Understanding and Coding MDS 3.0 Item GG0130E5: Shower/Bathe Self (OBRA/Interim Performance)

Understanding and Coding MDS 3.0 Item GG0130E5: Shower/Bathe Self (OBRA/Interim Performance)

Introduction

The ability of a resident to shower or bathe themselves is critical to maintaining personal hygiene and overall health in long-term care settings. Accurate coding of this ability helps ensure that the resident receives appropriate care and assistance. MDS Item GG0130E5 assesses a resident’s ability to wash, rinse, and dry their body during bathing without transferring in and out of the tub or shower.

Correct coding is essential for documenting the resident's needs, ensuring proper staffing, and developing individualized care plans that promote autonomy while providing necessary support.

What is MDS Item GG0130E5?

MDS Item GG0130E5, titled "Shower/Bathe Self," evaluates the resident's capacity to perform tasks such as washing, rinsing, and drying the face, upper and lower body, perineal area, and feet. The assessment excludes tasks like washing the resident’s back and hair or assisting with transfers in and out of the tub/shower. The coding applies to residents who perform bathing tasks in various settings, including at a sink, in a shower, or while seated on a tub bench.

Guidelines for Coding MDS Item GG0130E5

Coding Instructions

When coding GG0130E5, the assessor must determine the level of assistance the resident requires to complete the showering or bathing task, excluding the back or hair washing and the transfer process. Coding is based on a six-point scale:

1. Code 01 – Dependent: The resident requires full assistance from two or more helpers.
2. Code 02 – Substantial/Maximal Assistance: The resident performs less than half of the effort, and a helper provides more than half of the assistance.
3. Code 03 – Partial/Moderate Assistance: The resident performs more than half of the effort, and a helper provides less than half.
4. Code 04 – Supervision or Touching Assistance: The helper provides supervision or steadying assistance during bathing.
5. Code 05 – Setup or Clean-up Assistance: The helper provides only setup or clean-up assistance, such as retrieving items or covering wounds before bathing.
6. Code 06 – Independent: The resident completes the entire activity without any help from a helper.

Example Scenario

Scenario 1: Resident A sits on a tub bench while washing, rinsing, and drying their upper body and feet. A certified nursing assistant is present for safety, ensuring the resident does not fall. The assistant does not provide physical help with bathing but assists with getting on and off the tub bench.

• Coding: GG0130E5 would be coded 04 (Supervision or Touching Assistance).
• Rationale: The helper’s involvement is limited to supervision to ensure safety and does not include assistance with the actual bathing tasks.

Scenario 2: Resident B, who has reduced endurance due to a neurological condition, is seated on a shower bench. The resident is able to wash their upper body but requires a nursing assistant to finish washing the lower body and to dry the entire body due to fatigue.

• Coding: GG0130E5 would be coded 02 (Substantial/Maximal Assistance).
• Rationale: The helper provides more than half the effort in assisting with the bathing tasks, including washing and drying.

Best Practices for Accurate Coding

Documentation

Ensure all observations regarding the resident’s ability to perform showering tasks are well-documented in the medical record. Clearly state the type and level of assistance required, making sure to note any adaptive equipment used or environmental factors that may influence the resident’s performance.

Communication

Collaborate with the interdisciplinary team, including occupational therapists, nurses, and certified nursing assistants, to gather accurate information on the resident’s abilities. This communication ensures comprehensive assessment and consistent documentation.

Training

Ongoing education for staff is crucial for maintaining high standards in MDS assessments. Regular training should focus on how to observe resident behaviors, identify the need for assistance, and document activities accurately based on CMS guidelines.

Conclusion

Accurate coding of MDS Item GG0130E5 is vital for assessing a resident’s self-care abilities in bathing. Proper evaluation ensures residents receive the care they need to maintain hygiene and health while promoting as much independence as possible. Following the coding guidelines helps create individualized care plans and improves resource allocation.

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

Reference

CMS’s Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Page GG-27 to GG-28.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item GG0130E5: "Shower/Bathe Self" 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.