Achieving Accurate ADLs

The MDS nurse faces challenges when ADL documentation is sparse or even conflicting.  Everyone wants accurate ADL’s, but how often do we fall short?  How have pandemic staffing issues affected ADL accuracy?

The “Rule of Three” indicates we should use the most dependent level that occurred at least three times (with certain exceptions). The RAI (Resident Assessment Instrument) Manual also gives directions on what to do when an activity does not occur at any one time.

Digging deeper into the RAI, we can find specific tools to make our documentation and coding more accurate. Are you and your staff applying all the following approaches?

Staff only: The RAI states that this section includes, “… support provided by staff over the last 7 days, even if that level of support only occurred once.” This means that a resident who had all their care provided by family members throughout the lookback can be coded as “activity did not occur” even if they remained in the facility. Episodes of care provided by family members do not count. Make sure your documenting staff know this and do not enter family provided care into the medical record.

Independent and total dependence: Per the RAI Manual, these two levels of care are exceptions to the Rule of Three. When either level of care does not get documented every time, there are instructions in the manual on how we should code. If caregiving staff code either level of care every single time but there are gaps in the coding (missing documentation from that shift), then we are left with a dilemma. We can interview staff and add a note for that shift to correct the mistake. Otherwise, we have to change the coding from either independent to supervision or from total dependence to extensive assist as appropriate.

Rule of Three for column 1: Per the Manual, “If none of the above are met, code supervision.” So, if the documentation is being reviewed and does not fit any Rule of Three categories or exceptions, coding supervision is indicated by the rules. Even if the resident is not clinically at that level this is appropriate as it is based on the RAI Manual rules and the presence/absence of documentation.

Support provided, column 2: When it comes to the second column in G0110, the rules are different. This is a challenging twist because sometimes the two columns do not seem to line up. For example, a resident may be coded supervision in column one and two-assist in column two. Why?  Because the Manual rules for column two state that we should “Code for the most support provided over all shifts. Code regardless of how Column 1 ADL Self-Performance is coded.”

Bathing: Bathing should include documentation of, “How the resident takes a full body bath, shower, or sponge bath, including transfers in and out of the tub or shower. It does not include the washing of back or hair.” Make sure that your staff know what activities to count. The Bathing activity does not follow the Rule of Three but should be coded on the MDS at the most dependent level.

Bed Transfers: For coding bed transfers, consider the level of care on any furniture that the resident uses as a bed. The RAI Manual states, “Some residents sleep on furniture other than a bed (for example, a recliner). Consider assistance received in this alternative bed when coding bed mobility.” Staff documenting bed mobility must be aware of what furniture is considered for bed transfers.

Toileting/Transfers: Per the RAI Manual, “When a resident is transferred into or out of bed or a chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B, Transfers. How the resident uses the bedpan or urinal is coded in G0110I, Toilet use.” We should not include the emptying of bed pans or urinary/colostomy bags in this item. We can include, “how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes.

Eating: The RAI Manual states that this activity includes, “how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration).” Eating can include tube feedings administered under nursing care and should be documented by the nurse and should not code as “activity did not occur”.

Guiding vs. weight bearing: What is the difference between limited assistance and extensive assistance? The RAI Manual states, “determine who is supporting the weight of the resident’s extremity or body. For example, if the staff member supports some of the weight of the resident’s hand while helping the resident to eat (e.g., lifting a spoon or a cup to mouth), or performs part of the activity for the resident, this is “weight-bearing” assistance for this activity. If the resident can lift the utensil or cup, but staff assistance is needed to guide the resident’s hand to his or her mouth, this is guided maneuvering.” To be accurate, the MDS nurse can ensure caregiving staff know how to differentiate between weight bearing and guiding activities and how to document each activity. Commonly missed items are pulling up pants for the resident or placing compression stockings during dressing.

Staff involvement: To improve staff processes and procedures, include all levels of staff in the problem solving activities. Including those affected promotes a positive view of the change and is more effective than simply providing education. Gather ideas from staff on how everyone can contribute to improving the process.

Have you incorporated these documentation approaches into your ADL processes? Strategize on effective ways to involve your caregivers in implementing any changes so everyone has ownership in the new processes. Your caregivers are a critical component in providing diligent care and ensuring that the ADL assessments are accurate.

It can be a battle to maintain a highly trained staff and to root out inefficient care processes that lead to inaccurate ADLs. Through staff engagement we can share knowledge and build new processes to promote accurate coding for section G of the MDS.



MDS 3.0 RAI Manual v1.17.1_October 2019 (

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