Step-by-Step Coding Guide for Item Set GG0170FF1: Tub/Shower Transfer (Admission Performance)

This guide will help in accurately coding and documenting a resident's admission performance in tub/shower transfers, as specified in item GG0170FF1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to safely transfer in and out of a tub or shower upon admission.
• Key Points:
  • Thoroughly review the resident’s medical records, including nursing assessments, physical and occupational therapy evaluations, and care plans for any documentation on the resident’s ability to transfer to and from a tub or shower.
  • Note any mentions of the use of assistive devices, modifications to the bathroom setting, or the need for human assistance.

2. Understanding Definitions

• Objective: Define "Tub/Shower Transfer."
• Key Points:
  • Tub/Shower Transfer: Refers to the ability to safely move into and out of a tub or shower area. This includes actions such as stepping over the tub wall, balancing to shower standing or sitting, and exiting safely, with or without the use of assistive devices or human assistance.

3. Coding Instructions

• Objective: Document the resident's admission performance in tub/shower transfers accurately.
• Key Points:
  • Use the following scale to code tub/shower transfer performance:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • Code 88 if the activity did not occur during the assessment period.

4. Coding Tips

• Base the coding on the resident’s most dependent episode of tub/shower transfer during the first three days of the SNF stay.
• Consider any environmental modifications (grab bars, shower chairs) and their impact on the resident’s level of independence.

5. Documentation

• Objective: Ensure detailed documentation supporting the coding decision.
• Key Points:
  • Record observations about the resident's process of transferring to and from the tub or shower, including any required assistance and the use of equipment or modifications.
  • Document any relevant conditions affecting the resident’s ability to perform tub/shower transfers and any interventions aimed at improving this function.

6. Common Errors to Avoid

• Overlooking the resident’s use of environmental modifications as an aspect of independence.
• Not considering occasional assistance or supervision as a level of dependence when coding.

7. Practical Application

• Scenario: Mrs. Elena Rodriguez, upon admission, demonstrates the need for supervision while transferring into and out of the shower due to balance issues, despite the use of grab bars and a shower chair. This supervision ensures her safety during the transfer process. Therefore, she is coded as 4 (supervision or touching assistance) in GG0170FF1.

The Step-by-Step Coding Guide for item GG0170FF1 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.