Step-by-Step Coding Guide for Item Set: K0100B. Swallowing Disorder: Holds Food in Mouth/Cheeks

1. Review of Medical Records

   • Start by thoroughly reviewing the resident’s medical records, focusing on assessments from speech-language pathologists, nutritional assessments, and daily nursing notes. Look for any mentions of difficulties with oral phase swallowing, including instances where the resident holds food in their mouth or cheeks.

2. Understanding Definitions

   • Swallowing Disorder: A condition affecting any phase of the swallow process, from preparing food in the mouth to moving it to the stomach. Difficulties can arise from neurological conditions, structural issues, or other health problems.
   • Holds Food in Mouth/Cheeks: This specific swallowing disorder symptom involves the resident retaining food in the oral cavity, not moving it effectively to the throat (pharynx) for swallowing.

3. Coding Instructions

   • Code 0: No - If there is no evidence of the resident holding food in their mouth or cheeks.
   • Code 1: Yes - If the resident displays behaviors or symptoms of holding food in their mouth or cheeks as observed by care staff or documented in medical records.
   • Make this determination based on a comprehensive review of documented observations and direct assessments.

4. Coding Tips

   • Collaborate with the care team, especially speech-language pathologists and caregivers who assist with meals, to gather detailed observations about the resident’s eating behaviors.
   • Observe the resident during meals if possible, noting any tendency to pocket food and the types of food most commonly held.

5. Documentation

   • Document the coding decision in the MDS accurately. In the resident’s medical record and care plan, include observations of the resident holding food in their mouth or cheeks, detailing the frequency, types of food, and any related factors or interventions attempted.

6. Common Errors to Avoid

   • Failing to observe the resident across multiple meals or settings, which might result in missing instances of the behavior.
   • Confusing this behavior with other oral phase dysphagia symptoms or general disinterest in eating.

7. Practical Application

   • Example: During several mealtime observations, Mr. Clark was noted by nursing staff to frequently hold food in his cheeks, particularly with more solid textures like meat or vegetables. Speech-language pathology evaluation confirmed difficulty with the oral preparatory phase of swallowing. The care team implemented strategies, including modifying food textures and providing eating technique cues. For K0100B, Mr. Clark would be coded as "1" for Yes, indicating he holds food in his mouth/cheeks. Documentation includes these observations and the interdisciplinary strategies deployed to address his swallowing disorder.

The Step-by-Step Coding Guide for item K0100B in MDS 3.0 Section K 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.