Section K

Swallowing / Nutritional Status

MDS 3.0

By: Shelly Proctor RN, RAC-CTValley Vista Care

Objectives: State the intent of Section K. Describe the process for conducting

a resident’s nutritional assessment. Calculate a resident’s weight change

correctly. Code Section K of MDS 3.0 correctly. Determine Care Area Triggers.

Objectives continued: Describe the Care Area

Assessment process.

Explain resident centered care plans.

Intent of Section K:

To assess conditions that could affect the resident’s ability to maintain adequate nutrition and hydration.

K0100: Swallowing Disorder

Rationale: Safe swallowing ability can be affected by functional decline and several different disease processes. An alteration in a resident’s ability to swallow can result in choking &/or aspiration which can in turn, increase their risk for malnutrition, dehydration, and aspiration pneumonia.

Care Planning:

Include provisions for monitoring the resident during mealtimes or other occasions when the resident consumes food &/or fluids.

Additional evals necessary? Assess for s/s suggesting the swallowing

disorder has not been successfully treated.

Goal: Assist resident to maintain safe & effective swallow.

Assessment: Ask the resident

Observe

Interview staff

Review the medical record

Coding Instructions:

Check all that apply K0100A-Loss of liquids/solids from mouth when eating or

drinking.

K0100B-Holding food in mouth/cheeks or residual food in mouth after meals.

K0100C-Coughing or choking during meals or when swallowing medications.

K0100D-Complaints of difficulty or pain with swallowing.

K0100Z-None of the above.

Coding Tips: Do not code when

interventions have been successful.

Do code even if the symptom happened only one time in the 7-day look-back period.

K0200: Height and WeightRationale: Diminished nutritional and hydration status can lead to debility that can adversely affect a resident’s health and safety as well as their quality of life.

Care Planning: Knowing a resident’s height &

weight helps staff to assess their nutrition & hydration status by providing a mechanism for monitoring the stability of their weight over a period of time.

Knowing the weight is one guide for determining nutritional status.

Steps for assessment: K0200A-Height

-Measure resident upon admission in inches.-Consistent measurements over time.-If last height recorded was > 1 year,

re-measure.

Coding Instructions: Record to the nearest whole inch.

Use mathematical rounding.-Example: 62.5 inches would be

rounded to 63 inches.

Steps for assessment:

K0200B-Weight-Weigh resident on admission.-For subsequent assessments, record

weight taken w/in 30 days of the ARD.-If >30 days, re-weigh.-Record weight closest to ARD.-Measure consistently.

Coding Instructions:

Use mathematical rounding.

If weight cannot be obtained, use the standard no-information code (-) and document rationale in the medical record.

K0300: Weight Loss

Rationale: Weight loss can result in debility and can

adversely affect a resident’s safety, health, & quality of life.

For those with morbid obesity, a controlled & careful weight loss plan can improve their mobility and overall health status.

For persons with fluid overload, careful and safe diuresis can improve their health.

K0300: Weight Loss 5%5% weight loss in 30 days:-Determine the resident’s weight closest to 30 days ago & multiply it by 0.95 or 95%. The resulting # represents a 5% loss from the weight 30 days ago. If the resident’s current weight is = to or < than the resulting #, the resident has lost more than 5% of his/her body weight.

K0300: Weight Loss 10%

10 % weight loss in 180 days

-Determine the resident’s weight closest to 180 daysago & multiply it by 0.90 or 90%. This # represents a10% loss from the weight 180 days ago. If the

current weight is = to or < than the #, then the resident has lost 10% or more body weight.

Other Definitions: Physician Prescribed Weight Loss

Regimen

Body Mass Index (BMI)

Steps for assessment: This item compares the resident’s weight in the

current observation period to his/her weight at two snapshots in time:

-At a point closest to 30 days preceding the current

weight.-At a point closest to 180 days preceding the

current weight.

This item does NOT consider weight fluctuationsoutside of these two time points.

New Admission: Ask the resident or family about

weight changes in past 30 days & 180 days.

Consult with the MD. Review transfer documentation. If admit wt is < previous wt, calculate

the loss.

Subsequent Assessments

Coding Instruction Definitions:

Mathematically round weights before doing the

calculation.

Code 0, no or unknown.

Code 1, yes on physician-prescribed weight loss regimen.

Code 2, yes, not on physician-prescribed weight loss regimen.

Coding Tips

Example #1: Mrs. J has been on a physician

ordered calorie-restricted diet for the past year. She & her physician agreed to a plan of weight reduction. Her current weight is 169#. Her weight 30 days ago was 172# & her weight 180 days ago was 192#.

How should you code K0300?

Example #2: Ms. K underwent a BKA. Her

preoperative weight 30 days ago was 130#. Her most recent postoperative weight is 102#. The amputated leg weighed 8#. Her weight 180 days ago was 125#.

How should you code K0300?

K0500: Nutritional Approaches

Rationale:

Approaches that vary from the “norm” or that rely on alternative methods can diminish one’s sense of dignity & self-worth. They can also diminish pleasure in eating. A resident’s clinical condition may benefit from approaches included here. It is important to work with the resident/family to establish nutritional support goals that balance preference & overall clinical goals.

K0500 Nutritional Approaches

Care Planning: Alternative approaches should be

monitored to validate effectiveness.

Include periodic reevaluation.

Definitions: Parenteral/IV Feeding

Feeding Tube

Mechanically Altered Diet

Therapeutic Diet

Steps for Assessment:

Review the record to determine if any of the listed nutritional approaches were received by the resident during the 7-day look-back period.

Coding Instructions:

K0500A, parenteral/IV feeding K0500B, feeding tube K0500C, mechanically altered diet K0500D, therapeutic diet K0500Z, none of the above

Coding Tips:

K0500 includes any & all nutrition & hydration received by the nursing home resident in the last 7 days either at the nursing home, at the hospital as an outpatient or an inpatient, provided they were administered for nutrition or hydration.

Tips continued: Parental/IV feeding-The following fluids may be

included when there is supporting documentation that reflects the need for add’l fluid intake specifically addressing a nutrition or hydration need:

IV fluids or hyperalimentation, including TPN (continuous or intermittently).

IV fluids running at KVO IV fluids contained in IV Piggybacks. Hypodermoclysis & subcutaneous ports in

hydration therapy.

Do NOT code in K0500A: IV medications. IVF’s given solely for the purpose of

“prevention” of dehydration. IVF’s given as a routine part of an

operative or diagnostic procedure or recovery room stay.

IVF’s given solely as flushes. Parenteral/IVF’s given in conjunction

with chemo or dialysis.

Enteral Feeding Formulas: Should not be coded as a

mechanically altered diet.

Should only be coded as K0400D, Therapeutic Diet when the enteral formula is to manage problematic health conditions, (i.e.: enteral formulas specific to diabetics).

Examples

K0700: Percent Intake by Artificial Route

Complete only if K0500A or K0500B is checked. Otherwise, skip to Section L.

Rationale:

Health-related Quality of Life.

Care Planning.

Steps for assessment (K0700A): Proportion of Total Calories through Parenteral or TF in last 7 days

Review intake records. Determine actual intake through

parenteral or tube feeding routes. Calculate proportion of total calories

through these routes. If no food/fluids via mouth or only sips,

stop here & code 3, 51% or >. If resident had more substantial oral

intake than this, consult with the RD.

Coding Instructions: Select the best response:

1. 25% or less2. 26% to 50%3. 51% or more

Calculate Proportion of Total Calories from IV or TF:

Dietician reported calories/day below:

Oral TubeSunday 500 2,000Monday 250 2,250Tuesday 250 2,250Wednesday 350 2,250Thursday 500 2,000Friday 250 2,250Saturday 350 2,000

How should you code K0700A?

Answer? Review calculation Rationale

K0700B: Average fluid intake/day by IV or TF in the past 7 days.

Review intake records. Add up total amt of fluid rec’d each day

by IV or TF only. Divide the week’s total fluid intake by 7

to calculate the average fluid intake/day.

Divide by 7 even if the resident didn’t receive IVF’s &/or TF on each of the 7 days.

Coding Instructions:

Code 1: 500 cc/day or less

Code 2: 501 cc/day or more

Example: Ms. A has swallowing difficulties

secondary to Huntington’s disease. She is able to take oral fluids by mouth w/ supervision, but not enough to maintain hydration. She received the following daily fluid totals by supplemental tube feedings (including water, prepared nutritional supplements, juices) during the last 7 days.

Example continued:

Sunday: 1250ccMonday: 775ccTuesday: 925ccWednesday: 1200ccThursday: 1200ccFriday: 500ccSaturday: 450ccTotal: 6,300cc

Calculate her average daily fluid intake for K0700B: Calculation:

6300 / 7 = 900cc/day

* Because 900cc is > than 500cc, you should code 2, 501cc/day or more.

Care Area Triggers (CAT’s): Review Nutritional Status triggers.

Review CAT Legend.

Care Area Assessments (CAA’s):

Refer to Chapter 4 & Appendix C of the RAI Manual.

Specific Resources.

General Resources.

CAA’s continued: “…nursing homes should ensure

that whatever assessment and care planning resources are used are current, evidence-based or expert-endorsed research and clinical practice guidelines/resources.”

Appendix C, RAI Manual, 3.0 Version, June 2010

Transitioning

MDS 2.0 to MDS 3.0

Questions?

Sources

CMS MDS 3.0 Information Sitewww.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage