Hello everyone, I'm Doris McMillan, your moderator for this broadcast. Welcome to the second of the three satellite broadcasts focusing on minimum data set accuracy with a detailed analysis of the most common MDS coding discrepancies. This broadcast is part of the Centers for Medicare and Medicaid Services initiative to improve MDS coding by providing educational sessions for RAI coordinators and long-term care providers. The coding instructions provided in these broadcasts describe existing federal guidelines for MDS coding, as set forth in version 2.0 of the RAI user's manual with current updates. The manual may be accessed at cms.hhs.gov forward slash quality forward slash mds20. This broadcast will focus on disease diagnoses, health conditions and medications. We will demonstrate to our viewing audience how to assess MDS sections i, j and o. But before we get started, I'd like to introduce Thomas Hamilton, the Director of the Survey and Certification Group for CMS. Thank you and good afternoon. CMS is providing a series of training programs to improve coding for the minimum data set or MDS to achieve accuracy and consistency on a national basis. This effort is designed to assist health professionals in coding the MDS so that it reflects an accurate portrait of each resident's status. CMS's goal is to ensure that the MDS assessment would be the same no matter who performed the assessment. Accurate coding of the MDS is vital to providing good quality care. Since implementation of the MDS in 1990, CMS has used a train the trainer approach for educating regional office and state RAI coordinators who serve as the resource for providers and others who may have questions about the RAI process. Appropriate care for nursing home residents depends on the RAI and MDS coordinator's knowledge, skills and ability to educate long-term care providers and other interested stakeholders in the coding of the MDS. Therefore, CMS has recognized a need for providing a suite of training materials for the RAI and MDS coordinators to use in the field. The program today will provide a core set of basic training tools based on federal requirements and CMS policy. Because different people learn differently, the training tools developed by CMS include written and visual presentations, training videos, a sanitized medical record, internet-based training tools, answers to questions, and RAI manual updates. The satellite videos developed by CMS are intended to provide a visual demonstration of the services being provided and how staff may ensure correct coding of the MDS. The first satellite focuses on Section G1 of the MDS, Activities of Daily Living, also referred to as ADLs, and Section P3, Restorative Nursing. We are pleased to announce that another satellite program is scheduled for October 29, 2004. This second satellite program will include coding for infections, pain medications, and acute diseases that are coded in Sections I, J, and O of the MDS. On January 28, 2005, CMS will present our third and final satellite in this series. The third program will address accurate MDS coding of Section P, Special Treatments and Procedures in the MDS. Another piece of CMS's RAI training effort is the Web-Based Lessons Project. Using this interactive education tool, facility staff will be able to access the individual MDS training modules via the Internet. CMS plans to roll out the first module in the fall of 2004. Subsequent modules will continue to be developed and released throughout 2004 and 2005 as they are completed. The RAI and MDS is a complex instrument, but a very important tool that requires continuous training. We trust that this effort will assist you with coding the MDS accurately and consistently. Thank you. I hope you enjoy today's program. And thank you, Mr. Hamilton. And now I'd like to introduce our panel of MDS experts. Please meet Mary Pratt, MSN-RN Acting Director, Division of Ambulatory and Post-Acute Care, CMS. Judy Wilhide, R-N-B-A-R-A-I Manager, Commonwealth of Virginia. Rena Shepard, MHA-R-N President, RRS Healthcare Consulting Services. And Cheryl Rosenfeld, R-N-C Director of Clinical Operations, Zimit Healthcare Services. And Michelle McDonald, R-N-M-P-H, Dave Clinical Advisor, Joint Commission Resources. Now in this segment, Michelle will provide a description of the Dave project. So let's go to the videotape. Dave is an acronym for data assessment and verification. The primary objective of the Dave project is to assess and improve the accuracy of assessment information completed by nursing homes and later in the project, home health agencies. That one overriding goal is the basis for all our activities. The data analysis, clinical review processes, and educational aspects of the Dave project will support CMS's program integrity and payment policy initiatives, quality improvement efforts, and monitoring of the health and safety of the recipients of care. Those activities include reviewing assessment information and assessment practices, determining the causes of inaccurate data, and make recommendations to improve the overall assessment process. The Dave project also supports important CMS responsibilities and initiatives, ensuring program integrity, accurate Medicare payments, safeguarding the health and safety of residents and patients, improving the quality of care, and evaluating and refining federal policies. Although the Dave team's primary objective is to assess and improve the accuracy of assessment information, if in the course of our activities we should notice something that requires the attention of the fiscal intermediaries or state agencies, we would make a referral to those entities. We recognize that education is the most important remedy for inaccuracies that can occur because of confusion over policies, turnover in staff, and other factors, and the Dave project includes a significant education and training component. The Dave team is comprised of a variety of professional disciplines, information technology professionals, designed and can develop software applications used in the accuracy review process, data analysts and statisticians review assessment data and Medicare claims and gives guidance to the nurse reviewers. They also analyze the results of the clinical reviews to determine where inaccuracies occur most often and the impact on the coding of MDS assessments. In this next segment, Michelle will provide a recap of the Dave activities to date. Let's take a look. The Dave project expanded to a full national scope of MDS reviews in January of 2004. Approximately 2,000 providers were involved in the MDS review process, whether it was a request for copies of medical records or a notification that an onsite review was scheduled. The national data verification process occurred across all 50 states. To date, Dave's first quarter of offsite reviews have been completed, as well as 80% of the second quarter's offsite reviews. Analysis of the review findings is underway. Through September of 2004, Dave has reviewed over 1,200 records. The response rate from the providers has been very positive. Dave has had a 95% response rate for requested records. The first national onsite visits began in May of 2004. Between May and September 2004, the Dave onsite reviewers have been to a total of 38 facilities within the following 21 states. California, Colorado, Florida, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, West Virginia, and Wisconsin. Distribution of the onsite review results began in the first week of September. Participating providers and their respective state survey agency, RAI coordinator, and regional office representatives will receive copies of the onsite report. The Dave education team has engaged in several educational and outreach activities to address MDS accuracy and various coding issues. Seeking assistance and information from various state RAI coordinators, Dave developed and conducted RAI coordinator training in June 2004, focusing on the top five discrepant MDS sections identified during Dave's pre-national activities. In July of 2004, Dave also provided an RAI coordinator train the trainer course. During the fall of 2004, the Dave team shifted focus to assist CMS with their provider training efforts. While the initial training materials were drawn from the Dave project's experiences during pre-national reviews and a limited number of states, the analytic results from the first national sample showed that the items covered in the first tip sheet and the training materials continued to be problem areas for facility accuracy on a national level. The Dave project plans to focus future training efforts on these top five discrepant areas with the development of future tip sheets and by supporting CMS with its provider training efforts. By providing these materials for use, freeze-up time normally spent by providers and RAI coordinators on training development. Be sure to visit the Dave website for updates at www.cms.hhs.gov. Please direct any questions regarding the Dave project to the Dave toll-free number 1-800-561-9812 or send an email to dav-project at cse.com. In conclusion to Michelle's presentation, she will present a summary of the Dave findings. But before we see this last segment, Michelle, I just want to be sure that these findings are from your pre-national reviews. Yes, Doris. That is correct. We are going to see next are the findings from our pre-national reviews. Dave currently is performing national reviews and more to come on those findings at a later date. Alright, thanks a lot, Michelle. And now let's hear what she has to say. During pre-national phase of Dave project, the Dave team reviewed approximately 11,000 assessments in six states, Indiana, Georgia, Florida, Pennsylvania, Texas, and Washington. The offsite nurse reviewers conducted reviews for 580 facilities, which equates to approximately 4,000 stays and in excess of 10,000 assessments. The on-site nurse reviewers visited 127 facilities and reviewed more than 1,200 assessments. Throughout this period, there were five MDS sections, which consistently were identified as the top discrepant sections. Those sections were beginning with the section with the highest number of discrepancies to the least are Section P, Special Treatments and Procedures, Section I, Disease Diagnoses, Section O, Medications, Section J, Health Conditions, and Section G, Physical Functioning and Structural Problems. Although there were several different reasons for the various MDS discrepancies, one common theme for all sections was the facility's confusion with the correct look-back period assigned to a particular item. Providers need to be sure that all members of the interdisciplinary team are aware of the established assessment reference date, or ARD, and are aware of the specific observation periods for each specific section of the MDS. Not all sections have a 7-day look-back period. Some cover 14 days, other 30 days, depending upon the MDS section. Communication between the interdisciplinary care team is essential. Facilities should have policies and procedures in place as to whom encompasses the interdisciplinary team, who is responsible for establishing the ARD and ensuring that the MDS has been completed according to the regulatory standards, identifying which members of the interdisciplinary team is responsible for completing specific sections of the MDS, and how is the resident information to be shared. Whether it is short team meetings or more comprehensive weekly team meetings, it is absolutely necessary for all members to discuss and share information concerning a resident. What I would like to do now is walk you through our pre-national findings on sections I, O, and J. Section G was presented on an earlier satellite, and section P will be presented in January of 2005. The second highest section of the MDS with discrepancies was section I, the disease diagnosis, and the top five MDS items in section I with the most discrepancies were allergies, urinary tract infection, arthritis, anemia, and other, more specifically, cardiovascular disease. The most common reason for these discrepancies was due to allergies would be well documented in the medical record or on hospital history and physicals but omitted on the MDS for coding. Facilities were not clear on the definition of allergies as per the RAI manual. Facilities would include diagnoses when they no longer have a relationship to the resident's current ADL status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. This was usually attributed to vendor software packages which would not allow the removal of past diagnoses. No physician documented diagnoses in the clinical record, not using the 30-day look-back period for urinary tract infections, encoding and treating a UTI based on physicians working diagnosis without pending urine culture. We are now at the third highest discrepancy section which is section O, medications. The top five MDS items with the most discrepancies in section O were number of medications, injections, diuretics, antidepressants, and antipsychotics. For these five items, the most common reasons for discrepancies were facilities not using the correct look-back period to code these items, simple miscalculation or miscounting of the medication, not including the route, PRN, and stat doses of medications, not capturing medications administered in the hospital during the 7-day look-back period, count in the number of injections or doses versus the number of days the injections or medications were received, including IV medications under this item, omitting PPDs, not coding medications according to pharmacological classification versus how it is used. Working our way down to the fourth highest discrepancy section which is section J, health conditions, the top five MDS items with the most discrepancies were stability of conditions, acute episode flare-up, stability of conditions, conditions, diseases, make resident unstable, edema, fever, pain symptoms, more specific frequency. Common reasons for these discrepancies include facilities not using the correct look-back period to code these items, not coding these items when symptoms are well documented in the medical record that either a new concern, recurrent acute condition, or an acute phase of a chronic condition has occurred. Not coding these items when changes in resident condition is well documented in the medical record and facility is treating and caring for the instability. Coding fever that is not based on the REI manual definition of 2.4 degrees greater than baseline temperature. Facilities failure to capture pain frequency when the information is available on the MAR and or in the medical record. Specific examples and a detailed presentation on coding sections I, O, and J will be presented in today's broadcast. Thanks, Michelle. It was very informative presentation on the day project and its findings. Before we move right along, it's with much regret that Dr. Leonard Gelman, medical director on the Board of American Medical Directors Association is not able to be with us today. We do thank him, however, for providing us with his expertise regarding Section J health conditions. Michelle McDonald has graciously offered to present Dr. Gelman's perspective of Section J, which will help us to understand the importance of including physicians as an integral part of the clinical team and to understand some very important but common health conditions that impact the elderly population. Michelle? Physicians are an important part of the clinical team and it is essential that their input be utilized in completing MDS assessments for the residents. However, physicians are severely underutilized resource in this regard. One of the goals of this session is to help the nursing home staff to better utilize this resource. If the attending physicians themselves have difficulty participating because of time constraints or unfortunate lack of interest, the medical director can provide valuable assistance acting as a liaison between parties so the resident is described as accurately and completely as possible on the MDS. This collaboration can help to ensure that the resident will receive the best quality care possible. In fact, physician input into the process is mandatory. For example, as noted in the RAI users manual, physician documentation is required in Section I, Diseases Diagnosis. In Section J, health conditions, the MDS identifies several important and very common health conditions that impact this population immensely. It is imperative that this section, as well as Section I as noted previously, be understood and coded correctly so that the various resident assessment protocols are utilized appropriately and the quality indicators and rugs are scored correctly. The general goal of this section is to record specific problems or symptoms that affect the resident's health or functional status and to identify risk factors for illness, accident and functional decline. In particular, Section J1A-D reveals significant issues with hydration. Section J1E-O delineates several key symptoms that, if present, would lead to possible critical diagnostic workups. Section J2 and J3 have to do with pain issues and are covered elsewhere in this section. Section J4 puts into play the accidents, falls and fractures and all too common occurrence in Section J5 looks at the stability or instability of the resident and his or her conditions. As we all know, these residents are quite complicated, quite frail and have multiple co-mobilities and issues that are difficult at best to understand, even if we had unlimited time to do so. Taking care of these residents and care planning for them involves much more than accurately and correctly filling out an MDS and using the raps when required to do so. It is important to know, as stated in the MDS manual, one, completion of the RAI process does not necessarily fulfill a facility's obligation to perform a thorough assessment. This process focuses essentially on the resident's functional status and does not address other aspects of health status, such as medical condition, daily care needs and medication regimen. Two, facilities are responsible to assess areas that are relevant to individual residents regardless of whether or not the areas are included in the RAI. In addition, the evaluation should not be limited to MDS triggered RAP guideline only. This information supplements clinical judgment and we still need creative thinking to understand or resolve difficult or confusing symptoms. This is where clinical geriatrics comes into play and where the physician is best qualified to participate to help integrate this information into a meaningful resident assessment and care plan. This is particularly meaningful with the symptoms and conditions that are of focus of Section J. In the best interest of the residents, the assessment of these problems need to be ongoing and not limited to any artificial timeframe. It is, of course, understood that correct coding of the MDS will help lead to good assessments as well. In J1, problem conditions items A through D, the assessment focuses on conditions that have occurred in the past seven days, specific to indicators of fluid status. This is significant due to the fact that in the frail, chronically ill elder, it is often difficult to recognize signs or symptoms of dehydration or even alternatively fluid overload that could precipitate congested heart failure. The items are weight gain or loss of three pounds or more in a seven day period, inability to lie flat due to shortness of breath, dehydrated, output exceeds intake, insufficient fluid intake did not consume all or almost all liquids during last three days. Let's take these in detail. Weight gain or loss of three pounds or more in a seven day period. This can only be determined in residents who are weighed weekly, otherwise it is left blank. When residents are being weighed, it is essential to have a consistent weigh in process, which includes using the same scale and at approximately the same time of day. This is quite important because meals and elimination can affect weight tremendously. For instance, a usual urinary elimination may entail about 500 cc of fluid, which weighs over a pound, so that if a person is weighed just before an elimination and just afterwards, a difference of up to two pounds can be seen without any real or significant change in weight. The same could be said for meals and bowel elimination issues. Next, inability to lie flat due to shortness of breath. It appears that the erect position lowers the domes of the diaphragms to allow inspiration. The resident needs to use pillows or raise the head of the bed to get enough air. In this section, we are concerned about the potential fluid overload or CHF, but there are many other potential causes for this symptom, which must be addressed. These include, but are not limited to, COPD, thoracic deformities, airway obstruction, and neck tumors. Next section, dehydrated, output exceeds intake. This section has been problematic to say the least. This item needs to be checked if two of the three indicators are present. The indicators are, one, usually takes in less than 1,500 ml of fluids daily. Two, clinical signs of dehydration. And three, fluid loss exceeds intake. Let's go into these in more detail. One, while 1,500 ml per day is the recommended amount of fluid intake, a registered dietitian or physician should determine the resident's fluid needs based on the individual's size and health status. This information should be documented in the clinical record. A general rule of thumb is 30 ml per kilogram per day. Two, there are many and varied signs of dehydration. Most of them are generally nonspecific and present in many other situations as well. However, if these signs are present and the situation presents itself as such, certainly a diagnosis of dehydration may be considered. Some of these signs are dry mucus membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset of increased confusion, fever, and abnormal labs. Abnormal labs are mentioned in this section. We need to talk about the role of the labs in the diagnosis of dehydration. Although Dr. Gelman does not want to get too detailed, a basic explanation of how our body's handled fluid is necessary. There have been numerous studies that have shown that there are misconceptions and a significant number of misdiagnoses of dehydration. The body holds fluids into compartments, intracellular or in the cells, and extracellular outside of the cells. The extracellular fluid can be broken down as either intravascular in blood vessels or extravascular outside of the blood vessels. There is always flux of fluid from one compartment to another, as our bodies adjust to different conditions. True dehydration is really only a lack of fluid in the intracellular space. This cannot be directly measured, but the total sum osmolarity can be calculated, and this gives us a more accurate diagnosis of true dehydration. This calculation can be done by the lab or by staff using a straightforward formula. In other words, there are varying degrees of fluid depletion, and the intravascular depletion commonly seen as evidenced by an elevated BUN, hemoglobin hematocrit, or sodium, is not true dehydration. So to rely on these labs alone is misleading. This does not mean that these residents are without issues, but to diagnose and treat residents based upon labs alone is insufficient and unreliable. The last indicator is fluid loss. In this item, residents who have persistent vomiting, fever, and or diarrhea are at high risk for excessive fluid loss and must be watched closely. Again, two of the three indicators are needed to code this item. The next item is insufficient fluid intake. The resident did not consume all or almost all liquids during the last three days. Liquids can include water, juices, coffee, gelatin, and soups. This is to be coded only when the resident is receiving, but not consuming the proper amount of fluids to meet their daily minimum requirements. So, of these four items or indicators of fluid status, item A, C, and D are potential triggers for a wrap. The second part of section J1, Health Conditions, concerns other diagnoses that could be indicative of a significant medical issue. These include delusions, dizzy nurse vertigo, edema, fever, hallucinations, internal bleeding, recurrent lung aspirations in the last 90 days, shortness of breath, syncope, unsteady gait, and vomiting. Let's go over these in more detail. Delusions, fixed false beliefs not shared by others that the resident holds even when there is obvious proof or evidence to the contrary. For example, belief that food served by the facility is poisoned. Dizziness vertigo. The resident experiences the sensation of unsteadiness that he or she is turning or that the surroundings are whirling around. Edema, excessive accumulation of fluid tissues, other localized or systemic. This includes all types of edema, dependent, pulmonary, and pitting. Fever. A fever is present when the resident's temperature is 2.4 degrees greater than the baseline temperature. The baseline temperature may have been established prior to the assessment reference date. Rectal temperatures above 100 degrees Fahrenheit are considered significant in the nursing home population. Many frail elders have normally low rectal baseline temperatures, for example, 96 degrees Fahrenheit. Hallucinations. False perceptions that occur in the absence of any real stimuli. A hallucination may be auditory, visual, tactile, olfactory, or gustatory. Internal bleeding. Bleeding may be frank or a cult. Clinical indicators include black tarry stools, vomiting of coffee grounds, hematuria, homoptysis, and severe nosebleed that requires packing. However, nosebleeds that are easily controlled should not be coded as internal bleeding. Recurrent lung aspirations in the last 90 days. Note the extended timeframe often occurs in residents with swallowing difficulties or who receive tube feedings. Clinical indicators include productive cough, shortness of breath, and wheezing. X-ray evidence of lung aspiration is not necessary to code this item. Shortness of breath. Difficulty breathing occurring at rest with activity or in response to illness or anxiety. If the resident has shortness of breath while lying flat, also code item J1B, inability to lie flat due to shortness of breath. Syncopy. The transient loss of consciousness characterized by unresponsiveness and loss of postural tone with spontaneous recovery. Unsteady gate. A gate that places the resident at risk of falling. Unsteady gates take many forms. The resident may appear unbalanced or walk with a sway. Other gates may have uncoordinated or jerking movements. Vomiting. Regurgitation of stomach contents which may be caused by but not limited to drug toxicity or influenza. The next selection is J4 accidents. The goal of this section is to help determine the resident's risk of future falls or injuries. Falls are common cause of morbidity and mortality among elderly nursing home residents. Residents who have sustained at least one fall are at risk of future falls. About half of all residents fall each year with serious injury resulting from 6 to 10% of falls. Hip fractures account for approximately one half of all serious injuries. There has been much discussion on this topic, not just for the MDS but also for facility staff to be able to appropriately monitor and evaluate falls. Assessment, timely problem solving and development of interventions are the keys to resident safety. When a resident falls, again in spite of those efforts, the resident's situation must be reevaluated and interventions updated. The RAP for falls will help staff to focus on individual resident problems and strengths for care planning and effective intervention. What is a fall? A fall could be defined as an unplanned change in elevation from higher level to lower level. The following can be considered falls. Resident just tripping, an intercepted fall, a fall without injury. Resident is found on floor, rolling off mattress. The falls RAP is triggered if A or B are coded. Section J5, stability of condition is used to help determine if the resident's disease or health conditions over the last seven days are acute, unstable or deteriorating. This category reflects the degree of difficulty in achieving a balance between treatments for multiple conditions. For an acute episode, the resident is symptomatic for an acute health condition, a recurrent condition or an acute phase of a chronic disease. An acute episode is usually a sudden onset, has a time limited course, requires physician evaluation and a significant increase in nursing monitoring. End stage disease is defined that in one's best clinical judgment, the resident with any end stage disease has only six or fewer months to live. This judgment should be substantiated by a well documented disease diagnosis and deteriorating clinical course. A doctor's certification that the resident has six months or less to live must be present in the record before coding the resident as terminal on the MDS. Doris, although Dr. Gelman could not be with us today, he certainly has provided us with a great deal of information. Yes, he certainly has, Michelle, and thank you for explaining the importance of having a physician as part of the team and code health conditions that affect the elderly. Alright, let's continue with our next presentation from Michelle Doherty, a practice manager for the American Health Information Management Association, discussing the intricacies of how to complete Section I, Disease Diagnoses. During this videotape, Michelle will also provide you with a few tips on how to improve the accuracy of Section I. Let's see what she has to share with us. My name is Michelle Doherty, practice manager at AHIMA, and I have the privilege of talking to you about Section I. Section I is an important section capturing disease diagnoses for a resident. Unfortunately, the day of reviewers have found that this section has the second highest discrepancy rate of all sections on the MDS. Not only does this section capture the resident's health status and diagnoses, but also impacts the wraps, rugs, quality indicators, and quality measures. During the next 20 minutes, I am going to walk through the guidelines for completing this section and some tips on improving accuracy. I have coded many long-term care resident diagnosis lists in my career, so I understand the variety and sometimes the sheer volume of diagnoses a resident may have. To accurately report diagnoses on the MDS, it is important to report only those current diagnoses that have an impact on the resident and drive the current plan of care and functional status. This means not every diagnosis on a diagnosis or problem list will end up being reported on the MDS. So how do you decide what diagnoses to report on the MDS? Let's look at the intent statement in the RAI manual. Code diagnoses and infections that have a relationship to the resident's current functional status and care plan. That diagnoses impact a relate to the resident's ADL status, cognitive status, mood and behavior status, medical treatments, nursing monitoring, and risk of death. Generally, not always, but as a general rule, these are conditions which drive the care plan. Remember not to include diagnoses on the MDS that have been resolved or no longer affect the resident's functioning or care plan. Another critical point to remember when reporting a diagnosis on the MDS is that it must have physician-supporting documentation. Both MDS guidelines and standards of practice for ethical ICD-9-CM coding dictate that there must be physician-supporting documentation in the medical record for diagnoses coded and reported. The next logical question to ask is where do you find physician-supporting documentation in the medical record? Documentation of a diagnosis should have a reference back to documentation that was originally signed by the physician. For example, a transfer form from the hospital, a history and physical, a hospital discharge summary, physician progress notes and referrals or consultation reports, physician orders including telephone and fax orders. This is not an exhaustive list, but these are the most common sources of physician documentation. What do you do if you feel the patient has told you about a diagnosis that appears to be clinically valid? You should consult their physician for confirmation and document that confirmation in the medical record. Commonly, this is done via telephone or fax order or on the next doctor visit in the progress note. Another important point to remember when completing Section I is the look-back period. Most items in Section I have a 7-day look-back except for UTI, which has a 30-day look-back period. As I mentioned earlier, old, resolved or conditions that don't affect the resident's current functional status or care plan should not be reported on the MDS. A common error made is reporting a current diagnosis that has no link to the current care plan or functional status. For example, a resident may have a current diagnosis of hypertension, but there isn't active monitoring and it doesn't have an impact on the functional status or plan of care. In this instance, the diagnosis should not be reported on the MDS even though it is still considered a current diagnosis. Another logical question you might ask is where would you find supporting documentation for a diagnosis during the look-back period? The documentation can be anywhere in the medical record, but the most likely places you will find supporting documentation for a diagnosis are the hospital transfer documentation including H&P and discharge summary, the care plan including temporary and admission care plans. For example, the relationship may be documented in the problem statement. The resident has a dependency in dressing due to X diagnosis. You may also find supporting documentation in the physician orders including telephone orders and fax orders. A good practice in writing a complete order is to include the reason or diagnosis. You then have built-in physician documentation and supporting documentation in one step. Another location is the diagnosis or problem list in the resident's medical record, but there is a caveat if you use this type of list. It must be kept up to date. I recommend reviewing the diagnosis list at least with each MDS and care plan review and update as needed. Remember that the diagnoses will be reported on the MDS. They need to have a link to the resident's functional status or care plan. Another good practice in maintaining a diagnosis list is to document the onset date, the resolved date, and the source where physician documentation can be found in the medical record. Let's look more closely at Section I. As you can see in I-1, you report diagnoses using a checkbox. The diagnoses are grouped by broad categories. For example, musculoskeletal diagnoses are listed together. In I-2, you report infections using a checkbox. And in I-3, there is a free text area to report diagnostic statements and associated ICD-9-CM codes. Let's look at the steps in the process for reporting diagnoses in Section I. First, review the medical record. If it is a new admission or hospital return, review the hospital documentation including transfer form, H&P, and discharge summary. For an MDS completed during a stay, review the medical record for documentation that indicates a diagnosis is related to the resident's current functional status and plan of care. Once you have identified a diagnosis to go on the MDS, determine if there is an appropriate box to check. To help you decide if a diagnosis fits a checkbox, the RAI manual includes descriptions for many items in Section I. For example, a resident with chronic bronchitis should have the emphysema COPD box checked based on the description in the RAI manual. There was a change in the RAI manual that I would like to point out. There used to be a list of ICD-9-CM codes that related to the checkbox in I-1 and I-2. This list was deleted because it was out of date. You should rely on the descriptions to assist you in deciding if a box should be checked. If a relevant diagnosis does not fit the description for a checkbox, it should be reported in I-3, which brings us to one of the most challenging issues, deciding when to check a box and when to report a diagnosis in I-3. Here are some guidelines to assist you. First, report in I-3 the relevant diagnosis not reflected by a checkbox. If there are spaces left over, report a more specific diagnostic statement in ICD-9-CM code for a box that is checked. For example, a resident may have diabetes with a complication like renal manifestations. You should check the diabetes box, and if there is room, report the more specific diagnosis code in I-3 that reflects the complication. Now, let's look at some specific issues in I-1. First, I-1-N-N for allergies. Dave reviewers found a high discrepancy rate for allergies the box was frequently missed. The RAI manual defines an allergy as any hypersensitivity caused by exposure to a particular allergen, either natural or artificial. This includes natural and artificial agents, drugs, foods, environmental substances, animals, and cleaning products. The common errors made were not checking the allergy box when there were allergies documented in the medical record and excluding allergies to foods and environmental substances such as dust, pollen, and animals. The resident does not have to have had an allergic reaction in the last seven days to code this section. Allergies can be marked if the resident is susceptible for an allergic reaction. Another issue that may cause accuracy problems is diagnostic statements that result in checking more than one box. For example, CVA with hemiplegia, or CVA with aphasia, or diabetic retinopathy. These diagnoses are often reflected by one ICD-9-CM code, but to accurately report the condition on the MDS more than one box must be checked. Check box I-1-T for CVA and I-1-V for hemiplegia for CVA with hemiplegia. Check I-1-T, CVA, and I-1-R for CVA with aphasia. And box I-1-A, diabetes, and I-1-KK for diabetic retinopathy. In I-2 for infections, UTIs have been problematic. Dave reviewers also found a high level of discrepancy with I-2J urinary tract infection. The most common problem was the assessment reference period. Remember, for a UTI, the assessor must go back 30 days, not 7, like the rest of section I. UTI can be checked if there is a physician diagnosis supporting documentation of a symptomatic acute or chronic infection and significant laboratory findings in the past 30 days. You can also check UTI if it is suspected during the observation period if the physician has ordered a urine culture as long as there is supporting documentation of symptomatic acute or chronic infection and a physician's working diagnosis of UTI. However, if the culture comes back negative, a corrected MDS must be submitting removing UTI from the resident's MDS record. Next, let's talk about I-3. I-3 is not an optional field. Assessors should use this area to report other current diagnoses not reflected by a checkbox or to report a more specific diagnosis code. It is important to report diagnoses in I-3 because they can affect the wraps as well as the QI risk adjustment. For example, there are certain I-9 codes that exclude or place a resident in a high risk rather than sentinel event category. If you miss reporting the diagnosis code, you could end up with incorrect QIs. Finally, it is important to report accurate ICD-9 CM diagnosis codes. This means report the full number of digits. To wrap up, I would like to offer some tips for accurate ICD-9 CM coding and reporting on the MDS. Number one, if you have a computer system that populates section I, make sure the diagnoses are current and the system has been updated with the new ICD-9 CM codes. Number two, always review the checkbox as a software program auto-populated. If the diagnoses reported no longer meet the guidelines of the RAI manual, they should not be reported on the MDS. Number three, purchase new ICD-9 CM code books for the updates for code books annually. Number four, check to see if your software vendor updates with new codes annually. If they do not, you will need to update the files in the software program and update the diagnosis codes for a resident. Number five, be aware that new ICD-9 codes go into effect October 1. There is no longer a 90-day grace period to start using the new numbers. And number six, follow the official coding guidelines. They are available on the CDC website. Also follow the coding advice from the central office for ICD-9 CM. Coding clinic is their publication with official coding advice. The fourth quarter, 1999 issue, dealt with specific long-term care coding topics. This concludes the information in section I. Thank you for joining me today. And thanks, Michelle. That was a lot of information and some very useful tips on how to improve accuracy. Well, if you are looking for a reference on best practices and coding, there is a free resource available on the AHIMA website with practice guidelines for health information or medical record management, including a section on coding. The website address is www.ahima.org forward slash info center forward slash guidelines forward slash ITCS forward slash. All right. It's time for you, the viewing audience, to ask our experts questions on what you've heard thus far. If you'd like to call in your question, you should dial 1-800-953-2233. If you'd like to fax in your questions, the number is area code<PHONE_NUMBER>. And while we are waiting for our first caller, I'd like to throw out a couple of questions that I have here. Let's see, how do you code J1A when a resident has experienced a weight loss or gain of three pounds within a seven-day period, but he or she is not on a routine weight monitoring system? We'd like to answer that. Well, as Michelle said earlier, the only way we can monitor that weight loss is if that person is on a weekly weight. And if we aren't doing weekly or frequent weights on that person, then we would leave that item blank. Okay. I have another question. I understand the definition of a hallucination in that a resident has experienced false sensory perceptions in the last seven days, but can you provide any examples? Mary, that looks like your question. Very quickly. Like we have five senses, there are five ways people can experience hallucinations. They can be visual, such as seeing people. They can be auditory, hearing voices and different sounds. They can be tactile, actually feeling bugs crawling on you. They can be olfactory unusual smells that you aren't typically used to, and they can be taste-related tastes that are unfamiliar or unusual. Okay. Thank you very much. We have a telephone call. Sam is calling us from Tennessee. Thank you, Sam. Please go ahead. Thank you all for this interesting webcast. The question is about the section I. Why is not an item for hemiparesis? It's just hemiplegia, but sometimes the patient could have some voluntary movement and contraction. Who would like to take that? Thank you, Sam. We're going to check the manual. The manual, do you want to take it, Trudy? You code it in I-1-V, hemiplegia and hemiparesis. It is combined with hemiplegia, if that's your question, but the place to put hemiparesis is I-1-V. All right. We hope that answers your question, Sam. Thank you much. Thank you. If the resident had a new UTI during the observation period, do you have to have any documentation to support the diagnosis? Yes, you do. The RAI user's manual is very specific about the components that are required in order to be able to code it on the MDS. First of all, it has to be symptomatic. The instructions say acute or chronic symptomatic infection. There also has to be significant laboratory findings and documentation of all of that somewhere in the medical record. In addition, the physician has to provide in the medical record a diagnosis of UTI. Okay. And again, this is your opportunity to call in the number. If you have questions, it's 1-800-953-2233. And of course, if you'd like to fax in your questions, please call area code<PHONE_NUMBER>. And if we don't have any more questions, all we do. We have Sandy from New Hampshire. Thank you for calling Sandy. Please go ahead. Sandy? Given for a particular diagnosis. Sandy, turn down the volume on your set so that we don't get that feedback. Okay. Okay. We're doing it. Great. If a medication is being given for a particular diagnosis, why would we not code that on our MDS? Why wouldn't we use that diagnosis on our MDS? Definitely use it. Can you give me an example? I think the example was the hypertension that if a medication was being given for hypertension, it might or might not be used as a diagnosis on the MDS. No. Okay. I appreciate you asking that question because we do need to clarify that. If you have a diagnosis of hypertension and you're getting medication for that and the medication is working, that's still an active diagnosis. If you had episodes of high blood pressure in years past, maybe even a diagnosis of hypertension in years past, but you're on no medications, there's no care plan for monitoring. It's not affecting your current ADL status functioning or care plan or nursing monitoring. That's when you would not code hypertension on the MDS. But if you're still receiving medicine for high blood pressure, then you code hypertension on the MDS. That comes up with depression as well. Okay. We misunderstood that. I'm sorry. Thank you for asking. Okay. What about a past depression? If someone had a past depression, same scenario? Yes. Is it was active? Well, I don't want to say past depression. If you have a diagnosis of depression and you're on paxol or zoloft or whatever and it's working, you're asymptomatic from depression. It is the same situation. You have a diagnosis of depression. You're on medication for it. You're monitoring the medication. Your medication may be working right now, but you still have depression. Just like when your blood sugar is stable, you don't stop taking your insulin. You're still a diabetic and you're still taking the medicine for it. Okay. Thank you very much for clarifying. Okay. You're welcome. And I'd like to clarify. I made a mistake on the fax number. The number is<PHONE_NUMBER>. I like the way those numbers fall together anyway. All right. So if you'd like to fax this, that's the number. There it is. It's<PHONE_NUMBER>. We have Charlotte on the line calling from Florida. Please go ahead, Charlotte. Yes. My question is just to confirm what I thought I heard about UTIs and diagnosing that on the MDS. If the doctor has not actually called a UTI, but has ordered a culture and the patient is symptomatic or asymptomatic, would we still code it as a UTI? I think there are two questions there. All of the components that I mentioned have to be there. So the physician diagnosis, even if it's a working diagnosis, while the physician is waiting for the results of the culture, there still has to be a diagnosis from the physician in addition to all of the other components that I mentioned. If it turns out the culture comes back and it's not a UTI, then you need to go in and process a correction to have the UTI removed from the MDS. The other thing that I think I heard you say was symptomatic or not symptomatic. The only UTIs that are coded on the MDS are symptomatic UTIs. If there are not symptoms, then it's not coded, it's not considered to be a UTI. Those symptoms could be the obvious physical symptoms like burning on urination, frequency urgency, but they could also be in the cognitively impaired resident, an increase in agitation, or some other behaviors that we recognize as being symptomatic of an infection in our elderly residents. So one scenario that I've seen many times is an ARMP usually. We'll put a patient on antibiotics for UTI before any results of any culture for CNS, and then it'll come back negative. So does that mean we have to do a correction? Yes. And that was an update in the manual. That's one of the few times where the manual really instructs you to go back in once you have a negative culture, and obviously you wouldn't want to be giving antibiotics when they're not necessary.  I guess that would stand for any kind of infection? Well, specific to the updates in the manual it was referred to about the UTI. Remember that the snapshot and the reference date, you know, what was occurring during that look-back period, but specifically for UTI because of the implications and how that diagnosis would carry through for a long period of time. They want you to remove it if in fact it's not a UTI. Okay. Okay. Thank you very much. Charlotte, thank you for calling. Hawaii and Elena is on the line. Please go ahead, Elena. Thank you. Hi, good morning. Good morning. Good morning. I have one question, actually two. The number one is on fall. Will you code fall if a person was hit by a car prior to admission? Not if it wasn't a fall. There's no code for hit by a car, but it wasn't a fall. Right. No. Not code for. No. That's correct. The answer to your question is no. No. Okay. Another question on infection. Okay. How about MRSA? We have a lot of patients that are diagnosed MSSA, which is methicillin sensitive. Oh, no. Will you code that section? You could add it into the diseases and diagnoses at the bottom where there is specific coding. If there is an ICD-9 coding for that infection, you would in fact be adding in that code. The other thing that I would say is that that would be methicillin sensitive, meaning that the person has an infection somewhere. So if it's a lung infection or a wound infection, it would be coded according to where the infection is in that case. Okay. Okay. Thank you so much. And thank you for calling, Elena. Thank you. Let's move on to South Dakota. We have Diane on the line. Thank you for calling. Diane, please go ahead. Hi. This is Diane. We had some updating coding clarifications from our State Department. And it said, can UTI be coded even if the physician does not order a urine culture? And the answer they sent us was yes. And this question would be referred to CMS for confirmation. Well, that's the state-specific guidance. That's, yeah. The only thing that we can tell you is that significant laboratory findings is the requirement among the four that I listed for coding on the MDS. It doesn't say specifically a culture, but the definition of significant laboratory findings would be pretty narrow, I would say, the UA and the culture. And so that is a requirement for coding it on the MDS. So there has to be some kind of urine testing. That's right. Okay. Thank you. Diane, thank you for your call. If we don't have any more calls, we're going to move on. But just keep in mind that you can give us a call for our next question and answer session and the number again, 1-800-953-2233. And that fax number again is<PHONE_NUMBER>. We're going to continue now with the second part of our program. In the next half of the broadcast, you will see and hear presentations on section J.2 pain symptoms and section O medications. Our next presenter, Dr. Regina Fink, clinical instructor at the University of Colorado Hospital will guide us through section J.2 pain symptoms. So let's hear from Dr. Fink. Hello, my name is Regina Fink. I'm going to be discussing pain. Pain is a significant problem in nursing homes. More than half of the residents will experience pain at some point during their stay. This is due to the fact that residents in nursing homes have multiple complex medical problems that can cause pain. Today we're going to talk about pain, screening and assessing residents for pain, which is the cornerstone to providing optimal pain management. If we can't assess pain correctly, we're never going to be able to relieve pain. So what is pain? According to the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. This is an especially useful definition of pain because it suggests that pain is not just physical. It recognizes that pain is a personal experience affected by a personal's cultural and spiritual beliefs, including past experiences with pain, family values, expectations, and the meaning of the pain. Margo McCaffrey, a well-recognized nursing expert on pain, says that pain is whatever the person says it is, existing whenever he or she says it does. This is something that clinicians should always keep in mind when caring for nursing home residents. Pain can be categorized in several different ways. It can be classified as acute or chronic. Acute pain usually lasts for a very short period of time, hours, to days, to weeks, and is typically caused by surgery, tissue damage, or bone fractures. Chronic pain can last a lifetime, worsening and persisting for months or years. Chronic pain can be malignant, associated with a cancer diagnosis, or non-malignant due to arthritis, osteoporosis, or diabetic neuropathy, just to name a few. Pain also can be classified as psychological. That's a pain syndrome in which psychological factors play a major role in the onset or maintenance of pain. Regardless of the pain type, unreleaved pain can affect a resident's quality of life, resulting in depression and emotional distress, decreased socialization, disturbed sleep, and decreased appetite. We may observe agitated behaviors. In inhibits walking, activities of daily living, and can slow rehabilitation, delayed or impaired healing can ultimately increase health care costs. When it comes to pain management, an effective model might be characterized as a five-step ladder to optimal pain management. It is not just about getting to know the pain by assessing it. It is important to understand the pain experience, what the resident is going through, and how that pain affects the individual's quality of life. It's important to tell the person that you believe them. You believe he or she has pain, legitimizing that pain and communicating this understanding to all members of the health care team. This includes nurses, rehabilitation therapists, and nursing assistants. Open and frequent communication between the caregivers and the resident is essential. The nursing assistants play an extremely important role in helping the clinical team know about the resident's pain. Nursing home residents have the right to appropriate assessment and management of their pain. A pain assessment by the clinical team on admission is very important. Follow-up assessments must continue as the resident's condition changes, and at least weekly or daily, depending on the resident's pain status. If pain or discomfort is reported, a comprehensive pain assessment should be performed and documented in a consistent manner, either on a pain assessment form or in the nurse's notes. The frequency of a pain assessment is determined by the resident's clinical situation, as determined by the clinical team. If the resident is experiencing persistent, moderate to severe pain, which is pain equal to or greater than a 4 on a 0-10 scale, then pain should be assessed routinely every 4 hours or every shift, after analgesic administration and after any modification of the pain management plan of care. If a resident's pain is well controlled, meaning fewer or no complaints of pain and the resident is able to function or perform activities of daily living, pain then can be screened when other vital signs are taken. The resident's self-report about his or her pain is the gold standard and can be the primary source of information, even in individuals who are cognitively impaired. Residents who have dementia or are nonverbal may need a little more time to tell you about or describe their pain. When assessing a resident's pain, the best practices recommend the use of a rating scale. Caregivers need to teach residents and their families how to use a scale to measure pain intensity. Please remember that no single scale is appropriate for all residents. Therefore, it is important to have a variety of scales available in your nursing home. These will be discussed in more detail a little later in this presentation. I have developed a pain assessment tool called the Wilda Scale that includes five key components to a pain assessment. These are the words used to describe the pain, the intensity of the pain, the pain's location, the duration of the pain, and the aggravating and the alleviating factors. Let's look at this scale in more detail. Assessing pain begins with a simple statement, tell me about your pain. The W stands for the words used to describe the pain.  Some of your residents may not even say they have pain. They may say they have discomfort or they feel achy. Identifying the word qualifiers will help you understand the cause of the pain and optimize the treatment of that pain. For example, neuropathic pain is described as burning, shooting, numb pain, like an electrical jolt or like a fire. Neuropathic or nerve pain is typically caused by diabetic neuropathy, post-stroke, trigeminal neuralgia, post-herpatic neuralgia, phantom limb pain, sciatica, or nerve-involved by tumor. The treatment of choice for neuropathic pain is the use of adjuvant drugs, such as antidepressants or anticonvulsants, local anesthetics with or without the non-opioids or opioids. Non-pharmacological approaches such as transcutaneous electrical nerve stimulators, TENS units, may also be helpful. The second type of pain is visceral pain, which is described in a very different way. Words residents may use to describe visceral pain include squeezing, cramping pressure, sometimes a bloated or distended feeling. This type of pain is poorly localized. The possible causes for visceral pain can be an abdominal or thoracic surgery, bowel obstruction, residents with an abdominal cancer such as colorectal cancer, ascites, end-stage liver disease, and venous occlusion or thrombosis. The treatment of choice for visceral pain may be non-opioids and or the opioids, making sure that you titrate the medications to the proper effect. The third type of pain I want to mention is somatic pain or muscular skeletal pain. It is characterized as achy-throbbing, gnawing pain. Other words used are dull or soreness. This is typically well localized. That may be caused by degenerative joint disease, arthritis, osteoporosis, bone fractures, post-orthopedic surgery, for example a total knee or total hip arthroplasty, or bone metastasis due to cancer. Sometimes the immobility or contractures that some of our residents develop from not being able to get out of bed can be a possible cause of somatic pain. The treatment of choice are the non-steroidal anti-inflammatory drugs, also known as the NSAIDs, if the resident can tolerate them. At times, steroids are very useful as our muscle relaxants. The I stands for intensity of pain, which can be quantitatively measured using a variety of scales. The numeric rating scale is a 0-10 scale. The verbal descriptor scale is an adjective scale with different adjectives describing increasing levels of pain, such as mild, moderate, or severe pain. There are two phases scales, the Wong Baker phases scale with tears, and the Biieri phases scale, which is more adult-like in appearance. Both of these measure pain using different phases. There is also a pain thermometer that is vertical in appearance. Questions to ask your residents include the following. If 0 is no pain and 10 is the worst possible pain, what is your pain right now? It's also important to ask, what is the worst pain you've experienced in the past 24 hours? Now some of your residents won't be able to remember 24 hours ago, so you might ask them, since lunchtime yesterday, or since you received your pain medicine, what is your pain score? Also, be sure to ask the resident, where do you want your pain to be? This is what we call a comfort goal. Please remember that no single scale is appropriate for all residents. Therefore, it's important to have a variety of scales available in your nursing home. In the Agency for Healthcare Research and Quality-Funded Pain and Nursing Home study that I was a part of, we found that the majority of elders preferred the verbal descriptor scale. More men chose the numeric rating, or 0 to 10 scale. More minorities in our study, we had a high percentage of Hispanic-Latino residents, preferred the phases scale due to language barriers and difficulties associated with using a verbal descriptor scale. The L is for the location of the pain. Because most residents will have two or more sites of pain, ask your resident, where is your pain? Or do you have pain in more than one area? Ask your residents to point to the painful area. This may be more specific than a verbal self-report. Remember, greater than 75% of residents in your nursing home will have pain in more than one area. The D, or duration of the pain, describes the constancy of the pain. Is the pain always there? Pain of this type is referred to as continuous or persistent pain. If the pain comes and goes, it is referred to as intermittent or breakthrough pain. Most residents will have both types of pain. They may have a continuous pain that is a background type of pain and also a pain that comes and goes, perhaps with movement or activity. The actual definition of breakthrough pain, as described by Portnoy and Hagen, is the transitory exacerbation of pain occurring on a background of otherwise stable pain in a patient who is receiving chronic opioids. It's important to determine the duration of the resident's pain because if a resident is having continuous pain, it may be appropriate for a long-acting or extended-release pain medication to be used. When intermittent or breakthrough pain is experienced, a short-acting pain medicine that works very quickly for the painful exacerbation can be used. For the A, what is aggravating or alleviating the pain? Ask your resident, what makes the pain better and what makes it worse? Could it be a visit from a family member that makes it better or worse? Could it be a massage that might make it better or movement or activity that makes it worse? Or maybe just lighting and changing the environment, making it more peaceful, may make the pain better? As described earlier, pain does affect functional status, activities of daily living, sleep and appetite, energy, relationships, and mood. It is important to identify how much pain can exist without interfering with function. Research across cultures suggests that pain greater than or equal to a 4 on a 0-10 scale significantly interferes with daily function. It's recommended that if a pain score is greater than or equal to a 4, an evaluation of the pain management plan needs to occur. This may mean that an increase in analgesics is warranted or some other non-pharmacologic approach should be added to the pain plan of care. The quality and utility of any pain assessment scale is only as good as the nurse's ability to be thoroughly resident focused. This means listening empathetically, maintaining open communication, and believing the residents and family or significant others' concerns. Pain does not occur in isolation. Other symptoms and worries experienced by the resident may compound the suffering associated with pain. Understanding the meaning of pain is also important. I always ask my residents, how long have you been in pain? Has this pain affected your quality of life? And what does this pain mean to you? Many of our residents don't feel validated. They don't feel their pain is believed and are often reluctant to share their pain experience with us. Many of them have experienced losses. They're not able to walk or move or do the things they once were able to do. They've learned different self-care strategies or ways to cope with the pain, such as staying still, not moving, praying, using distraction, watching TV or talking on the phone. These are ways that help get their mind off the pain. Quite a few of our residents deal with system barriers, and sometimes we are the barriers. For example, we don't want to give them medication because of our concern about causing side effects. Maybe there's nothing that we can do for them because nothing's been ordered. Perhaps a medication or non-pharmacologic approach is not available. Or maybe there is an unwarranted fear of addiction on the part of healthcare professionals or the resident. All of these things are important to consider when understanding the meaning of the pain. When we did our study with 12 nursing homes in the state of Colorado, we asked residents why they didn't request pain medication if it was actually ordered. We found that residents didn't request pain medication because they were concerned about pain medication side effects. They were also concerned that if they took pain medication now, it may not work later when they really need it. Additionally, many residents are stoic and believe that pain is a part of aging. They often do not want to bother nursing staff and think we're too busy with other residents. Some of our residents said, when I take something, it really doesn't help. So why bother taking it? Or my doctor says there's really nothing I can do for you. You're just getting old. All of these are reasons why residents may not request pain medication. It is important that we address these myths and misconceptions about pain and medications with our residents. Now let's take a look at assessing pain in the cognitively impaired or nonverbal resident. The resident's self-report of pain is the gold standard, even in those who are cognitively impaired or nonverbal. However, it's not always possible for residents to tell you how they are feeling. Observing a resident during activity or at rest for nonverbal behaviors or cues is another way to determine if pain is present. Additionally, things that you want to ask yourself if you have a resident who is severely demented or confused, is there a reason why this person might be having pain? Was this resident treated for pain in the past? And if so, what was used? Now this may mean that you have to examine the medical record or speak to the physician when he or she comes to see your resident. I cannot emphasize enough the importance of getting to know your residents and what they've gone through in the past. You might also want to ask a family member or significant other how the resident usually acts when experiencing pain or what their perceptions or interpretations are of the resident's behavior. It's like being a detective, trying to find out what might be causing pain in your particular resident. Some common pain behaviors in cognitively impaired elderly persons are listed in six categories and are described in the American Geriatric Society guidelines. These are facial expressions such as a wrinkled forehead, furrowed brow, clenched jaw and teeth, sad or frightened facial expression, or frown. Verbalizations or vocalizations such as moaning, groaning, crying, whining, ooing, eyeing, screaming out, crying, cursing, or saying things such as, ouch, don't touch me, leave me alone, get out of here. Body movements such as jitteriness, agitation, restlessness, fidgeting, bracing or rubbing a body part, changes in interpersonal interactions and changes in activity patterns and routines. For example, residents who normally would go down for dinner might stay in their rooms or not engage in social activities. There also might be mental status changes such as disorientation, delirium, or confusion. It's important for you to observe residents both at rest and on movement because for some residents these behaviors aren't exhibited at rest. There are a number of pain assessment tools for use with the cognitively impaired, demented or nonverbal resident. Many of these tools have been reviewed by Dr. Keela Her and her colleagues from the University of Iowa. Results of Her review and the Will to Scale are available on the City of Hope pain website, www.coh.org. All of these tools have been trialed in elders and special populations. Reliability and validity testing is still ongoing. When assessing and treating pain in the nonverbal resident, it's important to try to obtain feedback from the resident by offering writing materials or pain scales. Many of these residents might be aphasic and not be able to talk to you and tell you about their pain or they may have been intubated in the past. Treating with analgesics and other pain relief measures is very appropriate and if your interventions modify pain behaviors continue with the treatment. I would now like to take a moment to discuss the importance of accurately assessing pain in the minimum data set or the MDS. The intent of the pain section on the MDS is to record the frequency and intensity of signs and symptoms associated with pain. Pain data should be collected from all shifts, all days of the week for the entire observation period. The resident, family caregivers and all direct care staff should be consulted and medical records should be reviewed. Ask your resident if he or she has experienced pain in the last seven days. Ask for a description of the pain and observe for pain pavers as we discussed earlier. For item J2A, frequency of pain, code how often the resident complained or showed evidence of pain in the last seven days. That would be no pain, pain less than daily or pain daily. If the resident has had no pain, even if it's because of an effective pain management program, code zero. In item J2B, code the highest intensity of pain that occurred during the observation period. Utilizing a pain scale of zero to ten, it is suggested that mild pain would be one, two or three, moderate pain, four, five or six and severe or horrible and excruciating pain, a seven or greater. Section J3 reflects pain site. In closing, pain affects the whole person and it is multi-dimensional. It is the nurse's responsibility to partner with the resident and family to identify mutual goals regarding pain assessment and management. Thank you for your time and consideration today. And we'd like to thank Regina for helping us understand the problem of pain and how to assess pain in nursing homes. Before we hear from our last speaker, though, I would like to give the numbers that you can use to call or fax in your questions for our final question and answer session. The number to call is 1-800-953-2233. The number to fax is<PHONE_NUMBER>. And now that I've given out that number, I do have a fax that we'd like to take care of right now, ladies, okay? Doreen from Nebraska says, the question is specific to J5. Conditions, diseases make residents cognitive, ADL, mood or behavior status unstable. The resident has current Parkinson's diagnosis with Medicare. The mood is from giggling to anger from day to day and it's long-term. Can you code J5A as unstable? Absolutely. Okay. That's what you're trying to gather and that unstable mood would have occurred within the past seven days and it's important. And it could be due to any range of reasons. Payment source is not at issue. It's the resident status that we're assessing. Okay. Thank you very much. All right. Let's take a look at the numbers and we're going to continue with our final speaker, Carla Saxton. She is professional affairs manager at the American Society of Consultant Pharmacists. The Saxton will cover the area known as Section O, Medications. Her presentation will discuss the four items under Section O and its intent. Let's take a look. My name is Carla Saxton and I'm a pharmacist on staff with the American Society of Consultant Pharmacists.


We've got undead all over the place. Every cursed spirit and vile ghost we sealed away has broken free and attacked the city. Nowhere is safe. Now what? Oh, well it's a pet. They're kind of like a wizard's familiar. They help out in all sorts of ways from discovery to dueling. But it shouldn't be in that tower. That's the caretaker's tower. Nobody's been in there since old Judd, the keeper of the cemetery pass. There's a cemetery in Wizard City? Wow, we need to see this please. Oh, right, undead. Wizard, go with the pet. Work together and find out what's happening in that tower. I'm pretty sure they wouldn't say that because they probably don't remember the last time you emailed them. Just saying. Right, go to pet, hi pet. You now have a pet egg in your inventory. Once it hatches, you can equip the pet just as you would have wanded and bring it into the tower. Once it hatches, but if you get a pet from a quest, it hatches it instantly, gamma. Thank you very much for telling me false information. Ugh, right, we need to equip this pet. We're gonna equip it because we have to. Why we don't have to, but we're going to. Bag, pets. Who is this? Midnight cat. I assume it's this one, possibly. Um, yeah, Midnight Cat, this one here. This one here. Cornel, or Colonel Lulu, which is cool. And then we're gonna search the tower because we can, why not? Let's go. Let's do this. Um. Who shouldn't have come to this tower? No, shouldn't have done that. Gonna interfere with things don't concern you. Like my plan to turn all pets into zombie pets. I'll, you'll see you will when it comes to pets. Sometimes a dead is better. If you have a pet equipped, it can help you in battle. Some pets even have a special power button you can press to make them attack. Right, let's do this. Let's do this. Oh, Judd, hello, buddy. This is gonna be a really like short-lived fight, but that's, we didn't even get a dead night. Okay, okay, game, that's fine. That's fine. That is fine. Um. Do, do, do, do, do, do, do, do, do, do, do. Yup, Penny is here. She's, she's just got herself stuck in a situation. As always, um, you know, she lives in a society. Oh, they changed the enchant thing. That's, so it comes up with like the, that's cool. I love that change. That is a really nice change. That is a really cool change. I love that a lot. I love that a lot. It's really subtle and I don't know if you saw that, but we'll go into a fight later and show you, show that. But that's cool. I like that. Um, why does he look so easy to defeat? Because he's like a level five boss. Like he's literally in the first half of the story, like the first part of the story now. Yeah, I can actually. Let's go. Oh, his jump's so cute. I love this jump. This jump is great. Fantastic. Collect the key. Here we go. Can't you just make a key with your magic? No, that's not how it works. We've got to get the correct key over here. And then return. Man, this pet is great.  Interesting. You can't see your spell deck or anything. Well, you're in this view. Interesting. Interesting. Sounds good, Penny. Sounds good. Let's hit up. Penny. Hello. Least favorite character in the game. Hi. I wonder what the combination is. Let's find out. I bit at 0, 0, 0, 3, I think it is. Yep. I saw that smelly guy put in the combo lots of times. It's 0, 0, 0, 0, 0, 0, 3. Pointer. Um, right. Let's unlock the combination.  What a very secure thing. A very, very secure code there. Use stronger codes in there, everybody. And that adds to her sidequests that is slightly later. Go tell the guard outside what's happened here. And I assume the sidequests are exactly the same. But we might check them out later. But yeah, that's basically the new part of the main storyline. The secret strife of Pett's quest. Yeah, just cast Reved Crafter. Can't open a lock. You can't just get a key. You need to get the key itself. You saved the Pett's and a young student? Not bad. But our work is just beginning and I need all the help I can get. I've got alarming reports from Cyclops Lane and Triton Avenue. And I haven't heard anything out of Firecat Alley. So, where do you want to start? Ah, that's cool. Leads right into it. Triton Avenue's being overrun by the undead. I don't have any guards left to try and deal with it either. Do we want to do? Do we want to keep going with this? I think we do. You're not the first student to offer help. Two wizards named Griffin Bane went in a little while ago. And there was another named Grimwater. But none of them have come out. And I've gotten no word. Can you help me try to find them? Good luck. And above all, be careful. Let's go and do the new Triton Avenue. Brand new. This is a brand new quest. So yeah, it is basically the same. Arthur... Yeah, this is completely new. Completely different because Arthur's actually free. Oh, my game crashed. That's great. Right, we're in Triton Avenue. Here we go. So, it did the first one. I think that might have been the problem. The first bit of the quest. Oh, why are we so fast? What the heck? Why are we so fast? That is a great question. It's only 40 minutes. What does this pet give? What does this pet give? Death Assistant pets can only have this... have one combat pet power. Fight happiness. How happy is that pet? Also, why do we have low health? I don't understand that either. I was probably from the last fight. Actually, why do we have 10,000 health? I am so confused. And over a thousand. Man, I am really... What the... Am I...? Do we just get an extra base stat, I guess? We have, like, 100% crit. What the heck? I am... Wait a second. If I change... If I change a piece of gear, will it change? Oh, my gosh. Wait a second. Wait a second. This is gonna be crazy. Hold up. I've been working on this mana set. What is our mana now? This game is perfectly balanced. I have infinite mana. I have infinite mana. Cyberina, thank you for the follow. Welcome. Gosh, that's funny. That is hilarious. I love that so much. We're gonna use this for it. Yeah, you are. Something has broken the flow of storm magic through the street. Those towers should have arcs of lightning between them. This is bad. My sister Suzy and I came to see if we could help get things back under control. But we got separated. The haunted minions drove me back. Can you create a diversion so I can try to break through? Attack the minions and I'll meet you by the river. Okay. Yeah, we'll put on my crit set for a second. I don't have that. What is my energy set? We go down a lot in crit. Block is 30% across the board. 116 outgoing, I think that's normal. What is my resist? 97% resist, that's more than normal. Plus 124 damage just because. That's crazy. Where is my crit set? Let me just quickly put on my crit set for a second. Or at least most of my crit set. I think it is... Not that one. It must be my normal one. And then my boots are... These I think? Or paradox boots? Paradox boots. And then my wand is this. And my ethame is... I think it's this one. Amulet is this one. So much gear. Is that it? Yeah, it must be it. And then the paradox ring. And then the pet will be... Luna mounts his fine deck. Will be the paradox deck. What is my stats now? 238% damage, fair enough. That's perfectly balanced. 77% resist with that as well. 56% accuracy. 1280 something crit. Which is really crazy. Plus 1% block which makes sense. You know, gotta be a bit better. 24% PS. 52% incoming from this. 164% shadowpuff. And 16% shadowpuff. This is perfectly balanced. This is the most balanced set in the game. I don't know how this has happened. But... I kind of want this health. Can we... Oh, we can't go above our max health. It's only visual. That's interesting. Oh, it's changed now. Bother. Bother, I think it's changed. I think it has changed. Why is death crit locked? No, it's so big that it doesn't fit on the line. It's a hundred... It's like thousands, 1,280 something. It wasn't lower, it's just because it was so big that it went down the bottom. Yeah. I don't know what that was. I am really confused about that. I'm gonna see if my stats are still the same. I assume not anymore. And it just needed a refresh for it to be... Oh no. That's strange. Really, really strange. I don't know whether this is my pet or not. I am so confused. Oh, we need to change our pet as well, just so we can have our old one. So it's not our pet. So we can have the will cast. Who does that dude sound like? What dude? I don't know. I have no idea. I have no idea. I wasn't really paying attention to his voice. I was more interested in my insane stats. It's frustrating you. Let's change our pet real fast. We're just gonna go to the main set as well. Oh, we can move sets up and down. That is fantastic. I love that change. I really, really love that change. That's actually the best change ever. Like actually. Waffles, Dr. Taz, Lulu, Equip. 50 happiness of 100. That'll be fine. That'll be fine. Right, this one. Next one. I think we only need to defeat three. So this will be the last one. Oh, and our pet can do it. 45. Yeah, we'll do that. Followed by a blade. Might as well. Might as well. And we'll see what this looks like. This is a will cast. Oh, they have glowing red eyes now. That's cool. You got two crits. That was my crit set. That was my crit set though. This is my non-crit set. So if I don't crit these next spells, that's what will happen. Does it use? I didn't crit this. I assume it's not. Guaranteed. That was actually quite cool. Right, we'll go speak to Arta, who is down here with Susie. Wow, they're all here. The whole squad. Who knows? Who knows, Duncan?  He's not dead, buddy. We haven't killed him yet. Uh-huh, yup. Oh, so it's completely opposite. Arta is not lost, and Susie is. So we previously found Arta, and now Susie's gone missing. Makes sense, makes sense. Except she's right here. So that's odd. We found her. Look, she's just up here. Oh, there's also... What is this? Oh, Wayard Barrel's all... We're going to do all of these, because this is fun. That's the telep... To the Crackenot. It's over here now? Interesting. We're going to do all of these. We're just going to do the main quest now. Welcome to the Death Walkthrough episode number 150. You know, probably 280 something, from memory. We aren't here, boys. But yeah, I don't think you can enchant your pet spells. Why do we get three now? That is interesting. Do they up the blades? You get four? Wow, okay. That's interesting. They must have up the blades that you get. Right, electric heal. Let's do this. They move so many people around in the Cracken teleporter. Yeah, they have. So I don't believe you can enchant the... You can have two selected at the same time. That's kind of crazy. But you can't enchant a will cast card. So yeah, we're just... I'm not going to use that. We're just going to do this just because it's quicker. Yeah, you can't enchant a will cast card because technically it's not yours. I hope that they add this functionality to minions, because this would be cool. Being able to select your minions' card and yours at the same time. That is an ideal situation there. Why are we lagging? I don't know. We just are. We just are. But yeah, there's one down. We're just going to actually... Oh, we got it. Wow, that was quick. That was quick. Nice. Good, good, good RNG here. We are also so damn quick, and I don't know why. Like I'm not complaining, but still. Kind of strange. Right, we'll put in the DNA and the headless. Just for fun. Because we don't see headless much. We see DNA, but not headless. We don't need that. I don't quite understand why we have Age of Reckoning when we don't have that pet on. Also, where's our Fox? We need the Foxy Boy. Right, let's go Duncan High. Excuse me, I am bitter than you buddy. Oh no, storm magic. They were wearing strange amulets that were crackling with storm energy. Bring me those amulets, and I can cast my spell. They're just called mastery amulets, bud. Look it up, please. Look it up. I'm not even going to leave a mark. He's also down... Okay, I think that's... a slightly issue. He's down there. Susie's up there still when she's meant to be lost. Luckily, Arthur isn't anywhere to be found, which is lucky. Also, the teleporters are so much smaller now. We'll save two blades. That's kind of funny, not going to lie. That is kind of funny. Rotting photo. Hello, buddy. I don't want to go... Okay, we're going into someone else's battle. That's fine. That's fine. Sorry. Don't worry, I can easily kill. It's fine. It's fine. You've got to be nice though. If you stumble into someone's battle, you've got to be really nice. Let's just... Let's just do this, buddy. Let's do this, buddy. Let's do this. Someone who used ghoul and vampire on me after Polaris? Yeah, exactly. Duncan just needs to take a step back. Honestly, just a step back. Also, there's... there's things on the side of the road. Interesting. We little crow thingies. Not crow. What am I... I don't even know what I'm... Gears. That's the word. Jeez, I can't English today, honestly. Right, let's just hit the lace. Hit the lace. We're not going to use pet wheel cast just because it takes a bit longer. And we kind of just want to get this done as quick as possible because the death walkthrough doesn't stop for nothing. You've got to go as fast as possible. Just kidding, the death walkthrough is pretty slow, but that's fine. Hit those. Let's do this. Kabam. Look at him. He put his head back on. He's a necromancer too, like us. Crit. He's probably better than Duncan. Duncan's just a bit jealous that I'm good. That's honestly what happens. Well, GG. He's dead. Nice. Number two, I assume. Yep, so it's not a hundred percent crit. Which is interesting. We're just going to change our pet over to Luna as well. And just get this last boy over here. Hopefully.  But luckily, it shouldn't be now. Which is great. And right, he fizzled. He's bad. That's a shame. And here we go with the headless again. No crit. Sad reacts. Kabam. Twenty-fourteen damage. Nice. GG. And we got the storm amulets. We're not going to go there. We're just going to run back. It's not too far. Two blades. Hi. Two blades too. Which one's better? Who knows? Are they going to fight each other? Probably not. But that'll be funny. Is Smith still here? Yeah, yeah. Look at him, just chilling over there. Nice work. Nice work.  Luckily I think they've made a hundred percent chance, which is great. Now, let's see what I can see. If I'm right and I usually am, whoever's enchanting these storm amulets also kidnapped Susie. They probably have Susie imprisoned close by. the link between the wand and Susie to find her and the link between the storm amulets and their maker to produce a vision here nothing whoever this is they have some powerful magic I think I could break through the interference with a charged Lumina crystal they make Lumina crystals at the mill across the river go talk to Vlad Raven I and get us a crystal okay we can do that we can do that Duncan can't even cast a simple spell is image oh so much better than him at least we don't embarrass ourselves by not try by trying Lumina crystal you're out of luck the undead stole all my crystals oh no I've got lots of raw crystal I could grind you another one but the mills broken are dead stole the wheel cogs and scattered them all over but even if I could grind you a crystal I couldn't charge it my lightning rod won't work a scarlet screamer stole the primary coil you could help get me up and running again gather up the cogs and get my coil back from the scarlet screamers and I'll get you a crystal okay I don't know what his sidequests does we're just gonna see that looks like a bug we're gonna come back to that later that looks like a bug I don't think what is this too high ledge where the heck is that oh oh oh oh oh this is where the old thing was that makes sense okay that makes sense weird right cog cog here is cog here is cog one I love this speed I really love it especially for testing it's great two and over here is three let's not get in the fight good job three fantabulous and scarlet screamers doon doon doon doon doon what's that here starboard you can use it you can use the character inspect thing to find out just saying we haven't actually tried that out yet we should do that in a sec doon doon doon doon doon doon doon doon doon doon doon um his quest is a member code wait I'm confusion did they rework firecat quest who know just um just tried an avenue at this point just tried an avenue member quest is still exactly the same it's just the free-to-play stuff that they have been reworking well by scarlet screamer is another one in of course it is of course it is you better be killing Austin I'll even give you a blade if you want buddy valerian coming in the fight as well okie dokie hopefully we get them all in one thing that'd be great you know what I'm gonna blade myself then Austin just chill in here not gonna do anything that's great clap clap for Austin I think comes into my fight and then does nothing fantastic that scarlet screamer attack is weird very very strange but that's fine oh it sounds different that's interesting that's cool and we will go for dinner because we can and that should hopefully kill hopefully no one else comes in otherwise someone else has to kill can you'll just pass please that'd be great I'm kind of running on a time Diana the diamond thank you for the follow welcome man this Austin guy just being weird being weird but that's fine and this dinner should hopefully kill hopefully hopefully hopefully should kill we will find out in half a second there nice noise caban three thousand love it love to see it love to see it evil goat yeah evil goat oh my gosh why would you do this I am disappointment I am very much disappointment in you Ryan why would you do this Ryan I can't right we're gonna do this because we can mr. Austin just chilling here doing nothing oh he's got a cramp it's nice some good which will kill first who will fizzle find out next time on craft box does site quest do we really get no rewards for tournaments um I have no idea absolutely no idea I haven't done any tournaments yet or looked at them at all so possibly possibly not I think there was a mention about something along those lines in the update notes somewhere somewhere maybe possibly which is exclamation point update just so I can get to the update notes because I closed out of that tab there was a mention of it PvP yes for now they have disabled tournament rewards so it says in the update notes first we added turn-based combat from tournaments to practice PvP which was a frequent community request please jump in and let us know how you like this also we disabled both tournament costs and rewards for the time being while we work on rebalancing PvP as a whole so they will be back once PvP has been finalized and basically in the next stage I would say so yeah for now they have been completely null voyage you can play it for free but you also don't get anything at all for it at the moment and that's not just history of that will be when it goes live as well and that'll be until they fix PvP basically so yeah no more easy easy arena tickets unfortunately right blad hi splendid now put those cogs to good use and get the old wheel turning I'll fix the lightning rod good job buddy you do that where are we putting these I don't know over here oh in the wheel finally we're ready here just pull this lever and we'll charge that luminic crystal what leader what lever oh this one here well done wizard that looks cool that's so cool okay I love that thanks to you I'm back in business clap clap for blad fully charged luvana crystal she's a beauty I hope she serves you well we're gonna look at that quest later it seems slightly bugged but that's fine alright let's head over here what do they mean turn based isn't it already too nice no it isn't I went the wrong way I showed that off previously before basically one opponent chooses a card then they cast this belt then the other opponent chooses a card and cast a spell it kind of slows PvP down but it was a much better change if you want to see we'll go back and watch a couple of matches there a little crystal this should be just what we need the luminic crystal will boost the power of my ritual it'll work this time I'm sure of it it's working Suzy I can see her but what was that horrifying thing with her that is so cool I love that can we get this as a background that would be great I would definitely use that holy frick that is amazing I love that that's the harvest Lord we studied him in class he's a powerful spirit from the underworld who harvest the souls of the innocent it looked like she's in galvanos tower that must be where the harvest Lord is enchanting the storm amulets wizard please free my sister okay okay we are gonna quickly run over here and use the teleporter because that is a long way away and we ain't walking all the way there for the a millionth time someone's messaging me in general what is it tacos amazing look at that fantastic I love that thank you tacos thank you tacos how close does the lock talents how does the lock talents work basically when your pet levels up wrong wrong thing you'll get a by the sounds of it from the update notes you will get a reagent and you can unlock them through that reagent but I'll check that out in a bit as well because I'm kind of interested in that I don't quite understand why they're in to start with so I'll see what it was like in a bit we're just doing the main the new main Trident Avenue quest line now another soul to harvest I knew my little prisoner would draw more to me like flies to honey wait my dark master warned me about you imagine the reward he will give me when I present him your fairy soul she's not even there she's already been devoured oh no oh no she is there don't worry it's just probably testosterone is testosterone you know we just got dinner just because this but 510 health and rotting photo that we've already faced before so not too bad they got to do more pictures and backgrounds like that they sure do they sure do I think it's really cool I think it really adds to the story I like it the themes of the tower are so nice I know we went into this tower previously before and man it is amazing I love it absolutely love the like the middle and the charge it's so cool so cool the animation of storm snake yeah apparently it's been changed she's still not there can we please save her properly she ain't there she ain't there Suzy hello finally we can see the harvest Lord's plans he was raising an army of rotting fodder armed with storm magic to attack wizard city but there's more the tempest nexus up on the ridge channel storm energy into Trident Avenue the harvest Lord diverted the flow of energy to enchant the amulets but after he finished the amulets he directed the flow back on itself the nexus will explode and take Trident Avenue with it use the teleporter by the mill to reach the tempest nexus I'll meet you up there the tempest nexus that's a confusing thing she ran off when you can just use the teleporter she dumb Suzy dumb right hello it's worse than I thought any moment the controls they aren't working I can't professor Bellstrom knows more about storm magic than anyone go ask him for help I'll try to keep the nexus stable hurry talk to gamma that is not gamma game you can get to Ravenwood and back quickly by pressing the mark button to set your location give it a try use the return to commons button to get back to the commons and then head to Ravenwood okay looks like it visit your room back at Ravenwood if you want to move stuff between your break and backpack I'm just gonna sell all of my seeds because we have so many of them that it would be great yes 203 will I have so many seeds holy moly fantastic there we go I don't need them to strum so that's why I'm doing that go to the commons please game okay it wants me to use that button but it's not allowing me to use that button that's fine that is fine it's the set bonus concept in the game I love that as well I really love that I'm excited to check that out unfortunately at the moment I don't have any gear that can do that or by the looks of it can't do that because I don't have Dragoon's gear at the moment because I haven't actually farmed for that as of yet but yeah let's head to Hairston hello hi buddy Um, okay, we will recall just as the quest wants. That'll be great. Do-do-do-do-do-do-do-do-do. Um, and we need to do this. Sweet. Um, we'll talk to Susie. Yes. Alright. Thank goodness. Take me to him. It'll be good to see him again. Um, do-do-do-do-do-do-do. Um, right, we will do this and go over here to Arta, who is down this way, over here. Also, Arta is back to normal by the looks of it, which is a slight shame. I love that insane crit and mana. Luckily, I have that recorded.  Most mana in the game. Maybe you should leave that for later. For now, tell Sergeant Muldoon that things are calming down. Okay, right, we'll go to Sergeant Muldoon. Our pets seem to get experience, which is a slight shame, because it is this pet that we did, and not this one. Um, so we might actually go and train up this pet afterwards, just because this is a pet we get from the main quest. But that's essentially that done. Um, we'll just go talk to Sergeant Muldoon, who is over here. And we will see what happens. Haha. Um, you reported the broken commons port button. Okay, nice. Swede, um, full waterworks or bust. We ain't doing waterworks in our way. No way, no, no, no, no. Um, who does this dude sound like? I don't know who this dude sounds like. I should hope not. Sounds like things are getting sorted out. Water relief. Thanks, wizard. Sounds like swan from Mirage. Ah. And forex pay. Okie dokie. Um, and that's the end of that quest.