Percent of Residents Who Made Improvements in Function – My facility generally performs very well in this Quality Measure but we have recently seen fewer residents triggering and a decline in our percentage. Most of our short-term residents are discharging to the community and therapy reports that residents are improving. What should I be monitoring to ensure accuracy for this measure?


This measure reports the percentage of short-stay residents who were discharged from the nursing home that gained more independence in G0110B1: transfer, G0110E1: locomotion on unit, and G0110D1: walk in corridor during their episodes of care. There may be several things to consider when reviewing this measure.

      1. Where is the documentation for the MDS coming from – CNAs, Therapy, both? Oftentimes, therapy may report an improvement but the MDS is coded based on CNA documentation that may not reflect an improvement (based on a misunderstanding of the Section G items, or differences in the resident’s ability for nursing vs. therapy).
      2. Is Section G coding accurate? It’s important to review each assessment used in the measure calculation. It’s possible that coding on the admission/5-day OR discharge may not accurately reflect the resident’s ability, either of which can affect the outcome.
      3. Is all other MDS coding accurate? There are certain exclusions and covariates for this measure that need to be accurately reported. For example, if the discharge was unplanned (A0310G = [2]) the resident will be excluded from the measure.
      4. What is the length of stay? If the stay is short (for example, 5-day assessment date 9/15 and discharge assessment date 9/17) the observation periods may overlap and leave no room for a documented improvement. You may consider scheduling the 5-Day assessment earlier for short stays to capture an improvement by discharge and/or if scheduling requirements permit, combining the 5-Day with the discharge as this combined assessment will not be included in the QM.
      5. If MDS coding is verified to be accurate and there is truly no improvement, consider reviewing other facility processes that may need attention (staffing, therapy, restorative nursing, etc.)


Eleisha Wilkes, RN, GERO-BC, RAC-CT, DNS-CT
Clinical Consultant

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