GG0130A5. Eating (OBRA/ Interim Performance), Step-by-Step

1. Review of Medical Records

• Objective: Ascertain the resident's eating abilities during an OBRA or interim assessment period.
• Key Points:
  • Examine nursing assessments, dietary consultations, occupational or physical therapy evaluations, and care plans for notes on the resident's ability to eat. This includes using utensils, swallowing, and the need for modified diets.

2. Understanding Definitions

• Objective: Clarify "Eating" as it relates to OBRA/Interim Performance.
• Key Points:
  • Eating: Refers to the process of being able to use suitable utensils to bring food and/or liquid to the mouth and swallow it. This can include managing a modified diet and using adaptive devices if necessary.

3. Coding Instructions

• Objective: Document the resident's eating performance accurately.
• Key Points:
  • Utilize the standardized coding scale to reflect the resident's performance:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • If the activity did not occur during the assessment period, code as 88 (not attempted).

4. Coding Tips

• Base coding on direct observation and consistent documentation across the assessment period.
• Consult with interdisciplinary team members for comprehensive insight into the resident's abilities and needs.

5. Documentation

• Objective: Maintain thorough documentation supporting the coding decision.
• Key Points:
  • Document detailed observations of the resident's eating abilities, including the use of adaptive equipment and any difficulties encountered.
  • Include information from family discussions or resident self-reports that provide insight into the resident's usual eating performance.

6. Common Errors to Avoid

• Coding based on assumptions or incomplete observations.
• Failing to note the use of adaptive equipment or dietary modifications that support the resident's eating independence.

7. Practical Application

• Scenario: During an interim OBRA assessment, Mrs. Lucia Gonzalez was observed to independently use utensils and consume her meals without difficulty. However, her care plan notes a preference for thickened liquids due to a past swallowing issue. Despite this modification, she requires no assistance during meals. Mrs. Gonzalez would be coded as 6 for GG0130A5, indicating independence in eating with a modified diet.

The Step-by-Step Coding Guide for item GG0130A5 in MDS 3.0 Section GG is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.