understanding and coding MDS 3.0 Item GG0100C: Stairs - Prior Functioning

MDS 3.0 Item GG0100C: Stairs - Prior Functioning

Introduction

Purpose: A resident’s ability to navigate stairs before their illness or injury is a critical part of their functional history. MDS Item GG0100C assesses how independently a resident was able to use stairs before their current illness, injury, or admission to a facility. Understanding the resident’s prior ability to manage stairs helps care teams create realistic rehabilitation goals and ensures that the care plan supports the resident’s functional needs.

What is MDS Item GG0100C?

Explanation: MDS Item GG0100C is part of Section GG: Functional Abilities and Goals. This section assesses the resident’s functional abilities, both current and prior. GG0100C specifically addresses how the resident managed stairs before their current illness, injury, or admission. This item evaluates whether the resident was independent, required assistance, or was unable to use stairs at all. Accurate assessment of the resident’s prior stair-climbing ability helps care providers plan rehabilitation and identify necessary support for the resident’s mobility and safety.

Guidelines for Conducting and Coding MDS Item GG0100C

Conducting the Assessment: Staff must collect information about the resident’s ability to use stairs before their illness or injury. Sources of information include:

• Interviews with the resident, family members, or caregivers.
• Reviewing past health records or medical assessments.
• Observations from previous care providers.

The assessment should focus on how independently the resident was able to navigate stairs, including whether they used assistive devices or needed the help of others.

Coding Instructions: MDS Item GG0100C uses a scale to reflect the resident’s level of independence in using stairs prior to their illness or admission. The coding options are:

• 3 - Independent: The resident was able to go up and down stairs without the assistance of another person or device.
• 2 - Needed Some Help: The resident required some assistance from another person or needed to use a mobility aid (such as a handrail, cane, or walker) to navigate stairs.
• 1 - Dependent: The resident was fully dependent on another person to help them use stairs or was unable to use stairs at all.
• 8 - Unknown: The resident’s prior ability to use stairs is not known.
• 9 - Not Applicable: The resident’s ability to use stairs is irrelevant to their current condition or environment (e.g., if they live in a single-level home).

Example Scenario: If a resident was able to navigate stairs independently before their admission, you would code GG0100C as 3 - Independent. If the resident used a handrail or required help from another person, you would code GG0100C as 2 - Needed Some Help. If no information is available, you would code GG0100C as 8 - Unknown.

Best Practices for Accurate Coding

Gather Reliable Information: Accurate information about the resident’s stair-climbing ability is essential. Interview family members or past caregivers, review previous medical records, and use all available resources to ensure the coding reflects the resident’s true prior abilities.

Thorough Documentation: Document the sources of information used to assess the resident’s prior ability to navigate stairs. Proper documentation supports accurate coding and provides a clear history for future care planning.

Collaborate with the Care Team: Share the results of the stair-climbing assessment with the interdisciplinary care team. Knowing the resident’s prior abilities helps set realistic goals for rehabilitation and supports efforts to improve or maintain mobility.

Conclusion

Summary: MDS Item GG0100C is critical for assessing a resident’s prior ability to navigate stairs before their illness or admission. Accurately documenting this information helps guide rehabilitation goals and ensures that the care plan is tailored to the resident’s functional needs, promoting recovery and safety.

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 GG-4.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item GG0100C: "Stairs - Prior Functioning" 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 item within MDS 3.0. Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice.