Step-by-Step Coding Guide for Item Set GG0170FF5: Tub/Shower Transfer (OBRA/Interim Performance)

This guide is crafted to facilitate the accurate coding and documentation of a resident's performance in tub/shower transfers during an OBRA or interim performance assessment, as indicated in item GG0170FF5 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to safely transfer in and out of a tub or shower during the OBRA or interim assessment period.
• Key Points:
  • Thoroughly review the resident’s medical records, including notes from nursing assessments, physical and occupational therapy evaluations, and any care plans that describe the resident’s tub/shower transfer abilities.
  • Identify any mentions of the use of assistive devices, modifications to the bathroom setting, or the necessity for human assistance.

2. Understanding Definitions

• Objective: Clarify what is meant by "Tub/Shower Transfer."
• Key Points:
  • Tub/Shower Transfer: Refers to the resident's ability to move into and out of a tub or shower area safely. This includes actions like stepping over the tub wall, balancing while standing or sitting in the shower, and exiting the area safely, with or without the aid of assistive devices or human assistance.

3. Coding Instructions

• Objective: Accurately document the resident's OBRA/interim performance in tub/shower transfers.
• Key Points:
  • Employ the standard coding scale for functional abilities and goals:
    • 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 was not attempted during the assessment period.

4. Coding Tips

• Base coding on observations of the resident's most dependent episode of performing the transfer during the assessment period.
• Consider the impact of any assistive devices or environmental modifications on the resident’s level of independence.

5. Documentation

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

6. Common Errors to Avoid

• Overlooking the resident’s occasional need for assistance or supervision, leading to an overestimation of their independence.
• Not updating the resident’s records based on the most current assessment information.

7. Practical Application

• Scenario: During the interim assessment period, Mrs. Anita Singh required substantial assistance to transfer into and out of the shower due to decreased lower limb strength. Occupational therapy notes highlight her use of a shower chair and grab bars, with staff assistance needed for safe entry and exit. Therefore, Mrs. Singh is coded as 2 (substantial/maximal assistance) in GG0170FF5.

The Step-by-Step Coding Guide for item GG0170FF5 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.