Understanding and Coding MDS 3.0 Item C0900C: Staff Assessment of Mental Status - Recall Staff Names/Faces

Understanding and Coding MDS 3.0 Item C0900C: Staff Assessment of Mental Status - Recall Staff Names/Faces

Introduction

Purpose:
MDS 3.0 Item C0900C is a critical aspect of evaluating a resident’s cognitive function in long-term care settings, specifically focusing on their ability to recognize and recall the names and faces of staff members. This item helps assess a resident’s orientation to people and social interactions, which is a key component of cognitive health. Accurate coding of this item aids in identifying residents who may have memory impairments or social disorientation, allowing for the development of personalized care plans to support their cognitive and social well-being.

What is MDS Item C0900C?

Explanation:
MDS Item C0900C, "Staff Assessment of Mental Status: Recall Staff Names/Faces," is part of Section C, which addresses cognitive patterns. This item evaluates whether a resident can accurately recognize and recall the names and faces of staff members who regularly interact with them. The ability to remember staff members is an important indicator of the resident’s social orientation and cognitive function, particularly their memory. Difficulty in recognizing or recalling staff names and faces may suggest cognitive impairments such as memory loss, confusion, or social disconnection.

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 C0900C

Coding Instructions:
When coding Item C0900C, staff should determine whether the resident can correctly recall and recognize the names and faces of staff members who provide regular care. The coding reflects the resident’s ability to accurately identify these individuals.

1. Code 0 - Incorrect: The resident is unable to recall or recognize the names and/or faces of staff members or provides incorrect information.
2. Code 1 - Correct: The resident accurately recalls and recognizes the names and faces of staff members who regularly care for them.

Example Scenario:
Ms. Johnson is regularly cared for by Nurse Smith and Nurse Johnson. When asked, “Do you know who Nurse Smith is?” Ms. Johnson correctly identifies Nurse Smith by name and face. In this case, Item C0900C should be coded as "1 - Correct" because Ms. Johnson accurately recalls the staff member's name and face.

On the other hand, if Mr. Brown frequently forgets or confuses the names and faces of his caregivers, such as mistaking Nurse Lee for Nurse Adams, Item C0900C should be coded as "0 - Incorrect," indicating an issue with his social orientation or memory.

Best Practices for Accurate Coding

Documentation:

• Detailed Observations: Record the resident’s responses when asked about recognizing or recalling staff members. Note whether the resident was able to correctly identify the names and faces of those who regularly interact with them.
• Consistency: Ensure that assessments are conducted consistently to monitor any changes in the resident’s ability to recognize staff over time, which may indicate shifts in cognitive function.
• Objective Evidence: Support coding decisions with documented interactions that clearly demonstrate the resident’s ability (or inability) to recognize and recall staff members.

Communication:

• Interdisciplinary Team: Share findings regarding the resident’s ability to recall staff names and faces with the interdisciplinary care team. This information is crucial for developing comprehensive care plans that address cognitive and social deficits.
• Family Involvement: Engage the resident’s family in discussions about the resident’s social orientation and cognitive status, as they can provide additional insights and help validate the staff’s observations.

Training:

• Staff Education: Train staff to assess social orientation accurately by recognizing the specific indicators of intact or impaired memory for names and faces.
• 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 and social assessments.

Conclusion

Summary:
Accurately coding MDS Item C0900C is essential for assessing a resident’s ability to recall and recognize the names and faces of staff members. This evaluation provides valuable insights into the resident’s cognitive health and social orientation, which are crucial for developing care plans that support their mental and social well-being. 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 C0900C.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item C0900C: Staff Assessment of Mental Status - Recall Staff Names/Faces 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.