MDS 3.0 Item D0150C2: PHQ Response - Frequency of Trouble with Sleep

MDS 3.0 Item D0150C2: PHQ Response - Frequency of Trouble with Sleep

Introduction

Purpose: Sleep disturbances are a common and significant issue in long-term care settings, impacting residents' overall health and well-being. MDS Item D0150C2 focuses on assessing how frequently a resident has experienced trouble with sleep, such as difficulty falling asleep, staying asleep, or sleeping too much, over the past two weeks. Accurate coding of this item is crucial for identifying the severity of sleep problems and informing appropriate care interventions.

What is MDS Item D0150C2?

Explanation: MDS Item D0150C2 is part of the Patient Health Questionnaire (PHQ-9) interview in Section D: Mood. This item assesses the frequency with which a resident has experienced trouble with sleep over the last two weeks. Understanding the frequency of sleep disturbances is essential for determining their impact on the resident’s health and daily functioning, and for planning effective interventions.

Guidelines for Coding MDS Item D0150C2

Coding Instructions: To code MDS Item D0150C2, the interviewer asks the resident how often they have had trouble with sleep—whether it's difficulty falling asleep, staying asleep, or sleeping too much—over the past two weeks. The response is coded as follows:

• 0 - Not at all: The resident has not experienced trouble with sleep.
• 1 - Several days: The resident has had trouble with sleep on several days.
• 2 - More than half the days: The resident has experienced trouble with sleep on more than half of the days.
• 3 - Nearly every day: The resident has had trouble with sleep nearly every day.

Example Scenario: If a resident reports that they have struggled to fall asleep on four out of the last fourteen days, you would code D0150C2 as 1 - Several days. If the resident indicates that these sleep issues have occurred nearly every day, the appropriate code would be 3 - Nearly every day.

Best Practices for Accurate Coding

Documentation: Accurately document the resident's report on the frequency of sleep disturbances, including any specific details they provide. This documentation is vital for justifying the coding decision and for developing an appropriate care plan.

Communication: Ensure that all members of the interdisciplinary team are informed about the resident’s sleep issues. Addressing sleep problems often requires input from multiple disciplines, including nursing, medical, and psychological professionals.

Training: Regular training for staff on conducting the PHQ-9 interview is important. Training should focus on how to sensitively discuss sleep issues with residents and how to accurately document and code their responses.

Conclusion

Summary: MDS Item D0150C2 is essential for assessing the frequency of sleep disturbances in long-term care residents. By accurately coding this item, healthcare professionals can better understand the severity of the resident’s sleep problems and implement appropriate interventions to support their overall health and quality of life.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference

This guide is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Page D-6.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item D0150C2: "PHQ Response - Frequency of Trouble with Sleep" was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide.

This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.