• Acknowledgements
• Preface
• 1.0 Executive Summary
• 2.0 Methods
• 3.0 Findings
• 3.1 Demographics
• 3.2 Urinary Incontinence
• 3.3 Pressure Ulcers
• 3.4 Infectious Illnesses
• 3.5 Pain Assessment and Pain Control
• 3.6 Fall Risk Management Practices
• 3.7 Immunization Practices
• 3.8 Advance Care Planning
• 3.9 Artificial Nutrition and Hydration
• 3.10 Nutrition, Unintended Weight Loss, and Hydration
• 3.11 Medication Practice and Safety
• 3.12 Psychoactive Medication Usage
• 3.13 Restraints
• 3.14 Quality of Life/Consumer Satisfaction
• 4.0 DADS Initiatives and Collaborative Efforts
• 5.0 Conclusion
• 6.0 References
• Appendix A — 2008 Nursing Facility Quality Review Survey
• Appendix B — Acronyms
• Report in PDF format
• 2008 NFQR home
• Legislative summaries and reports home

• Learn about DADS home

Other DADS resources

• Help for Texans
• Doing business with DADS
• Rules and statutes
• DADS home

More questions?
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Appendix A – 2008 Nursing Facility Quality Review Survey

Department of Aging and Disability Services
2008 Nursing Facility Quality Review Resident Assessment

Part 1. Identifying Information

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. Male (31%)
2. Female (69%)

1.8* How long has the resident lived in this facility?

1. 0-3 months (17%)
2. 3-6 months (9%)
3. 6-9 months (9%)
4. 9-12 months (6%)
5. 1-2 years (18%)
6. more than 2 years (41%)

Part 2. Assessment of Urinary Continence

2.1* Did you find (see, smell, or feel) evidence of urinary incontinence?

1. Yes (44%)
2. No (56%)

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.)

1. Yes (3%)
2. No (97%)

2.3* In your professional opinion, does this resident require a mechanical lift or 2-person assistance to get out of bed?

1. Yes (31%)
2. No (69%)

2.4* Is the resident unable to ambulate or sit for ANY routine daily activity due to pain?

1. Yes (4%)
2. No (96%)

2.5* Does the resident have a terminal condition or palliative plan of care that precludes toileting?

1. Yes (11%)
2. No (89%)

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)

1. Yes-PV (3%)
2. Yes-SV (10%)
3. Yes-BR (1%)
4. No (86%)

2.7* Is the plan based on the individual’s voiding pattern and needs?

1. Yes (7%)
2. No (2%)
3. q2h SV (6%)
4. There is no plan (85%)

2.8* Is the resident ALWAYS continent without needing a toileting plan, incontinence products or a catheter?

1. Yes (30%)
2. No (70%)

2.9 Have there been two or more episodes of urinary incontinence each week in the last two weeks?

1. Yes (89%)
2. No (11%)

2.10 Have any of these episodes occurred during normal waking hours?

1. Yes (87%)
2. No (13%)

2.11 Does the resident refuse to use the toilet and all toileting devices? (e.g. BSC, urinal, bedpan)

1. Yes (10%)
2. No (90%)

Part 3. Pressure Ulcers

3.1* Does the resident have risk factors for a pressure ulcer?

1. Yes (66%)
2. No (34%)

3.2 Does the treatment plan address (check one):

1. Bedridden and Repositioned every 2 hours? (18%)
2. In chair and able to self shift weight every 15 minutes? (15%)
3. In chair and repositioned by staff every 1 hour? (6%)
4. There is no plan (20%)
5. Other (41%)

3.3 Does the resident have any pressure ulcers?

1. Yes (19%)
2. No (81%)

3.4 What is the next highest stage pressure ulcer they have?

1. Stage 1 (34%)
2. Stage 2 (42%)
3. Stage 3 (13%)
4. Stage 4 (11%)

3.5 Where is the highest stage pressure ulcer located?

1. Arms or hands (2%)
2. Legs or feet (36%)
3. Buttocks or Sacrum (58%)
4. Other (4%)

3.6 Is there a treatment plan for this pressure ulcer?

1. Yes (89%)
2. No (11%)

3.7 If the resident has more ulcers, what is the lowest stage pressure ulcer?

1. Stage 1 (13%)
2. Stage 2 (12%)
3. Stage 3 (2%)
4. 4 Stage 4 (2%)
5. no other ulcers (71%)

3.8 Is there a treatment plan for this pressure ulcer?

1. Yes (86%)
2. No (14%)

Part 4. Infectious Illnesses

4.1* Has the resident had a urinary tract infection at any time in the last 7 days?

1. Yes-MRSA (0%)
2. Yes-VRE (0.3%)
3. Yes-other (4.9%)
4. No (94.8%)

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)

1. Yes-MRSA (0.3%)
2. Yes-VRE (0.1%)
3. Yes-other (2.8%)
4. No (96.8%)

4.3* Has the resident had pneumonia at any time in the last 7 days?

1. Yes-MRSA (0.1%)
2. Yes-VRE (0%)
3. Yes-other (1.7%)
4. No (98.2%)

4.4* Has the resident had diarrhea AND fever at any time in the last 7 days?

1. Yes-C. dif (0.2%)
2. Yes-other (0.1%)
3. No (99.6%)

4.5* Has the resident had any other infection at any time in the last 7 days?

1. Yes-MRSA (0%)
2. Yes-VRE (0%)
3. Yes-other (3.8%)
4. No (96.1%)

Part 5. Pain Assessment

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.)

1. no pain (65%)
2. mild (10%)
3. moderate (7%)
4. severe (2%)
5. very severe (1%)
6. worst (0%)
7. Unable to determine (15%)

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.)

1. no pain (48%)
2. mild (6%)
3. moderate (8%)
4. severe (3%)
5. very severe (1%)
6. worst (1%)
7. Unable to determine (33%)

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?

1. Yes (38%)
2. No (62%)

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.)

1. Yes (35%)
2. No (6%)
8. Not Applicable (59%)

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)

1. Yes (63%)
2. No (37%)

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.)

1. Yes (57%)
2. No (7%)
8. Not Applicable (36%)

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.)

1. Yes (69%)
2. No (4%)
3. Unable to determine (27%)

5.8* How often is pain assessed?

1. every shift (32%)
2. every day (8%)
3. once a week (4%)
4. once a month (12%)
5. before pain meds (11%)
6. after pain meds (3%)
7. no record of assessment (16%)
8. N/A (no pain) (14%)

Part 6. Fall Risk Assessment

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.)

1. Yes (79%)
2. No (21%)

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?

1. Yes (7%)
2. No (93%)

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?

1. Yes (51%)
2. No (39%)
3. Transferred to ER or Hospital (10%)

Part 7. Immunizations

7.1* Is there any documentation that the resident has ever received polyvalent (including trivalent) Pneumococcal vaccine? (Any form of documentation is acceptable.)

1. Yes (61%)
2. No (39%)

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.)

1. Yes (34%)
2. No (66%)

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.)

1. Yes (67%)
2. No (33%)

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.)

1. Yes (50%)
2. No (50%)

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)

1. Aug ’07 (0.4%)
2. Sep ’07 (1.2%)
3. Oct ’07 (43.3%)
4. Nov ’07 (12.4%)
5. Dec ’07 (2.1%)
6. Jan ’08 (1.5%)
7. Feb ’08 (0.8%)
8. Mar ’08 (0.3%)
9. Apr ’08 (0.1%)
10. May ’08 (0%)
11. Influenza Vaccine was Not Given (38%)

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)?

1. Yes (2%)
2. No (98%)

7.7* Is there documentation that the resident (or family) REFUSED the Influenza shot?

1. Yes (13%)
2. No (87%)

Part 8. Advance Care Planning

After a thorough search of the clinical record, which of the following ACP documents did you find?

8.1a* Out-of-Hospital DNR (OOHDNR)

1. Yes (52%)
2. No (48%)

8.1b* Directive to Physicians

1. Yes (24%)
2. No (76%)

8.1c* Durable Medical Power of Attorney

1. Yes (30%)
2. No (70%)

8.1d* DNR order

1. Yes (42%)
2. No (58%)

8.1e* Other intervention-limiting orders

1. Yes (8%)
2. No (92%)

8.2* According to facility documents, when did the facility staff first discuss advance care planning with the resident or family?

1. Prior to admission (25%)
2. Within 21 days of admission (50%)
3. Within the first 90 days of admission (3%)
4. 90 or more days after admission (11%)
5. Advance Care Planning has not been discussed with the resident or family (11%)

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?

1. Yes (59%)
2. No (41%)

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?

1. Yes (91%)
2. No (9%)

8.5 Is the care being provided consistent with the instructions in the advance care planning documents?

1. Yes (97%)

2. No (3%)

8.6 Does the Advance Care Plan address artificial nutrition and hydration?

1. Yes (24%)

2. No (76%)

Part 9. Tube Feeding

9.1* Is the resident receiving tube feedings? (Includes NG tube, PEG, or other enteral tube providing artificial nutrition and/or hydration)

1. Yes (8%)
2. No (92%)

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)?

1. Yes (45%)
2. No (55%)

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?

1. Yes (40%)
2. No (60%)

9.4 Is there evidence that the resident or resident’s representative provided informed consent for tube feeding? (See the Guidance.)

1. Yes (32%)
2. No (68%)

9.5 Has tube feeding been provided for more than 30 days?

1. Yes (90%)
2. No (10%)

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.)

1. Yes (53%)
2. No (30%)
8. Not Applicable (17%)

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?

1. Yes (2%)
2. No (86%)
8. Not Applicable (12%)

Part 10. Nutrition

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.)

1. Yes (93%)
2. No (7%)

10.2 Does the nutritional assessment include estimating resident nutritional needs?

1. Yes (97%)
2. No (3%)

10.3 Have risk factors for weight loss been identified?

1. Yes (69%)
2. No (31%)

10.4 Have risk factors for the potential of dehydration been identified?

1. Yes (63%)
2. No (37%)

Part 11. Use of Anti-anxiety Medications

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?

1. Yes (16%)
2. No (84%)

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.)

1. Yes (13%)
2. No (12%)
8. Not Applicable (75%)

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?

1. Yes (6%)
2. No (94%)

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)

1. Yes (10%)
2. No (12%)
8. Not Applicable (i.e., no measurable goals) (79%)

Part 12. Use of Hypnotic Medications

12.1* Has the resident complained of sleep problems within the last 14 days?

1. Yes (8%)
2. No (92%)

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)

1. Yes (9%)
2. No (91%)

12.3* Do the last 14 days of MAR show an active prescription for sleep problems?

1. Yes (15%)
2. No (85%)

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.)

1. Yes (12%)
2. No (88%)

12.5* Has the resident’s sleep pattern been consistently monitored during the last 14 days?

1. Yes (26%)
2. No (74%)

Part 13. Restraints

Question 13.1 MUST BE ANSWERED.

13.1* Has the person been restrained in the last 30 days?

1. Yes (29%)
2. No (63%)
3. Unknown (8%)

13.2 What type(s) of restraints were used? (mark all that apply)

1. Mechanical (87%)
   1. Full bed rails (58%)
   2. Other types of bed rails (32%)
   3. Trunk restraints (3%)
   4. Limb restraints (1%)
   5. Chair prevention rising (18%)
2. Personal (2%)
3. Chemical (2%)
   1. Topical (0%)
   2. Injectable (0.3%)
   3. Oral (1%)
   4. IV (0%)
   5. Other (0.5%)
4. NACES evaluator unable to determine from record (0.3%)

13.3 If bedrails were used as a restraint device, why were they used? (mark all that apply)

1. To control disruptive behavior (2%)
2. To control person from wandering (6%)
3. To control from getting up at night (12%)
4. Other (58%)
5. NACES evaluator unable to determine from record (23%)

13.4 Did the resident’s family or guardian request the use of restraints?

1. Yes (28%)
2. No (66%)
8. Not Applicable (6%)

13.5 What alternatives were tried to prevent the use of restraints? (mark all that apply)

1. Verbal de-escalation or redirection (5%)
2. Interpersonal physical separation (0%)
3. Environmental remediation (5%)
4. Other (9%)
5. None (23%)
6. NACES evaluator unable to determine from record (63%)

Part 14. Quality of Life / Consumer Satisfaction

14.1* Who is responding to this survey?

1. Resident (69%)
2. Family member or Guardian (10%)
3. Neither (21%)

14.2* Was a translator used for this survey?

1. Yes (4%)
2. No (96%)

14.3 Can you find a place to be alone when you wish?

1. Always (51%)
2. Sometimes (20%)
3. Rarely (7%)
4. Never (13%)
5. No Answer (9%)

14.4 Can you make a private phone call?

1. Always (57%)
2. Sometimes (14%)
3. Rarely (4%)
4. Never (14%)
5. No Answer (11%)

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)

1. Always (55%)
2. Sometimes (23%)
3. Rarely (5%)
4. Never (9%)
5. No Answer (9%)

14.6 Can you be together in private with another resident (other than your roommate)? (Responses do not sum to 100% due to rounding)

1. Always (40%)
2. Sometimes (21%)
3. Rarely (7%)
4. Never (16%)
5. No Answer (17%)

14.7 Do you participate in religious activities here?

1. Always (32%)
2. Sometimes (26%)
3. Rarely (8%)
4. Never (31%)
5. No Answer (3%)

14.8 Do the religious observances here have personal meaning for you?

1. Always (39%)
2. Sometimes (20%)
3. Rarely (7%)
4. Never (22%)
5. No Answer (12%)

14.9 Do you enjoy the organized activities here at the nursing home?

1. Always (31%)
2. Sometimes (31%)
3. Rarely (12%)
4. Never (22%)
5. No Answer (4%)

14.10 Outside of religious activities, do you have enjoyable things to do at the nursing home during the weekends?

1. Always (13%)
2. Sometimes (23%)
3. Rarely (22%)
4. Never (31%)
5. No Answer (11%)

14.11 Do you like the food here?

1. Always (41%)
2. Sometimes (41%)
3. Rarely (9%)
4. Never (7%)
5. No Answer (2%)

14.12 Do you enjoy mealtimes here? (Responses may not sum to 100% due to rounding)

1. Always (53%)
2. Sometimes (30%)
3. Rarely (7%)
4. Never (6%)
5. No Answer (5%)

14.13 Can you get your favorite foods here?

1. Always (25%)
2. Sometimes (35%)
3. Rarely (15%)
4. Never (14%)
5. No Answer (11%)

14.14 Do you feel that your possessions are safe at this nursing home?

1. Always (65%)
2. Sometimes (19%)
3. Rarely (4%)
4. Never (6%)
5. No Answer (6%)

14.15 Have your clothes gotten lost or damaged in the laundry in the last month?

1. Always (10%)
2. Sometimes (22%)
3. Rarely (11%)
4. Never (45%)
5. No Answer (12%)

14.16 Do you feel safe and secure?

1. Always (84%)
2. Sometimes (11%)
3. Rarely (1%)
4. Never (1%)
5. No Answer (3%)

14.17 Do you feel unsafe and insecure because of? (mark all that apply)

1. Direct Care Staff (33%)
2. Non Care Staff (13%)
3. Other Residents (29%)
4. Environmental Concerns (12%)
5. Other (34%)

14.18 Do you ever have concerns that the facility does not address?

1. Yes (13%)
2. No (87%)

14.19 Have you heard of the Ombudsman Program?

1. Yes (16%)
2. No (84%)

14.20 Do you know how to contact an Ombudsman?

1. Yes (7%)
2. No (93%)

14.21 Have you used the services of an Ombudsman in the last 12 months?

1. Yes (2%)
2. No (98%)

14.22 How helpful has your Ombudsman been to you?

1. Not helpful (40%)
2. Neutral (53%)
3. Very helpful (7%)

14.23 In the last month, have you had a concern that you did not express because you were afraid of retaliation?

1. Yes (5%)
2. No (95%)
3. Don’t’ Know (0%)

14.24 Have you been given a choice of hospice care?

1. Yes (10%)
2. No (37%)
3. Don’t’ Know (53%)

14.25 Does your facility offer a variety of hospice agency providers from which to choose?

1. Yes (8%)
2. No (9%)
3. Don’t Know (83%)

14.26 Overall, how satisfied are you with your (your family member's) experience in this nursing facility?

1. Very Dissatisfied (3%)
2. Dissatisfied (2%)
3. Somewhat Dissatisfied (4%)
4. Neither (2%)
5. Somewhat Satisfied (14%)
6. Satisfied (44%)
7. Very Satisfied (31%)
8. Not applicable (0%)

14.27 Overall, how satisfied are you (your family member's) with your health care services?

1. Very Dissatisfied (3%)
2. Dissatisfied (3%)
3. Somewhat Dissatisfied (4%)
4. Neither (2%)
5. Somewhat Satisfied (11%)
6. Satisfied (46%)
7. Very Satisfied (30%)
8. Not applicable (1%)

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Updated: June 8, 2010