Step-by-Step Coding Guide for Item Set GG0130F1: Toilet Transfer (Admission Performance)

This guide aims to assist in accurately coding and documenting a resident's admission performance in toilet transfers, as specified in item GG0130F1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to transfer to and from the toilet upon admission.
• Key Points:
  • Examine the resident's medical records for details from nursing assessments, physical and occupational therapy evaluations, and care plans regarding the resident’s ability to transfer to and from the toilet.
  • Look for mentions of the use of assistive devices, modifications to the bathroom setting, or the need for human assistance.

2. Understanding Definitions

• Objective: Define "Toilet Transfer."
• Key Points:
  • Toilet Transfer: The ability to safely move to and from the toilet. This includes actions such as standing up from a seated position, moving from a wheelchair to the toilet, and vice versa, with or without the use of assistive devices or human assistance.

3. Coding Instructions

• Objective: Accurately document the resident's admission performance in toilet transfers.
• Key Points:
  • Use the following scale to code toilet 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

• Assess the resident’s performance based on the most dependent episode of toilet transfer during the first three days of the SNF stay.
• Consider the entire process of transferring, including any required adjustments to clothing and the use of grab bars or other assistive devices.

5. Documentation

• Objective: Ensure comprehensive documentation supporting the coding decision.
• Key Points:
  • Record detailed observations about the resident's process of transferring to and from the toilet, noting any assistance needed and the use of equipment.
  • Document any relevant conditions affecting the resident’s ability to perform toilet transfers, such as balance issues or lower body strength limitations.

6. Common Errors to Avoid

• Misinterpreting the resident's use of assistive devices as full independence.
• Overlooking temporary conditions that might affect the resident's ability to transfer during the assessment period.

7. Practical Application

• Scenario: Mr. George Smith, recently admitted following a stroke, demonstrates the ability to transfer to and from the toilet with supervision for balance support. Despite his ability to perform most of the transfer independently, he requires a staff member to be present to ensure safety due to his impaired balance. Thus, he is coded as 4 (supervision or touching assistance) in GG0130F1.

The Step-by-Step Coding Guide for item GG0130F1 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.