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Q:
For section GG, we understand that unless the professional-nurse or therapist-views the resident doing the task we would fill out 88. Instead, the therapy provider is using their “clinical judgement” . For example, resident may be dependent, can walk 5’ with max assist barely. They know they wouldn’t be able to walk 10, 30, 150’ feet so they are coding this a 1, not 88. We believe we should code these 88 because we didn’t observe the resident walk these distances. Should they be doing it differently, or should we?
A:
RAI pg. GG-15: Code based on the resident’s performance. Do not record the staff’s assessment of the resident’s potential capability to perform the activity. If the resident is unable to complete an activity, one of the activity not attempted codes should be used. Per RAI page GG-40: If the resident does not attempt the activity and a helper does not complete the activity for the resident during the entire assessment period, code the reason the activity was not attempted. For example, code as 07, if the resident refused to attempt the activity; code as 09, if the activity is not applicable for the resident (the activity did not occur at the time of the assessment, and prior to the current illness, exacerbation, or injury); code as 10, if the resident was not able to attempt the activity due to environmental limitations; or code as 88, if the resident was not able to attempt the activity due to a medical condition or safety concerns.
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Blog by Jessica Cairns, RN, RAC-CT, Clinical Consultant, Proactive Medical Review
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