Minimum Data Sets are taken whenever a resident is admitted or discharged from a nursing home. They are important records that follow a resident to indicate their needs. In today’s episode, attorneys Rob Schenk and Will Smith discuss nursing home minimum data sets and their role in nursing home care with guest Margo Craig, a legal nurse consultant with Sentry Medical Legal Services.
Schenk: All right, welcome to the show. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And we are your co-hosts for this episode. I think this might be the longest title we have for a Nursing Home Abuse Podcast episode. I think this expands beyond like 180-characters here.
Smith: Yeah, and I think it could have just been “Understanding MDS Reports.”
Schenk: Well you know, and that’s what we’ll talk about, because people won’t know what an MDS report is. But if I say “minimum data sets,” people still probably won’t know what that is, and that’s the point of this episode. By the end of this episode, our audience will be informed about what a minimum data set is, why they are conducted, what they’re for and how to read them if you need to read them. But we’re not doing this alone. We will have lots of help, and that help is coming in the form of a special guest. Her name is Margo Craig. Will, tell us about Margo.
Smith: Margo is an RN, a registered nurse, and a legal nurse consultant who founded Sentry Medical Legal Services in 2007. She’s got over 30 years of nursing experience combined with criminal justice and forensic studies. And she is able to investigate and develop medically related legal claims for her clients who tend to be attorneys.
Her clinical backgrounds include many diverse practice areas with concentrations in long-term care, infusion therapy, labor delivery and nursery and oncology nursing, so dealing with cancer-related issues. Early in her nursing career, Margo was appointed the quality assurance director in a large hospital. She was responsible for the development and implementation of ongoing quality assurance activities based on standards established for accreditation by the joint commission and the state health department. The experience working with these physicians and hospital staff and later nursing home administration has given her significant insight into how to go about improving the quality and safety of resident and patient care, and we’re very happy to have Ms. Craig on today.
Schenk: Margo, welcome to the show.
Margo: Thank you so much. Thank you for having me. How are you all doing?
Schenk: We’re doing fantastic. Couldn’t be better.
Margo: Good.
Schenk: All right, Will. What do we got?
Smith: So Margo, what you’re going to be talking about today is you and I discussed this briefly before we started the podcast is one of the more complex issues in nursing home litigation and also just basic nursing home administration, and it’s the minimum data sets, what we call MDS reports. Let’s jump right into it. What exactly is a nursing home minimum data set, and when do they collect them?
Margo: Well the minimum data set is a comprehensive assessment tool and it’s used by nursing homes to gather information about residents in order to establish a plan of care. It’s required by the Centers for Medicare and Medicaid Services, and by the time it’s all done, it’s about 70 pages, so you can imagine, it’s pretty complicated and it’s either related with other aspects of nursing home care.
Schenk: So what is the data, from a general standpoint, what is the data that is collected?
Margo: Well when a new resident enters a nursing home, they start gathering historical data from family medical records, physicians, and in regards to whatever diagnoses and conditions they have, their functional status and anything that’s really going to impact them being able to maintain a reasonably – they call it a reasonably possible or practicable quality of life, so physical, functional, psychosocial status as well as the resident’s preferences are all included in that data.
Schenk: I guess that’s why it’s 70 pages.
Margo: That’s right. Exactly.
Smith: It kind of throws you off because it says minimum data set.
Schenk: The minimum amount.
Smith: It’s really the maximum data you can get.
Schenk: So Margo, how is the – you mentioned that the information, the data that’s placed into this document, can be acquired from other healthcare providers, but in general, is this an interview with the resident? Is it an interview with the family? Can you break down exactly how most of the time or a predominant amount of the information is acquired?
Margo: Right. Well the Centers for Medicare and Medicaid have a 1,300-and-something-page manual that tells you exactly how you’re supposed to gather that data and who’s supposed to get it and what’s supposed to be included. So God bless our nursing home staff and the people that are involved in this process for even attempting to satisfy all of that.
But the process really starts before a resident is admitted and if they’re in the hospital, the staff in the hospital start gathering information. The family has the opportunity to provide input and any type of medical records pertaining to physician’s office, home health, therapy can be included. But very important for families to know is that they do have the right to contribute to the data that is gathered, and their priorities for their loved ones need to be heard and must be included in the process.
So we have before admissions, and then just before admissions, the intake coordinator gathers forms and does interviews with the resident, if possible, and with family members or the legal guardians of the resident to get the ball rolling. And then process continues on. There’s a regular nursing assessment that happens on admission that’s a good-sized document on its own, but then within 14 days, they have to develop this huge data set based on all of those sources.
Schenk: So let me ask this. Let me jump into a more specific component of this, but the MDS, like you said, consists of a lot of different categories of assessments, so cognitive capacity a cognitive impairments, preferences, religious preferences, skin assessments, things like that – what do you see, in your experience, what is the family helping with in terms of the data that’s acquired? Where are they usually the most beneficial in the accumulation of the data that makes up the MDS?
Margo: Well unfortunately it’s been my experience that the family input is not considered as strongly as observational and medical record type of input. That’s an area we need to work on as a culture, but specifically, what illnesses they have experienced in their life, medications and treatments, things about that resident that would be helpful for anyone who’s going to start to provide care, such as are they used to getting up at 5 o’clock in the morning and milking the cows, you’re going to have a hard time keeping them in bed if they have dementia until 9 o’clock when breakfast is ready.
Schenk: Right.
Margo: So there are behavioral concerns if we don’t respect the person’s prior life. And then of course there are medical conditions that have been managed for a long time on either medication therapies or just conservative home management, and all of those things can be helpful to a staff if they accept the task of providing care.
Schenk: And so the family can have input oftentimes – well not oftentimes, but sometimes it can be disregarded or not place in a priority with medical records or other data. I guess, the next question I would have then if I’m a family member is when do we expect that an MDS is done? I know that by operation of law, it’s required to be done – can you kind of elaborate on that?
Margo: Well the nursing homes that I have dealt with really do a pretty good job of meeting their deadline of completing that data set. There are consequences for failing to do things. I guess they’ve made it significant enough of a consequence for not meeting their deadlines that they’ll do it, but what that causes, having these looming deadlines, the first one being at 14 days, the data collection begins on admissions and it’s added to throughout that 14-day period, and the outcome of having these stringent guidelines is whether it’s practical or not, by golly, we’re going to finish it, but it may not be a very good quality instrument.
If it is erroneous, it can be amended, but I’ve been to care planning conferences and talked to other care planners in other facilities, and I did this when I was a bit younger and on fire, “let’s do this the best we can,” and they laughed at me. They said, “Oh, you are never going to have time to do that the way it needs to be done, but hit the high spots and do the best you can.”
Schenk: Because I guess in our experience, when the MDS has been completed appropriately to the best of their ability, it seems to me you’ve got multiple personnel doing these assessments over the course of these 14 days. You’ll see that one nurse might have filled out the skin assessment on day four, whereas one person might have done a BIM score day one.
Margo: Right.
Schenk: But then it’s finalized on that 14th day, and you’re looking at six different people having done six different tasks as opposed to maybe one person scribbling it all down on day 14.
Margo: Yeah, that is true. There are a lot of people contributing, and one of the goals of the Centers for Medicare and Medicaid to improve care was because some of the errors and injuries that happened in nursing homes were due to poor communication, and so this document, this data set, was intended to solve that, but because it’s such a big deal, it really does cause somewhat of a fragmentation, because too many cooks spoil the pot in the kitchen sometimes.
Schenk: Yeah.
Smith: Absolutely. So where do you see a lot of issues with MDS reports?
Margo: Well for what I’ve been doing for the last 10 years, which is investigate claims of injury and help develop cases, I’m seeing more and more nursing home cases being brought. Are you seeing that in your practice as well?
Smith: Oh, absolutely. It’s unfortunately a burgeoning area in plaintiff’s law.
Margo: Right. So as the cases come across my desk, they really do boil down to some very foundational nursing issues, such as overdosing someone on Coumadin. It’s been around for how many years? We really should understand how to get that safely, and yet people are so hurried. I like to say in my own life when I’ve taken on too much, I say, “I am too busy to think.” And that’s what I’m seeing in nursing home cases. These staff members are pushed to the wall day-in and day-out to the point where they can’t even rely on the very basic nursing principles that would make such a difference, like looking at your medications list and actually reading it instead of glancing at it and saying, “Oh, I’ve got to get Coumadin. What time do I have to get it? It’s 9 o’clock and it’s already – it’s a 9 o’clock dose and it’s already 9:45. I’m late. I’ve got to hurry,” and you grab that dose and you go give it, and it may be you’re giving the wrong day’s dose or something very simple, human error and those things just keep happening because people are in such a hurry.
The other thing I’m seeing – sorry, did I interrupt?
Schenk: No, go ahead.
Smith: Go ahead.
Margo: Okay. The other thing I’m seeing is a lot of wounds where even 20 years ago, there didn’t seem to be quite as many, and I’m seeing more now. So if you think about how much an adult person weighs when they’re unable to really help themselves out of the chair or to turn effectively, just think about three stacks of concrete, which is about what an adult person weighs, and whether or not you can just pick that straight up in the air without dragging it across the sheets and causing damage. So I’m seeing not enough staff that’s causing simple human errors and then all of this, incontinence and improper use of mobility is causing more and more skin breakdowns.
Schenk: Yeah, that’s on our side as well. We’re seeing a lot of those types of cases.
Margo: Yeah.
Schenk: With regard to the MDS, we’ve talked about that it’s required by CMS. We’ve talked about the time frame in which CMS requires that it be conducted, but can you go a little bit more into like what purpose does the MDS, what purpose does it have with regard to the care, with regard to the administration of the treatments? Where does it fit alongside other, or if it is a medical document, if you consider it a medical document, where does it fit alongside other documents in the resident’s chart?
Margo: Right. Well since it contains information gathered as primarily part of a nursing assessment, but there are segments in there for all of the healthcare professionals who provide care, whether it’s therapy or dietary, occupational, physical, whatever they’re getting, everyone weighs in, and so as everyone contributes to this information that we have about this person, the computer then crunches the data and gives you a list of what they call triggers, or red flags, really, that will help the healthcare providers understand more about ways that these conditions are going to contribute to their risk for complications.
For example, someone who has had a stroke in the last few weeks is now maybe has residual weakness on one side and some swallowing difficulties, but they can still eat. But maybe it’s on their right side and now they have to eat left-handed. So there are all kinds of simple, daily functions that are going to be totally different for this patient. And the computer does a fair job, not a great job, of saying, “Hey, you now have potential for skin breakdowns, aspiration pneumonia, swallowing difficulties, complications of immobility, like the arm that’s affected may draw up and can lead to further skin breakdown on bony prominences. So when we say is it a standalone document, it’s really the beginning of a process, and so it’s going to help you think through the aspects of care that are customized to this patient’s condition at the time of the assessment.
Schenk: That makes sense. So it’s the data that’s used to prepare the care plan.
Margo: Right.
Schenk: And so in that regard, in a family member or a resident, him or herself, are they allowed to view the MDS? And if so, do they just go, “Hey, can I go take a look at the data that you used to create this care plan?” Is that an easy process in your experience?
Margo: Well most people who enter the nursing home have some degree of cognitive decline and many of them will have a family member that has power of attorney. So the MDS is not available to just anyone who wants to look at it, but the patient certainly has access to it, but as far as their legal representative, there’s likely a process for getting permission to see it, so you wouldn’t want the neighbor up the street to come and see your medical records.
Smith: It’s still medical records. You still need to overcome HIPAA or get some sort of HIPAA release.
Schenk: Yeah.
Smith: Yeah, exactly.
Margo: Right.
Schenk: And then, Margo, we talked about a 14-day assessment. What are the other times that an MDS report would need to be generated? What are the times in which they would need to update that was originally updated?
Smith: And do they update it?
Schenk: Do they?
Smith: Yeah.
Margo: Right. Well I identified about 13 different reasons why it would need to be updated. So I will try to do that in a concise way. The 14-day one is considered a comprehensive admissions assessment, and that’s the 65-or-so pages of forms. They also prompt the staff to fill out other assessment forms, so you’ve really got more than 65 pages. You’ll have a skin assessment, a fall risk assessment on most people, so it’s a lot.
But any time there is a significant change, and unfortunately a lot of people are injured or have a significant decline within the first few weeks of going to a nursing home, so these significant changes happen pretty frequently, so you’ve got a lot of MDSes being generated, or they’re supposed to. They don’t always get done, but a significant change of status is not a gradual decline like you’ll get with some types of diseases. This would be a major decline in a short period of time, something like when they came in, they could get up to the bathroom and a month later, they’re in a wheelchair all day in a diaper. So those kinds of things are considered significant changes. So that’s going to be a reason to have to do another MDS.
The quarterly ones are done, obviously, three times a year and then at the end of the year, you’ll do an annual one. So the quarterly MDS are not as involved as the comprehensive one. There are select items that you have to do each time, and the care plan may or may not change based on the outcome of that update.
But then you have the question of hospitalization. So if someone has a brief hospitalization, like less than 24 hours, we expect them to come back in to the nursing home after being treated, then they just do a simple transfer entry form and an MDS isn’t required. But if they’re discharged without an expected return, but they are then admitted again after a hospitalization, then an MDS has to be generated.
Schenk: And will that be a comprehensive one again or will that be just like a quarterly one?
Margo: I believe it’s a comprehensive one but I will have to look that one up.
Schenk: I believe that you’re right as well.
Smith: Yeah.
Margo: Yeah.
Smith: Yeah, it would make sense.
Margo: So if a resident goes from one nursing home to another, and this happens a lot when someone goes to the hospital, even briefly, that bed that they were in may be taken by a new resident and they’ll go to a different nursing home when they leave there, and then that nursing home is required to do a whole other MDS.
Let’s see, what else? If there is a 30-day gap in care, whether they go home or they go somewhere – hospital, and it’s more than 30 days, I believe they have to have a whole new MDS. So there are a couple of pages in that manual, but it’s like reading Latin.
Schenk: Yeah, I agree with you. I agree with you.
Margo: To figure out, “Okay, now when, but okay, 24, but how about 36 hours?”
Smith: Right.
Schenk: Right.
Margo: It raises more questions than answers sometimes.
Smith: Yeah.
Margo: But there is one nurse in each facility, one registered nurse that’s required to coordinate all of that, and boy, does she have a big job. Most nursing homes have close to 100 people, and all of them have to have all those MDSes done quarterly, so you can imagine it’s a never-ending story.
Smith: It’s around the clock. Yeah, she never finished. Ever.
Margo: No. No. When I did it, I had three young children, and I would try to finish in eight hours, and I started coming in earlier and earlier and earlier. I’m getting there at 4:30, 5 o’clock in the morning so that I could finish, and it was just a lot of pressure because I was not one who would take shortcuts.
Smith: You were actually doing what you were supposed to do.
Margo: I was doing it, yeah.
Schenk: And so is there an individual generally that is assigned to sign off on the MDS reports?
Margo: Well she is required to sign it, and then any of the contributors, any of the professionals that are pertinent – you wouldn’t have a physical therapist sign an MDS for someone who’s not getting physical therapy – but any of the disciplines that are involved in the data collection are supposed to sign. The physician does not have to sign, but his data has to be included. So I’m not seeing physicians getting involved really in the MDS, and most of them admit to not even reading them.
Schenk: Yeah, that’s been our experience as well. And can you speak to – they’re signed and submitted to CMS under penalty of perjury, right?
Margo: It’s a big deal, yeah.
Schenk: Yeah. No lying on this stuff.
Smith: Yeah.
Margo: No. Don’t fudge.
Schenk: And Margo, some of our audience are family members of individuals that are residing in nursing homes, and some of our audience are attorneys of different stripes. If anyone wants to get a hold of you, how would they do that? How would they give you a call or shoot you an email?
Margo: Right. Well my website is SentryLegalNurse.com, and that’s spelled S-E-N-T-R-Y. And so there are plenty of ways to contact me on there. My email address is sentrylegalnurse@gmail.com, and my phone number is 256-426-8371. And I would be happy to answer any questions.
Smith: And we’re going to put that information up there because what you do and your specific skillset with knowledge on MDS reports is really invaluable. I mean these are not some things that you’re just going to look at for the first time and figure out and go, “Okay, I’ve got it now.” It’s way more complicated.
Margo: That’s like me trying to do your job in filing a brief.
Smith: Yeah, absolutely.
Margo: No, we are all in this together, and it does take someone with clinical insight to really understand how to investigate and develop these cases. I very much appreciate your kind words and your honor for me to take part in contributing to quality care. My family members, many of them live in their 90s and even one to 104. I adore the elderly and the nursing homes, some of them I’ve been to resemble the old poor house from really old movies with just devastating, very poor living conditions, but hopefully with your help bringing awareness and with all these lawsuits being brought, maybe we can get some more staff in there to make that better.
Schenk: That’s right.
Smith: Absolutely.
Schenk: I hope so. Well awesome, Margo. Thank you again for coming on the show and sharing your knowledge and hopefully we’ll get you back on the program real soon.
Margo: I would be happy to do that. Thanks for inviting me.
Smith: Thank you, Margo.
Schenk: Thanks. Bye-bye.
Margo: Bye-bye.
Schenk: Yeah, she’s great.
Smith: Yeah, she’s extremely knowledgeable about a specific area that is extremely complex and confusing.
Schenk: Yeah.
Smith: So that is very helpful.
Schenk: Here’s something that is also extremely complex and confusing. It’s why, as children, my family forced my mother to not only make stuffing like from the brand Stovetop Stuffing, so we have Stovetop-brand stuffing, but we also make her cook from scratch Mimi’s famous stuffing for Thanksgiving. So we have literally two different casserole dishes with stuffing in them. Like we want the cheap, terrible stuffing, but we also make her get up at 4 in the morning to make stuffing from scratch. Like it’s the real deal. What do you got?
Smith: That’s it. I don’t know what we’re going to do Thursday. I think Clay has to work. As a nurse, he’s always on duty. So I may just go up there and cook something. We may cook out, something like that.
Schenk: Are you going to make a turkey?
Smith: I’m not a huge fan of turkey. I don’t like turkey.
Schenk: I think we talked about this last year, literally the same thing, and I think I talked about frying turkeys. My brother has a hook-up on a dude that fries turkeys. And I think we talked about how people explode their houses trying to make fried turkeys?
Smith: Yes, yes. Yeah. I’ll probably cook a ham on the grill, some sort of pork.
Schenk: Yeah.
Smith: We like pork.
Schenk: Yeah. But this is going to be the first Thanksgiving with Daniela there. I think the first Thanksgiving with Daniela at all, because she’s either been away at work or been out of the country.
Smith: Ah, yes.
Schenk: And it’ll be her first Thanksgiving here as fiancée. So this is going to be interesting.
Smith: Interesting. It’s not going to be any different.
Schenk: No, she’s going to be like, “What is this stuffing? Why is there two stuffings?”
Smith: That’s what she sounds like.
Schenk: “I don’t understand stuffing.”
Smith: She’s Brazilian.
Schenk: So anyways. I guess with that, everybody, we wish for you to have a happy and safe Thanksgiving. Say hi to all your family for us. Be sure that on those long drives to listen to old episodes of the Nursing Home Abuse Podcast. There are, at this point, 95 of them to choose from. I like Episode 29. Just throwing it out there because they’re all equally good.
Smith: Oh, okay.
Schenk: Yeah. Anyways, you can watch this episode or any episode on our YouTube channel or on our website, which is NursingHomeAbusePodcast.com, or you can check us out on iTunes, Stitcher, Spotify, Google Play, Podcast Puppies, or wherever you get your podcasts from. And with that, happy Thanksgiving and we’ll see you next time.
Smith: See you next time.
