Department of Aging and Disability Services
2008 Nursing Facility Quality Review Resident Assessment
Instructions: CHOOSE ONLY ONE ANSWER FOR EACH QUESTION that offers a choice of responses. Questions marked with an asterisk (*) MUST be answered. Please print clearly.
1.1* Date of Assessment
1.2* Facility's Texas Vendor Number
1.3* Quality Review Nurse’s Identifier Number
1.4* Resident's DADSID
1.5* Resident's Name (First Name MI Last Name)
1.6* Resident’s Date of Birth? (Day) (Mo) (Year)
1.7* Resident’s Gender
1.8* How long has the resident lived in this facility?
NOTE: For all questions in Parts 2 through 14, with a few exceptions that are noted explicitly in the guidance, each question is meant to be answered independently of all other questions.
Questions 2.1 through 2.8 MUST BE ANSWERED. Questions 2.9 through 2.11 MUST BE ANSWERED when the answer to 2.8 is NO.
NOTE: Perform a continence check (ITEM 2.1) on every resident in the sample prior to collecting the remaining data items for any resident.
2.1* Did you find (see, smell, or feel) evidence of urinary incontinence?
2.2* Is the resident unresponsive (usual baseline level of responsiveness is comatose, semi-comatose, stuporous, persistent vegetative state, unarousable, etc.)? (This does NOT mean, “Is the resident cognitively impaired.” One can be very impaired and still not be unresponsive.)
2.3* In your professional opinion, does this resident require a mechanical lift or 2-person assistance to get out of bed?
2.4* Is the resident unable to ambulate or sit for ANY routine daily activity due to pain?
2.5* Does the resident have a terminal condition or palliative plan of care that precludes toileting?
2.6* Is a toileting plan (prompted voiding-PV, scheduled voiding-SV or bladder retraining-BR) specifically documented as part of the resident’s care plan? (NOTE: If more than one applies, answer with first answer from the list that applies to this resident)
2.7* Is the plan based on the individual’s voiding pattern and needs?
2.8* Is the resident ALWAYS continent without needing a toileting plan, incontinence products or a catheter?
If item 2.8 was answered YES, then skip to Part 3
2.9 Have there been two or more episodes of urinary incontinence each week in the last two weeks?
2.10 Have any of these episodes occurred during normal waking hours?
2.11 Does the resident refuse to use the toilet and all toileting devices? (e.g. BSC, urinal, bedpan)
Question 3.1 must be answered.
3.1* Does the resident have risk factors for a pressure ulcer?
If item 3.1 was answered NO, then skip to 3.3.
3.2 Does the treatment plan address (check one):
3.3 Does the resident have any pressure ulcers?
If item 3.3 was answered NO, then skip to Part 4.
3.4 What is the next highest stage pressure ulcer they have?
3.5 Where is the highest stage pressure ulcer located?
3.6 Is there a treatment plan for this pressure ulcer?
3.7 If the resident has more ulcers, what is the lowest stage pressure ulcer?
If the answer to 3.7 is 5, no other ulcers, then skip to Part 4.
3.8 Is there a treatment plan for this pressure ulcer?
All questions in this section MUST BE ANSWERED.
4.1* Has the resident had a urinary tract infection at any time in the last 7 days?
4.2* Has the resident had a skin or wound infection at any time in the last 7 days? (Responses do not sum to 100% due to rounding)
4.3* Has the resident had pneumonia at any time in the last 7 days?
4.4* Has the resident had diarrhea AND fever at any time in the last 7 days?
4.5* Has the resident had any other infection at any time in the last 7 days?
All questions in this section MUST BE ANSWERED.
5.1* What is the resident’s current level of pain? Perform the assessment with the Wong-Baker tool provided. (Note: Unable to determine means that you cannot determine the resident’s level of pain because the resident cannot tell you.)
5.2* According to the last 7 days of documentation in the clinical records, what has the resident’s most severe level of pain been? (Note: Unable to determine means that the clinical record does not address the presence or absence of pain.)
5.3* Is an observational pain assessment tool (e.g., PAINAD, DS-DAT (Discomfort Scale for Dementia of the Alzheimer’s Type) Pain Scale) being used to assess the resident’s pain?
5.4* Is the same assessment tool (used for 5.3) used every time the resident is assessed for pain? (Answer this item NA if 5.3 is answered NO.)
5.5* Is a validated self-report pain assessment tool used to assess the resident’s pain? (e.g., Wong-Baker Scale, Pain thermometer, a six-step verbal description scale or a numeric 0-10 rating scale)
5.6* Is the same assessment tool (used for 5.5) used every time the resident is assessed for pain? (Answer this item NA if 5.5 is answered NO.)
5.7* Is the resident (or family) satisfied with the resident’s level of pain relief during the last 24 hours? (Note: Unable to determine means that neither the resident nor family can tell you.)
5.8* How often is pain assessed?
Questions 6.1 and 6.2 MUST BE ANSWERED. Question 6.3 MUST BE ANSWERED when the answer to 6.2 is YES.
6.1* Is there evidence that the resident was assessed for fall risks within 14 days of admission or within 14 days of the most recent FULL MDS assessment? (Use most recent event.)
6.2* Is there evidence that the resident fell in the past 30 days AND was in the facility at some point in the subsequent 24 hours?
If item 6.2 was answered NO, then skip to Part 7
6.3 If the resident fell in the last 30 days, is there documentation that the resident was reassessed for fall risks within 24 hours after the fall?
All questions in this section MUST BE ANSWERED.
7.1* Is there any documentation that the resident has ever received polyvalent (including trivalent) Pneumococcal vaccine? (Any form of documentation is acceptable.)
7.2* Is there proper documentation of the pneumococcal vaccine that the resident received? (Look for documentation of Pneumovax or Pneu-Immune or Pneumococcal vaccine. Documentation must be by the entity that actually gave it and must include date, name of vaccine, and signature. “Received at hospital,” is not sufficient. The documentation of the event must be from the hospital, clinic or doctor’s office itself, and the same data elements must be present.)
7.3* Is there any documentation that Influenza vaccine for the 2007 (August 2007 thru May 2008) Influenza Season was given? (Any form of documentation is acceptable.)
7.4* Is there proper documentation that Influenza vaccine for the 2007 Influenza Season was given? (Documentation must be by the entity that actually gave it and must include date, name of vaccine, and signature. “Received at hospital,” is not sufficient. The documentation of the event must be from the hospital, clinic or doctor’s office itself, and the same data elements must be present.)
7.5* In what month did the resident receive a 2007 Influenza Season Vaccine? (See documentation requirements in 7.1.) (Responses may not sum to 100% due to rounding)
7.6* Is there evidence that the resident is allergic to either eggs or a previous Influenza shot or has had Guillain-Barré syndrome (GBS)?
7.7* Is there documentation that the resident (or family) REFUSED the Influenza shot?
Questions 8.1 through 8.3 MUST BE ANSWERED. Questions 8.4 through 8.6 MUST BE ANSWERED when the answer to any item from 8.1a-8.1e is YES.
After a thorough search of the clinical record, which of the following ACP documents did you find?
8.1a* Out-of-Hospital DNR (OOHDNR)
8.1b* Directive to Physicians
8.1c* Durable Medical Power of Attorney
8.1d* DNR order
8.1e* Other intervention-limiting orders
8.2* According to facility documents, when did the facility staff first discuss advance care planning with the resident or family?
8.3* Did the facility staff discuss advance care planning with the resident or family within the 21 days after the most recent full MDS assessment?
If ALL items 8.1a-8.1e were answered NO, then skip to Part 9
8.4 On first accessing the chart, were you able to find all of the existing advance directives and care limiting order documents within 30 seconds?
8.5 Is the care being provided consistent with the instructions in the advance care planning documents?
8.6 Does the Advance Care Plan address artificial nutrition and hydration?
Question 9.1 MUST BE ANSWERED.
Questions 9.2 through 9.7 MUST BE ANSWERED when the answer to 9.1 is YES.
9.1* Is the resident receiving tube feedings? (Includes NG tube, PEG, or other enteral tube providing artificial nutrition and/or hydration)
If item 9.1 was answered NO, then skip to Part 10
9.2 Is the reason for tube feeding the occurrence of aspiration pneumonia or pressure sores in the context of late-stage dementia (non-verbal, non-ambulatory)?
9.3 Does the resident have late-stage dementia (non-verbal, non-ambulatory) or endstage illness such as metastatic cancer or organ failure or poor performance status (ECOG performance score 3 or greater) related to advanced cancer?
9.4 Is there evidence that the resident or resident’s representative provided informed consent for tube feeding? (See the Guidance.)
9.5 Has tube feeding been provided for more than 30 days?
9.6 If the resident has been receiving tube feeding for more than 30 days, has there been a reassessment of the effectiveness of the feeding tube in the last 30 days? (Reassessment must be based on progress toward specific measurable goals.)
9.7 Does the resident have a feeding tube in place that has not been used for more than 30 days for nutrition or hydration?
Question 10.1 MUST BE ANSWERED.
10.1* Is there a comprehensive nutritional assessment completed for the resident? (This may be an initial assessment done on admission or an annual if the resident has been in the facility for a year. You need to review the most recent.)
If item 10.1 was answered NO, then skip to 10.3
10.2 Does the nutritional assessment include estimating resident nutritional needs?
10.3 Have risk factors for weight loss been identified?
10.4 Have risk factors for the potential of dehydration been identified?
All questions in this section MUST BE ANSWERED. Each of these questions must be answered independently (For examples, see items 11.3 through 11.5 “If there is no valid anxiety diagnosis…” in the Guidance).
11.1* Is there documentation of a psychiatric consultation or a primary care visit that gives a diagnosis of generalized anxiety disorder, panic disorder, social anxiety disorder, agoraphobia, PTSD, or anxiety due to a medical illness that is not Dementia?
11.2* Is there documentation of one or more anxiety symptoms characteristic of the disorder identified in 11.1? (If item 11.1 is answered NO, then answer 11.2 Not Applicable. If 11.1 is answered YES, then refer to the symptom list in the guidance.)
11.3* Is there documentation that the resident has been assessed for anxiety symptoms using a Beck Anxiety Inventory or Hamilton Anxiety Scale in the past 6 months?
11.4* Is there documentation of ongoing anxiety symptom assessment (at least every 2 weeks) for the stated, measurable therapeutic goals of anti-anxiety therapy? (Responses do not sum to 100% due to rounding)
All questions in this section MUST BE ANSWERED.
12.1* Has the resident complained of sleep problems within the last 14 days?
12.2* Has the resident had a hospitalization, experienced a sudden loss of physical functioning or independence, experienced the death of a loved one, or had a significant change in personal environment in the last 14 days? (e.g., a change in personal environment can be new admission to the facility, loss of roommate, new roommate, or conflict with family)
12.3* Do the last 14 days of MAR show an active prescription for sleep problems?
12.4* Is there evidence that the resident has been evaluated for sleep hygiene including all of the following: diet history, daytime habits, sleeping habits, and sleeping environment? (Refer to the Guidance for examples.)
12.5* Has the resident’s sleep pattern been consistently monitored during the last 14 days?
Question 13.1 MUST BE ANSWERED.
13.1* Has the person been restrained in the last 30 days?
If item 13.1 was answered NO or UNKNOWN, then skip to Part 14
13.2 What type(s) of restraints were used? (mark all that apply)
13.3 If bedrails were used as a restraint device, why were they used? (mark all that apply)
13.4 Did the resident’s family or guardian request the use of restraints?
13.5 What alternatives were tried to prevent the use of restraints? (mark all that apply)
Questions 14.1 & 14.2 MUST BE ANSWERED. If the resident is unable to answer, then a family member or guardian may only answer items 14.26 and 14.27. No other individual may answer for the resident. If ANY question from 14.3 to 14.25 is answered, then EVERY question in this section must be answered.
14.1* Who is responding to this survey?
14.2* Was a translator used for this survey?
If 14.1 was answered, “Family member of Guardian” then SKIP to 14.26
If item 14.1 was answered, “Neither” then STOP
14.3 Can you find a place to be alone when you wish?
14.4 Can you make a private phone call?
14.5 When you have a visitor, can you find a place to visit in private? (Responses do not sum to 100% due to rounding)
14.6 Can you be together in private with another resident (other than your roommate)? (Responses do not sum to 100% due to rounding)
14.7 Do you participate in religious activities here?
14.8 Do the religious observances here have personal meaning for you?
14.9 Do you enjoy the organized activities here at the nursing home?
14.10 Outside of religious activities, do you have enjoyable things to do at the nursing home during the weekends?
14.11 Do you like the food here?
14.12 Do you enjoy mealtimes here? (Responses may not sum to 100% due to rounding)
14.13 Can you get your favorite foods here?
14.14 Do you feel that your possessions are safe at this nursing home?
14.15 Have your clothes gotten lost or damaged in the laundry in the last month?
14.16 Do you feel safe and secure?
If item 14.16 was answered YES, then skip to 14.18
14.17 Do you feel unsafe and insecure because of? (mark all that apply)
14.18 Do you ever have concerns that the facility does not address?
14.19 Have you heard of the Ombudsman Program?
14.20 Do you know how to contact an Ombudsman?
14.21 Have you used the services of an Ombudsman in the last 12 months?
If item 14.21 was answered YES, then skip to 14.25
14.22 How helpful has your Ombudsman been to you?
14.23 In the last month, have you had a concern that you did not express because you were afraid of retaliation?
14.24 Have you been given a choice of hospice care?
14.25 Does your facility offer a variety of hospice agency providers from which to choose?
14.26 Overall, how satisfied are you with your (your family member's) experience in this nursing facility?
14.27 Overall, how satisfied are you (your family member's) with your health care services?
I certify by my signature below that the DADS ID number of the resident has been doubled-checked for accuracy, and that the information in this document is an accurate assessment of the resident.
QR Nurse Signature
Updated: June 8, 2010