CMD Case Analysis & Practical Application 3 — Questions and Answers
Question 1: A resident refuses all meals for three days, citing depression. The CMD's most appropriate initial intervention is:
- Insert a PEG tube immediately to prevent malnutrition
- Initiate a psychiatric evaluation and depression screening while optimizing oral intake strategies (Correct answer)
- Document refusal and take no further action
- Restrict the resident's privileges until eating resumes
Correct answer: Initiate a psychiatric evaluation and depression screening while optimizing oral intake strategies
Depression is a reversible and common cause of anorexia in SNF residents; psychiatric evaluation combined with oral intake support addresses root cause before invasive feeding.
Question 2: The state surveyor cites the facility for deficient physician visit frequency. Under CMS regulations, how often must physicians visit SNF residents during the first 90 days of a Medicare-covered stay?
- Every 30 days (Correct answer)
- Every 60 days
- Every 14 days
- Weekly
Correct answer: Every 30 days
CMS requires physician visits at least every 30 days for the first 90 days of a Medicare-covered SNF stay, then at least every 60 days thereafter.
Question 3: A 79-year-old resident on warfarin for atrial fibrillation sustains a minor fall without injury. The CMD should:
- Discontinue warfarin immediately to prevent bleeding
- Reassess fall risk, review INR, and evaluate anticoagulation benefit-risk balance with the resident (Correct answer)
- Order bed restraints to prevent future falls
- Switch to aspirin without a cardiovascular risk assessment
Correct answer: Reassess fall risk, review INR, and evaluate anticoagulation benefit-risk balance with the resident
Fall risk management in anticoagulated patients requires individualized benefit-risk analysis rather than automatic discontinuation of stroke-protective therapy.
Question 4: A family alleges that a resident's wound has worsened due to nursing neglect. As CMD, you should:
- Immediately side with the family to avoid litigation
- Conduct a clinical wound assessment, review nursing documentation, and convene a care conference (Correct answer)
- Dismiss the concern and attribute deterioration to underlying disease
- Transfer the resident to another facility before investigation
Correct answer: Conduct a clinical wound assessment, review nursing documentation, and convene a care conference
Objective clinical assessment and documentation review are necessary to distinguish disease progression from care failures before any conclusions are drawn.
Question 5: A facility wants to implement a new pain assessment protocol for non-verbal residents. Which validated tool is MOST appropriate?
- Visual Analog Scale (VAS)
- Numeric Rating Scale (NRS)
- Pain Assessment in Advanced Dementia (PAINAD) (Correct answer)
- McGill Pain Questionnaire
Correct answer: Pain Assessment in Advanced Dementia (PAINAD)
PAINAD is validated specifically for non-verbal residents with advanced dementia, assessing breathing, vocalization, facial expression, body language, and consolability.
Question 6: During a care conference, a resident's surrogate decision-maker requests CPR despite the resident's documented DNR. The CMD should:
- Revoke the DNR to comply with surrogate wishes
- Explain that the resident's own advance directive takes precedence over surrogate preferences (Correct answer)
- Perform CPR if the surrogate insists at the time of arrest
- Transfer the resident to a facility willing to honor the surrogate's request
Correct answer: Explain that the resident's own advance directive takes precedence over surrogate preferences
A competently executed advance directive reflecting the resident's own wishes legally and ethically supersedes surrogate preferences under U.S. law.
Question 7: The MDS Coordinator reports that a resident's Section GG functional scores declined significantly without a documented clinical rationale. As CMD, this finding MOST likely signals:
- A billing optimization opportunity
- A potential quality indicator gap requiring clinical investigation and documentation improvement (Correct answer)
- Normal aging progression requiring no action
- An MDS coding error that the coordinator should correct independently
Correct answer: A potential quality indicator gap requiring clinical investigation and documentation improvement
Unexplained functional decline in Section GG warrants clinical investigation to identify reversible causes and ensure accurate documentation of care delivered.
CMD Case Analysis & Practical Application 3
A resident refuses all meals for three days, citing depression.
The CMD's most appropriate initial intervention is: