There are 3 primary facets to the effective management of the quality measure (QM) Percentage of Long Stay Residents Who Lose too Much Weight: 1. Understanding the ins and outs of the QM calculation2. Ensuring Correct MDS Coding of Weight and Weight Loss 3. Preventing Weight Loss in the Nursing Home Setting
Understanding the Quality Measure Calculation
The Percentage of Residents Who Lose Too Much Weight measure captures the percentage of long-stay residents who had a weight loss of 5% or more in the last month or 10% or more in the last 6 months who were not on a physician prescribed weight-loss regimen noted in an MDS assessment during the selected quarter.
The Numerator consists of long-stay nursing home residents with a selected target assessment which indicates a weight loss of 5% or more in the last month or 10% or more in the last 6 months who were not on a physician prescribed weight-loss regimen (K0300 = ).
The Denominator consists of long-stay nursing home residents with a selected target assessment except those with exclusions.
- Target assessment is an OBRA Admission assessment (A0310A= ) or a PPS 5-Day assessment (A0310B= )
- Prognosis of life expectancy is less than 6 months (J1400 = ) or the Prognosis item is missing (J1400 = [-]) on the target assessment.
- Receiving Hospice care (O0100K2 = ) or the Hospice care item is missing (O0100K2 = [-]) on the target assessment.
- Weight loss item is missing (K0300= [-]) on the target assessment.
In simple terms, this QM will trigger for a resident that meets all of the following:
- Has been in the facility for 101 or more days (without a discharge as described above), AND
- Has had a loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and is not on a physician prescribed weight-loss regimen (MDS item K0300 =  on the target assessment), AND
- Does not have a prognosis of life expectancy of less than 6 months (MDS item J1400=  on the target assessment), AND
- Is not receiving Hospice care (MDS item O0100K2 =  on the target assessment), AND
- MDS item K0300 is not dash filled on the target assessment.
Ensuring Correct MDS Coding of Weight and Weight Loss
It is essential to ensure the weight is coded correctly. The RAI manual has specific instructions on accurately assessing and coding the weight.
Steps for Assessment for K0200B, Weight
- Base weight on the most recent measure in the last 30 days.
- Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.).
- For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment.
- If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again.
- If the resident’s weight was taken more than once during the preceding month, record the most recent weight.
Coding Instructions for K0200B, Current Weight
- Use mathematical rounding (i.e., If weight is X.5 pounds or more, round weight upward to the nearest whole pound. If weight is X.1 to X.4 pounds, round down to the nearest whole pound). For example, a weight of 152.5 would be rounded to 153 and a weight of 152.4 would be rounded to 152.
- If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no-information code (-) and document rationale on the resident’s medical record.
How to Calculate Weight Loss
- 5% WEIGHT LOSS IN 30 DAYS: Start with the resident’s weight closest to 30 days ago and multiply it by .95 (or 95%). The resulting figure represents a 5% loss from the weight 30 days ago. If the resident’s current weight is equal to or less than the resulting figure, the resident has lost more than 5% body weight.
- 10% WEIGHT LOSS IN 180 DAYS: Start with the resident’s weight closest to 180 days ago and multiply it by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident’s current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight.
K0300 compares the resident’s weight in the current observation period with his or 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.
EXAMPLE OF WEIGHT COMPARISON: If the ARD is 8/1/23 and the most recent weight within 30 days was obtained on 7/20/23, then the 30-day comparison weight would be the weight closest to 30 days from 7/20/23, NOT 8/1/23. The same applies for the 180-day comparison, using 180 days prior to 7/20/23
Second, make sure weights are accurate.
Best practices for obtaining accurate weights:
- Perform routine maintenance on your scales and have them calibrated according to manufacturer’s recommendations.
- Start with an accurate admission weight by obtaining daily weights X 3 to set the baseline weight.
- Attempt to weigh residents at the same time of day using the same scale if possible.
- Incorporate the practice of obtaining a reweight within 24-48 hours if weekly/monthly weight differs by 5 or more pounds.
Preventing Weight Loss in the Nursing Home Setting
Common conditions that may result in weight loss in the elderly include disease process, medication use, psychological issues and pain/discomfort. Here are some examples of conditions/factors which may contribute to the risk of weight loss-
- Alzheimer’s Disease or Dementia
- Gastrointestinal Issues
- Heart Disease
- Side Effects of Medications:
- May alter sense of smell or taste
- Dry mouth
- Psychological Issues
- Progression of Alzheimer’s and dementia
- Mood Disorder
- Pain when trying to chew or swallow
- Abdominal Pain
- Chronic pain issues
Treatment Interventions should be related to the specific causes/risks for weight loss identified for each individual. Examples of person centered interventions include:
- Diet changes – food preferences, liberalized diet; small frequent meals; enhanced/fortified foods; scheduled snacks; increased portion sizes, finger foods
- Modifications to the Dining location/environment – restorative dining; larger or smaller dining room; in room dining; up in chair for meal, table location (near window for natural light, facing away from kitchen or other distractions)Functional Adaptations -Adaptive equipment, modified diet
- Referrals/Consultations – Physician for tx of disease or other symptoms; Pharmacist review of medication regime; Dental consult for denture adjustments, tooth decay, oral pain, etc.; Speech Therapist for chewing/swallowing difficulties; Occupational Therapist for coordination, visual perceptual deficits, attention to task, assistive devices; Registered Dietician
- Psychosocial – Family involvement with meals; activities that include food; considerations for table mates that may promote intake
- Monitoring – NAR (Nutritionally at Risk) weekly review; detailed intake records (to determine if resident is consuming the fortified foods, snacks, large portions, etc.); weight review per policy
- Staff Education and QAPI Involvement – as indicated for compliance with nutrition/weight related policies and protocols.
In conclusion, obtaining/monitoring accurate weights and food intake should be a priority in the identification and prevention of unplanned weight loss. Accurate coding of the MDS items for weight (K0200B), unplanned weight loss (K0300) and QM exclusions (J1400 or O0100K2) must also be a priority. If these two processes are in place, then you are well on your way to managing the QM Percentage of Residents Who Lose Too Much Weight. Make Proactive part of your 5 Star Team—contact us to learn more about QM support services. Register to join us September 21, 2023 for the MDS Mastermind Webinar: Expert Quality Measure Management
Written By: Angie Hamer, RN, RAC-CT
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