Section K

1. Section K Swallowing / Nutritional Status MDS 3.0 By: Shelly Proctor RN, RAC-CT Valley Vista Care

2. 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.

3. Objectives continued: • Describe the Care Area Assessment process. • Explain resident centered care plans.

4. Intent of Section K: • To assess conditions that could affect the resident’s ability to maintain adequate nutrition and hydration.

5. 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.

6. 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.

7. Assessment: • Ask the resident • Observe • Interview staff • Review the medical record

8. 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.

9. 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.

10. K0200: Height and Weight Rationale: 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.

11. 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.

12. Steps for assessment: • K0200A-Height -Measure resident upon admission in inches. -Consistent measurements over time. -If last height recorded was > 1 year, re-measure.

13. Coding Instructions: • Record to the nearest whole inch. • Use mathematical rounding. -Example: 62.5 inches would be rounded to 63 inches.

14. 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.

15. Coding Instructions: • Use mathematical rounding. • If weight cannot be obtained, use the standard no-information code (-) and document rationale in the medical record.

16. 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.

17. 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.

18. K0300: Weight Loss 10% 10 % weight loss in 180 days -Determine the resident’s weight closest to 180 days ago & multiply it by 0.90 or 90%. This # represents a 10% 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.

19. Other Definitions: • Physician Prescribed Weight Loss Regimen • Body Mass Index (BMI)

20. 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 fluctuations outside of these two time points.

21. 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.

22. Subsequent Assessments

23. 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.

24. Coding Tips

25. 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?

26. 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?

27. 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.

28. K0500 Nutritional Approaches

29. Care Planning: • Alternative approaches should be monitored to validate effectiveness. • Include periodic reevaluation.

30. Definitions: • Parenteral/IV Feeding • Feeding Tube • Mechanically Altered Diet • Therapeutic Diet

31. 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.

32. Coding Instructions: • K0500A, parenteral/IV feeding • K0500B, feeding tube • K0500C, mechanically altered diet • K0500D, therapeutic diet • K0500Z, none of the above

33. 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.

34. 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.

35. 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.

36. 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).

37. Examples

38. K0700:Percent Intake by Artificial Route Complete only if K0500A or K0500B is checked. Otherwise, skip to Section L.

39. Rationale: • Health-related Quality of Life. • Care Planning.

40. 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.

41. Coding Instructions: • Select the best response: • 25% or less • 26% to 50% • 51% or more

42. Calculate Proportion of Total Calories from IV or TF: • Dietician reported calories/day below: OralTube Sunday 500 2,000 Monday 250 2,250 Tuesday 250 2,250 Wednesday 350 2,250 Thursday 500 2,000 Friday 250 2,250 Saturday 350 2,000

43. How should you code K0700A? • Answer? • Review calculation • Rationale

44. 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.

45. Coding Instructions: • Code 1: 500 cc/day or less • Code 2: 501 cc/day or more

46. 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.

47. Example continued: Sunday: 1250cc Monday: 775cc Tuesday: 925cc Wednesday: 1200cc Thursday: 1200cc Friday: 500cc Saturday: 450cc Total: 6,300cc

48. 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.

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

50. Care Area Assessments (CAA’s): • Refer to Chapter 4 & Appendix C of the RAI Manual. • Specific Resources. • General Resources.