Understanding and Coding MDS 3.0 Item C0900D: Staff Assessment of Mental Status - Recall in Nursing Home

Understanding and Coding MDS 3.0 Item C0900D: Staff Assessment of Mental Status - Recall in Nursing Home

Introduction

Purpose:
MDS 3.0 Item C0900D is an essential component in evaluating a resident’s cognitive function, specifically focusing on their awareness of their living environment. This item assesses whether a resident can correctly recall that they are currently residing in a nursing home. Accurate coding of this item helps identify residents who may be experiencing cognitive impairment or confusion about their surroundings, which is crucial for developing effective care plans that support their cognitive and emotional well-being.

What is MDS Item C0900D?

Explanation:
MDS Item C0900D, "Staff Assessment of Mental Status: Recall in Nursing Home," is part of Section C, which addresses cognitive patterns. This item evaluates a resident’s ability to accurately recall that they are living in a nursing home. The ability to recognize and remember their current living situation is a key indicator of the resident’s orientation to place and cognitive health. Difficulty in recalling that they are in a nursing home may indicate disorientation or cognitive decline, such as dementia or confusion, which requires further assessment and intervention.

Staff conduct this assessment based on observations and interactions with the resident, particularly when the resident is unable to participate in the Brief Interview for Mental Status (BIMS).

Guidelines for Coding C0900D

Coding Instructions:
When coding Item C0900D, staff should determine whether the resident can correctly recall that they are in a nursing home. The coding options reflect the resident’s ability to accurately identify their current living situation.

1. Code 0 - Incorrect: The resident is unable to recall that they are in a nursing home or gives an incorrect response, indicating confusion or disorientation about their living environment.
2. Code 1 - Correct: The resident accurately recalls that they are living in a nursing home.

Example Scenario:
Ms. Johnson is asked by a staff member, “Do you know where you are right now?” Ms. Johnson responds, “Yes, I’m in the nursing home,” which is correct. In this case, Item C0900D should be coded as "1 - Correct" because Ms. Johnson accurately recalled that she is in a nursing home.

On the other hand, if Mr. Smith responds, “I’m at home,” or expresses uncertainty about where he is, Item C0900D should be coded as "0 - Incorrect," indicating an issue with his orientation to place.

Best Practices for Accurate Coding

Documentation:

• Detailed Observations: Record the resident’s response when asked about their current living situation, noting whether the answer was correct or incorrect. This documentation is important for tracking the resident’s orientation to place and cognitive abilities over time.
• Consistency: Ensure that assessments are conducted regularly to monitor any changes in the resident’s ability to recall their living situation, which may indicate shifts in cognitive function.
• Objective Evidence: Support coding decisions with documented interactions that clearly demonstrate the resident’s ability to recognize and recall that they are in a nursing home.

Communication:

• Interdisciplinary Team: Share findings regarding the resident’s ability to recall their living situation with the interdisciplinary care team. This information is vital for developing comprehensive care plans that address cognitive deficits and support the resident’s orientation.
• Family Involvement: Engage the resident’s family in discussions about the resident’s cognitive status, as their insights can help validate the staff’s observations and inform care strategies.

Training:

• Staff Education: Train staff to assess orientation to place accurately by recognizing the specific indicators of intact or impaired memory regarding the resident’s current living situation.
• Assessment Techniques: Provide training on effective assessment techniques, including how to interact with residents who may have varying levels of cognitive function or communication barriers.
• Updates and Refresher Courses: Regularly update staff on any changes to MDS guidelines and offer refresher courses to maintain high standards in cognitive assessments.

Conclusion

Summary:
Accurately coding MDS Item C0900D is essential for assessing a resident’s orientation to place, specifically their ability to recall that they are in a nursing home. This evaluation is crucial for understanding the resident’s cognitive health and for creating care plans that support their mental well-being and sense of security. By adhering to the coding guidelines and best practices, healthcare professionals can ensure comprehensive and accurate cognitive assessments, leading to improved care outcomes for residents in long-term care settings.

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

Reference

Please refer to CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, specifically Chapter 3, Page C-10, for detailed instructions on coding Item C0900D.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item C0900D: Staff Assessment of Mental Status - Recall in Nursing Home 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.