Understanding and Coding MDS 3.0 Item C1310D: Signs of Delirium - Altered Level of Consciousness

Introduction

Purpose:
MDS 3.0 Item C1310D is a vital component in assessing a resident’s cognitive function, specifically focusing on the identification of an altered level of consciousness as a sign of delirium. Delirium is a serious and often acute condition that can severely impact a resident's health. Identifying an altered level of consciousness is crucial for early detection and intervention, which can prevent further complications and improve outcomes.

What is MDS Item C1310D?

Explanation:
MDS Item C1310D, "Signs of Delirium: Altered Level of Consciousness," is part of Section C, which addresses cognitive patterns. This item evaluates whether the resident exhibits an altered level of consciousness, a key indicator of delirium. Altered consciousness can manifest as drowsiness, lethargy, stupor, or hyper-alertness and indicates that the resident’s awareness of their environment is impaired.

An altered level of consciousness is a significant symptom of delirium and suggests that the resident’s cognitive and neurological functions are affected. This symptom requires immediate attention to identify underlying causes, such as infections, medication effects, or metabolic imbalances, and to provide appropriate treatment.

Guidelines for Coding C1310D

Coding Instructions:
Item C1310D should be coded based on observations of the resident’s level of consciousness during the assessment period.

1. Code 0 - Behavior not present: The resident does not exhibit signs of an altered level of consciousness. They are awake, alert, and aware of their surroundings, with no signs of drowsiness, hyper-alertness, or reduced responsiveness.

2. Code 1 - Behavior continuously present, does not fluctuate: The resident consistently shows signs of an altered level of consciousness throughout the day, with no significant periods of improvement or fluctuation.

3. Code 2 - Behavior present, fluctuates: The resident exhibits signs of an altered level of consciousness, but these signs fluctuate throughout the day. There may be times when the resident is more alert or responsive, followed by periods of drowsiness, lethargy, or other alterations in consciousness.

Example Scenario:
Mrs. Green, usually alert and responsive, has recently been observed to be unusually drowsy, with periods where she seems unable to stay awake or respond appropriately. These episodes vary, with times of normal alertness followed by periods of lethargy. In this case, Item C1310D should be coded as "2 - Behavior present, fluctuates," indicating that Mrs. Green's level of consciousness varies throughout the day.

Conversely, if Mr. Brown remains consistently alert and aware throughout the day with no signs of drowsiness or hyper-alertness, Item C1310D should be coded as "0 - Behavior not present."

Best Practices for Accurate Coding

Documentation:

• Detailed Observations: Record specific instances where the resident exhibits signs of altered consciousness, including the context, time of day, and any triggers or related events. Note whether these signs are continuous or fluctuate.
• Consistency: Assess the resident’s level of consciousness at different times of the day to determine if the behavior fluctuates or remains consistent.
• Objective Evidence: Use observations from multiple staff members and different settings (e.g., during personal care, meals, and activities) to ensure a comprehensive assessment.

Communication:

• Interdisciplinary Team: Share observations of altered consciousness with the interdisciplinary care team to ensure prompt evaluation and intervention. This is crucial for addressing potential delirium and mitigating associated risks.
• Family Involvement: Discuss any changes in the resident’s level of consciousness with their family, as they may notice similar issues during visits and can provide additional context about the resident’s cognitive status.

Training:

• Staff Education: Train staff to recognize signs of altered consciousness and other symptoms of delirium, emphasizing the importance of distinguishing these from chronic cognitive impairments like dementia.
• Assessment Techniques: Provide training on effective observation techniques and documentation practices to ensure that altered consciousness is accurately identified and reported.
• Updates and Refresher Courses: Regularly update staff on best practices for identifying and coding signs of delirium, including altered consciousness, to maintain high standards in cognitive assessment and care.

Conclusion

Summary:
Accurately coding MDS Item C1310D is essential for identifying an altered level of consciousness as a sign of delirium. This assessment is crucial for early detection and intervention, which can prevent further complications and improve the resident’s overall health outcomes. By following the coding guidelines and best practices, healthcare professionals can ensure that signs of delirium are promptly identified, leading to better care and support 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-13, for detailed instructions on coding Item C1310D.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item C1310D: Signs of Delirium - Altered Level of Consciousness 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.