothing; knowing when to go to meals; using environmental cues to organize and plan (e.g., clocks, calendars, posted event notices); in the absence of environmental cues, seeking information appropriately (i.e. not repetitively) from others in order to plan the day; using awareness of one’s own strengths and limitations to regulate the day’s events (e.g., asks for help when necessary); acknowledging need to use appropriate assistive equipment such as a walker.