Question Number | Question Item | Code Categories | Resident Asked | Skip Pattern |
---|---|---|---|---|
R_A_INTRO1 | In order to obtain national level data about the residents of residential care facilities such as this one, we are collecting information from a sample of current residents. I will be asking questions about the background, health status, and charges for each sampled resident. The information you provide will be held in strict confidence and will be used only by persons involved in the survey and only for the purpose of the survey. The interview for each of the selected residents should take about 20 minutes to complete. | 1 CONTINUE | All residents | |
R_A_INTRO 1A | Now I am going to ask questions about the following resident--[RESIDENT INITIALS]. | 1 CONTINUE | All residents | |
R_A_INTRO 2 | Do you have the resident records for [RESIDENT INITIALS]? (You may want to use the resident file in answering a few of the questions in this survey. If you have not retrieved the records and would like to do so now, I can wait a few minutes while you obtain them.) |
1 RECORD OBTAINED 2 RECORD NOT OBTAINED |
All residents | |
R_A1 | Please tell me [RESIDENT INITIALS]gender? | 1 MALE 2 FEMALE |
All residents | |
R_A3 | Is [RESIDENT INITIALS]of Hispanic, Latino, or Spanish origin or descent? | 1 YES 2 NO |
All residents | |
R_A2 | Please tell me [RESIDENT INITIALS] age? | 0-120 | All residents | |
ENDINT | I am sorry but our survey is about residents that are 18 or older. Since this person is not eligible, I wont complete an interview for this particular resident. I need to check my records for any other selected residents for whom you were identified as a caregiver. |
1 CONTINUE | R_A2 = < 18 | |
R_A4 | HAND R SHOWCARD Which one or more of the following would you say is [RESIDENT INITIALS] race? SELECT ALL THAT APPLY |
1 WHITE/CAUCASIAN 2 BLACK OR AFRICAN AMERICAN 3 ASIAN 4 HAWAIIAN OR OTHER PACIFIC ISLANDER 5 AMERICAN INDIAN OR ALASKA NATIVE |
All residents | |
R_A5 | What is the highest grade or level of education [RESIDENT INITIALS] completed...? High school or less or Some college or more |
1 High school or less 2 Some college or more |
All residents | |
R_A6 | Is [RESIDENT INITIALS] currently married, divorced, legally separated, widowed, or never married? | 1 Married 2 Divorced 3 Legally separated 4 Widowed 5 Never married |
All residents | |
R_A7 | How well does [RESIDENT INITIALS] speak English...? Excellent very well well fair poor or not at all |
1 Excellent 2 Very well 3 Well 4 Fair 5 Poor or not at all 6 DOES NOT SPEAK BECAUSE OF A DISABILITY, OR SEVERE DEMENTIA |
All residents | |
R_A8a | Overall, is [RESIDENT INITIALS] health...? Excellent very good good fair or poor |
1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor |
All residents | |
R_A9 | HAND R SHOWCARD Which of these places best describes [RESIDENT INITIALS] living quarters? |
1 ROOM DESIGNED FOR ONE PERSON 2 ROOM DESIGNED FOR TWO PERSONS 3 ROOM DESIGNED FOR THREE OR MORE PERSONS 4 STUDIO APARTMENT 5 ONE BEDROOM APARTMENT 6 TWO BEDROOM APARTMENT 7 THREE BEDROOM APARTMENT |
All residents | |
R_A10 | Does [RESIDENT INITIALS] currently share this (room/ apartment) with another person? | 1 YES 2 NO |
All residents | |
R_A11 | Is this person [RESIDENT INITIALS] spouse or other relative? | 1 YES 2 NO |
If R_A10 = 1 | |
R_A12 | How many other residents not counting [RESIDENT INITIALS] live in the (room/apartment)? | 1 ONE OTHER PERSON 2 TWO OR MORE OTHER PERSONS |
If R_A10 = 1 | |
R_A13 | Does [RESIDENT INITIALS] live in a Dementia/Alzheimers Special Care Unit? | 1 YES 2 NO 3 FACILITY DOES NOT HAVE DEMENTIA/ ALZHEIMERS UNIT |
All residents | |
New question | HAND R SHOWCARD Which of the following are located inside [RESIDENT INITIALS] (room/apartment)? SELECT ALL THAT APPLY |
1 MICROWAVE 2 COOK TOP OR HOT PLATE 3 OVEN 4 REFRIGERATOR 5 KITCHEN SINK 6 NONE OF THE ABOVE |
All residents | |
R_A15 | Does [RESIDENT INITIALS] (room/apartment) have a door to the hallway that can be locked from the inside? | 1 YES 2 NO |
All residents | |
R_A15A | Does [RESIDENT INITIALS] (room/apartment) have a bathroom located inside the (room/apartment) or between (rooms/apartments)? | 1 YES 2 NO |
All residents | |
R_A15Bath | HAND R SHOWCARD Which type of bathroom is in [RESIDENT INITIALS] (room/apartment) |
1 FULL BATHROOM INCLUDING A TOILET, SINK, AND SHOWER OR TUB 2 HALF-BATH INCLUDING A SINK AND TOILET |
If R_A15A = 1 | |
R_A16 | HAND R SHOWCARD Please read this list of activities and tell me whether [RESIDENT INITIALS] regularly participates in any of these at least twice a month, regardless of whether or not it is arranged by the facility. SELECT ALL THAT APPLY |
1 CARDS, BOARD GAMES, BINGO, PUZZLES 2 ARTS OR CRAFTS, SUCH AS SEWING, KNITTING, PAINTING, QUILTING, FLOWER ARRANGING 3 EXERCISE OR SPORTS 4 PLAYING OR LISTENING TO MUSIC, OR SINGING 5 READING OR WRITING 6 SPIRITUAL OR RELIGIOUS ACTIVITIES 7 SHOPPING OR TRIPS 8 WATCHING TELEVISION 9 LEAVING THE FACILITY GROUNDS 10 TALKING WITH FRIENDS OR RELATIVES 11 GOING OUT TO THE MOVIES, DINING OUT OR OTHER SOCIAL ACTIVITIES 12 GARDENING 13 TAKING CARE OF PETS 14 OTHER HOBBIES OR ACTIVITIES 15 NONE OF THE ABOVE |
All residents | |
R_A16_outside | HAND R SHOWCARD Does [RESIDENT INITIALS] go outside the facility to do any of the following activities? SELECT ALL THAT APPLY |
1 WORK AT A JOB FOR PAY 2 PARTICIPATE IN A SHELTERED WORKSHOP 3 PARTICIPATE IN A WORK TRAINING PROGRAM 4 ATTEND DAY PROGRAMS FOR SOCIAL OR RECREATIONAL ACTIVITIES 5 ATTEND AN EDUCATIONAL PROGRAM 6 ATTEND AN ADULT DAY CARE PROGRAM 7 NONE OF THE ABOVE |
All residents | |
R_A17 | Does [RESIDENT INITIALS] still drive? | 1 YES 2 NO |
All residents | |
R_A18 | How often does [RESIDENT INITIALS] drive? Daily or every other day Once or twice a week or Less than once per week |
1 Daily or every other day 2 Once or twice a week 3 Less than once per week |
If R-A17 = 1 | |
R_B1Month | When did [RESIDENT INITIALS] first move into this facility? MONTH |
1 January 2 February 3 March 4 April 5 May 6 June 7 July 8 August 9 September 10 October 11 November 12 December |
All residents | |
R_B1Year | (When did [RESIDENT INITIALS] first move into this facility?) YEAR |
1970-2010 | All residents | |
R_B1Range | HAND R SHOWCARD Please look at this card and tell me approximately how long it has been since [RESIDENT INITIALS] first moved into this facility? |
1 0 TO 3 MONTHS 2 MORE THAN 3 MONTHS TO 6 MONTHS 3 MORE THAN 6 MONTHS TO 1 YEAR 4 MORE THAN 1 YEAR TO 3 YEARS 5 MORE THAN 3 YEARS TO 5 YEARS 6 MORE THAN 5 YEARS |
If R_B1Year = DK | |
R_B2 | When [RESIDENT INITIALS] first moved into this facility, was (he/she) directly admitted from a short-term stay at a: READ CHOICES hospital rehabilitation facility nursing home |
1 Hospital 2 Rehabilitation facility 3 Nursing home 4 NONE OF THE ABOVE |
All residents | |
R_B3 | HAND R SHOWCARD Where did (he/she) live prior to (his/her) (moving to this facility/stay at the (hospital/rehabilitation facility/nursing home))? |
1 PRIVATE HOME, APARTMENT, RENTED ROOM, OR FAMILY RESIDENCE 2 DIFFERENT RESIDENTIAL CARE, ASSISTED LIVING, OR GROUP HOME FACILITY 3 RETIREMENT OR INDEPENDENT LIVING COMMUNITY 4 NURSING HOME (THIS EXCLUDES SHORT NURSING HOME STAYS FOR REHABILITATION) 5 PSYCHIATRIC FACILITY 6 JAIL 7 HOMELESS 8 OTHER |
All residents | |
R_B4 | For last month, what was the total charge for [RESIDENT INITIALS] to live in this facility? Include the basic monthly charge and charges for any additional services. | 0-8000 | All residents | |
R_B5 | During the last 30 days did [RESIDENT INITIALS] have any of (his/her) long-term care services at this facility paid by Medicaid? | 1 YES 2 NO |
All residents | |
R_B6 | Is [RESIDENT INITIALS] a veteran of U.S. Military service? | 1 YES 2 NO |
All residents | |
R_B6a | Is [RESIDENT INITIALS] the spouse, or widow/widower, of a veteran of U.S. Military service? | 1 YES 2 NO |
All residents | |
R_C_INTRO | The next questions are about [RESIDENT INITIALS] health status and physical functioning. | 1 CONTINUE | All residents | |
R_C1 | HAND R SHOWCARD As far as you know, has a doctor or other health professional ever diagnosed [RESIDENT INITIALS] with any of the following conditions? Please tell me the numbers that apply from this card. SELECT ALL THAT APPLY |
1 ALZHEIMER'S DISEASE OR OTHER DEMENTIA 2 ANEMIA 3 ARTHRITIS OR RHEUMATOID ARTHRITIS 4 ASTHMA 5 CANCER OR MALIGNANT NEOPLASM OF ANY KIND 6 CEREBRAL PALSY 7 CHRONIC BRONCHITIS 8 CONGESTIVE HEART FAILURE 9 COPD 10 CORONARY HEART DISEASE 11 DEPRESSION 12 DIABETES 13 EMPHYSEMA 14 GLAUCOMA 15 GOUT, LUPUS, OR FIBROMYALGIA 16 HEART ATTACK (MYOCARDIAL INFARCTION) 17 HIGH BLOOD PRESSURE OR HYPERTENSION 18 INTELLECTUAL OR DEVELOPMENTAL DISABILITIES SUCH AS MENTAL RETARDATION, SEVERE AUTISM, OR DOWN SYNDROME 19 KIDNEY DISEASE 20 MACULAR DEGENERATION 21 MUSCULAR DYSTROPHY 22 NERVOUS SYSTEM DISORDERS, INCLUDING MULTIPLE SCLEROSIS, PARKINSON'S DISEASE, AND EPILEPSY 23 OSTEOPOROSIS 24 OTHER MENTAL, EMOTIONAL OR NERVOUS CONDITION 25 PARTIAL OR TOTAL PARALYSIS 26 SERIOUS MENTAL PROBLEMS SUCH AS SCHIZOPHRENIA OR PSYCHOSIS 27 SPINAL CORD INJURY 28 STROKE 29 TRAUMATIC BRAIN INJURY 30 ANY OTHER KIND OF HEART CONDITION OR HEART DISEASE (OTHER THAN LISTED ABOVE) 31 OTHER 32 NONE OF THESE |
All residents | |
R_C1OTH | Specify other condition. | SPECIFY | R_C1 = 31 | |
R_C1_Cancer | What kind of cancer? SELECT ALL THAT APPLY |
1 BLADDER 2 BLOOD 3 BONE 4 BRAIN 5 BREAST 6 CERVIX 7 COLON 8 ESOPHAGUS 9 GALLBLADDER 10 KIDNEY 11 LARYNX, WINDPIPE 12 LEUKEMIA 13 LIVER 14 LUNG 15 LYMPHOMA 16 MELANOMA 17 MOUTH, TONGUE, OR LIP 18 OVARY 19 PANCREAS 20 PROSTATE 21 RECTUM 22 SKIN, NON-MELANOMA 23 SKIN, DON'T KNOW WHAT KIND 24 SOFT TISSUE (MUSCLE OR FAT) 25 STOMACH 26 TESTIS 27 THROAT, PHARYNX 28 THYROID 29 UTERUS 30 OTHER |
R_C1 = CANCER | |
R_C1FLU1 | HAND R SHOW CARD Please look at this card and tell me which category best describes [RESIDENT INITIALS] documented vaccination status for a flu shot during the past 12 months. |
1 VACCINATED WHILE RESIDING AT THIS FACILITY 2 VACCINATED BEFORE ADMISSION TO THIS FACILITY 3 NOT VACCINATED IN past 12 MONTHS--NO RECORD OF DOCTOR'S ORDER OR OF VACCINATION OFFERED 4 NOT VACCINATED IN past 12 MONTHS--VACCINATION MEDICALLY CONTRAINDICATED 5 NOT VACCINATED IN past 12 MONTHS--RESIDENT/ FAMILY REFUSED VACCINATION 6 NOT VACCINATED IN past 12 MONTHS--OTHER REASON 7 NOT VACCINATED IN PAST 12 MONTHS--REASON UNKNOWN 8 DID NOT RESIDE IN THE FACILITY DURING THE MOST RECENT FLU SEASON |
All residents | |
R_C1FLU2 | HAND R SHOW CARD Which statement on this card best describes the documented vaccination status for whether [RESIDENT INITIALS] has ever had a pneumococcal vaccine? |
1 VACCINATED WHILE RESIDING AT THIS FACILITY 2 VACCINATED BEFORE ADMISSION TO THIS FACILITY 3 NEVER VACCINATED--NO RECORD OF DOCTOR'S ORDER OR OF VACCINATION OFFERED 4 NEVER VACCINATED-- VACCINATION MEDICALLY CONTRAINDICATED 5 NEVER VACCINATED-- RESIDENT/FAMILY REFUSED VACCINATION 6 NEVER VACCINATED-- OTHER REASON 7 NEVER VACCINATED-- REASON UNKNOWN |
All residents | |
R_C1_impair_4 | HAND R SHOWCARD Which statement on this card best describes [RESIDENT INITIALS] hearing without a hearing aid? |
1 HEARING IS GOOD 2 HAS A LITTLE TROUBLE HEARING 3 HAS A LOT OF TROUBLE HEARING 4 DEAF |
All residents | |
R_C1_impair_6 | Is [RESIDENT INITIALS] blind in both eyes or unable to see? | 1 YES 2 NO |
All residents | |
R_C1_impair_5 | Does [RESIDENT INITIALS] have any trouble seeing even when wearing glasses or contact lenses | 1 YES 2 NO |
R_C1_impair_6 = 2 | |
R_C2a | These next questions refer to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility). During this time, has [RESIDENT INITIALS] been treated in a hospital emergency room? |
1 YES 2 NO |
All residents | |
R_C2b | (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).) During this time, has [RESIDENT INITIALS] been a patient in a hospital overnight or longer (excluding trips to the emergency room that did not result in a hospital stay)? |
1 YES 2 NO |
All residents | |
R_C2c | (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).) During this time has [RESIDENT INITIALS] had a stroke? |
1 YES 2 NO |
All residents | |
R_C2d | (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).) During this time has [RESIDENT INITIALS] had a heart attack? |
1 YES 2 NO |
All residents | |
R_C2e | (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).) During this time has [RESIDENT INITIALS] had a fall that caused a hip fracture? |
1 YES 2 NO |
All residents | |
R_C2f | (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).) During this time has [RESIDENT INITIALS] had a fall that caused an injury other than a hip fracture? |
1 YES 2 NO |
All residents | |
R_C2g | (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).) During this time has [RESIDENT INITIALS] had a stay in a nursing home? |
1 YES 2 NO |
All residents | |
R_C2i | During the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility). During this time, has [RESIDENT INITIALS] had a stay in a rehabilitation facility? |
1 YES 2 NO |
All residents | |
R_C3 | During the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility). How many times has [RESIDENT INITIALS] been treated in a hospital emergency room over this period? |
1-35 | R_C2a = 1 | |
R_C4 | HAND R SHOWCARD Does [RESIDENT INITIALS] currently use any of the items listed on this card? SELECT ALL THAT APPLY |
1 DENTURES, INCLUDING A PARTIAL PLATE 2 GLASSES OR CONTACT LENSES 3 HEARING AID 4 CANE, INCLUDING A TRIPOD CANE 5 WALKER 6 MANUAL WHEEL CHAIR 7 ELECTRIC OR MOTORIZED WHEEL CHAIR OR SCOOTER 8 OXYGEN 9 COMMUNICATION BOARD OR OTHER APPLIANCE TO COMMUNICATE 10 ARTIFICIAL LIMB 11 NONE OF THE ABOVE |
All residents | |
R_C4a | Does [RESIDENT INITIALS] currently use telescopic lenses, Braille, readers, a guide dog, white cane, or any other equipment for people with severe visual impairments? | 1 YES 2 NO |
R_C1_impair_ 6 = 1 | |
R_C5a | Is [RESIDENT INITIALS] limited in any way because of difficulty remembering or because [RESIDENT INITIALS] experiences periods of confusion? | 1 YES 2 NO |
All residents | |
R_C5 | During the last 7 days, has [RESIDENT INITIALS] given evidence of a problem with short-term memory, such as difficulty remembering what (he/she) had for breakfast or something you told (he/she) a few minutes earlier? | 1 YES 2 NO |
All residents | |
R_C6 | During the last 7 days, has [RESIDENT INITIALS] given evidence of a problem with long-term memory, such as forgetting how old (he/she) is or forgetting that (he/she) was married? | 1 YES 2 NO |
All residents | |
R_C7 | During the last 7 days, has [RESIDENT INITIALS] had any of the following problems with orientation, such as: Knowing the location of (his/her) bedroom? Recognizing staff names or faces? Knowing that (he/she) is in a facility? Knowing what the season of the year it is? READ CHOICES. SELECT ALL THAT APPLY |
1 Knowing the location of (his/her) bedroom 2 Recognizing staff names or faces 3 Knowing that (he/she) is in a facility 4 Knowing what the season of the year it is 5 NONE OF THE ABOVE |
All residents | |
R_C8 | HAND R SHOWCARD The next question refers to the residents actual performance in making everyday decisions about the tasks or activities of daily living. During the last 7 days, which of these answers best describes [RESIDENT INITIALS] decision-making about such things as what to wear, how to organize (his/her) day, etc? |
1 INDEPENDENT--DECISIONS WERE CONSISTENT, REASONABLE 2 MODIFIED INDEPENDENCE--HE/SHE HAD SOME DIFFICULTY IN NEW SITUATIONS 3 MODERATELY IMPAIRED-- HIS/HER DECISIONS WERE POOR; CUES AND SUPERVISION WERE REQUIRED 4 SEVERELY IMPAIRED--HE/ SHE NEVER OR RARELY MADE DECISIONS |
All residents | |
R_C9 | HAND R SHOWCARD During the last 7 days, which of these answers best describes [RESIDENT INITIALS] ability to make (himself/ herself) understood by others? |
1 ALWAYS UNDERSTOOD BY OTHERS 2 USUALLY UNDERSTOOD-- DIFFICULTY FINDING WORDS OR FINISHING THOUGHTS 3 SOMETIMES UNDERSTOOD-- ABILITY IS LIMITED TO MAKING CONCRETE REQUESTS 4 RARELY OR NEVER UNDERSTOOD |
All residents | |
R_C9a | Is [RESIDENT INITIALS] difficulty in making (himself/herself) understood by others due to a severe speech impairment or other disability? | 1 YES 2 NO |
R_C9 = 2-4 | |
R_C10 | Next, I would like to ask about everyday activities and whether [RESIDENT INITIALS] receives any assistance in doing them. By assistance, I mean help from special equipment, another person or both. |
1 CONTINUE | ||
R_c10a | Does [RESIDENT INITIALS] currently receive assistance in bathing or showering? This includes standby assistance. | 1 YES 2 NO |
All residents | |
R_c10a1 | Does [RESIDENT INITIALS] bathe or shower with the help of: Special Equipment Another Person |
1 Special Equipment 2 Another Person |
R_c10a = 1 | |
R_c10b | Does [RESIDENT INITIALS] currently receive assistance in dressing? This includes standby assistance. |
1 YES 2 NO |
All residents | |
R_c10b1 | Does [RESIDENT INITIALS] dress with the help of: Special Equipment, such as zipper pulls or button hook aids, or another person, or both? |
1 Special Equipment 2 Another Person |
R_c10b = 1 | |
R_c10c | Does [RESIDENT INITIALS] currently receive assistance in eating, such as cutting up food, or cueing? | 1 YES 2 NO |
All residents | |
R_c10c1 | Does [RESIDENT INITIALS] eat with the help of: Special Equipment Another Person |
1 Special Equipment 2 Another Person |
R_c10c = 1 | |
R_C10d | Is [RESIDENT INITIALS] confined to bed by health problems? | 1 YES 2 NO |
All residents | |
R_C10e | Is [RESIDENT INITIALS] confined to a chair by health problems? | 1 YES 2 NO |
R_C10d = 2 | |
R_C10f | Does [RESIDENT INITIALS] currently receive any assistance in transferring in and out of bed or a chair? | 1 YES 2 NO |
R_C10e = 2 | |
R_C10f1 | Does [RESIDENT INITIALS] transfer in or out of a bed or a chair with the help of: Special Equipment Another Person |
1 Special Equipment 2 Another Person |
R_C10f = 1 | |
R_C10g | Does [RESIDENT INITIALS] currently receive any assistance in walking? | 1 YES 2 NO |
R_C10d = 2 and R_C10e = 2 | |
R_C10g1 | Does [RESIDENT INITIALS] walk with the help of: Special Equipment Another Person |
1 Special Equipment 2 Another Person |
R_C10g = 1 | |
R_C10h | Does [RESIDENT INITIALS] currently receive any assistance going outside the grounds of this facility? | 1 YES 2 NO 3 DOES NOT GO OUTSIDE FACILITY GROUNDS |
R_C10d = 2 and R_C10e = 2 | |
R_C10h1 | When [RESIDENT INITIALS] goes outside the grounds does [RESIDENT INITIALS] require the help of: Special Equipment Another Person |
1 Special Equipment 2 Another Person |
R_C10h = 1 | |
R_C10i | Does [RESIDENT INITIALS] have an ostomy, an indwelling catheter or similar device? | 1 YES 2 NO |
All residents | |
R_C10i1 | Does [RESIDENT INITIALS] receive any help from another person in caring for this device? | 1 YES 2 NO |
R_C10i = 1 | |
R_C10j | Does [RESIDENT INITIALS] currently receive any assistance using the bathroom? | 1 YES 2 NO 3 DOES NOT USE TOILET (AN OSTOMY PATIENT, CHAIRFAST, ETC.) |
All residents | |
R_C10j1 | When [RESIDENT INITIALS] uses the bathroom, does [RESIDENT INITIALS] require the help of: Special equipment Another person |
1 Special equipment 2 Another person |
R_C10j = 1 | |
R_C10k | Has [RESIDENT INITIALS] had any episode of bowel incontinence during the last 7 days? | 1 YES 2 NO 3 NOT APPLICABLE (E.G., HAD A COLOSTOMY, ILEOSTOMY) |
All residents | |
R_C10l | Has [RESIDENT INITIALS] had any episode of urinary incontinence during the last 7 days? | 1 YES 2 NO 3 NOT APPLICABLE (E.G., HAS AN INDWELLING CATHETER, HAD A UROSTOMY) |
All residents | |
R_C10m | Is [RESIDENT INITIALS] able to get out of the facility without the help of another person in case of an emergency? | 1 YES 2 NO |
R_C10d≠1 and R_C10e≠1 | |
R_C11 | HAND R SHOWCARD For the next questions, please tell me whether or not [RESIDENT INITIALS] needs help from another person or does not perform this activity. |
1 CONTINUE | ||
R_C11a | Does [RESIDENT INITIALS] currently need help from another person with: Going shopping for personal items, such as toilet items or medicine. If the only help [RESIDENT INITIALS] needs is for transportation to and from the store, choose No. |
1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY |
All residents | |
R_C11b | (Does [RESIDENT INITIALS] currently need help from another person with:) Managing money, such as keeping track of expenses or paying bills? |
1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY |
All residents | |
R_C11c | Does [RESIDENT INITIALS] currently need help from another person or a special device with: Using the telephone? This includes TTY or dialing out. |
1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY |
All residents | |
R_C11c_1 | Does [RESIDENT INITIALS] receive help using the telephone from another person or a special device? | 1 ANOTHER PERSON 2 SPECIAL DEVICE 3 BOTH |
R_C11c = 1 | |
R_C11d | Does [RESIDENT INITIALS] currently need help from another person with: Doing light housework, like straightening up (his/her) room or apartment? |
1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY |
All residents | |
R_C11e | (Does [RESIDENT INITIALS] currently need help from another person with:) Taking medication--this includes opening the bottle, remembering to take medication on time, and taking the prescribed dosage? |
1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY |
All residents | |
R_C12a | Does [RESIDENT INITIALS] now use an amplifier for the telephone, a TDD, TTY or teletype, closed caption TV, assistive listening or signaling devices, an interpreter, or any other equipment for people with hearing or speech impairments? | 1 YES 2 NO |
All residents | |
R_C13 | Does [RESIDENT INITIALS] have a landline telephone or cellular telephone in (his/her) room? | 1 YES 2 NO |
All residents | |
R_C12 | HAND R SHOWCARD Over the last 30 days, how often did [RESIDENT INITIALS] receive one or more outside visitors? |
1 EVERY DAY 2 AT LEAST SEVERAL TIMES A WEEK 3 ABOUT ONCE A WEEK 4 SEVERAL TIMES DURING THE PAST 30 DAYS BUT LESS THAN EVERY WEEK 5 AT LEAST ONCE IN THE LAST 30 DAYS 6 NOT AT ALL IN THE LAST 30 DAYS |
All residents | |
R_C12a1 | HAND R SHOWCARD Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to... Walk a quarter mile, about three city blocks? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
R_C10d and R_C10e≠1 | |
R_C12a2 | Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to... Walk up 10 steps without resting? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
R_C10d≠1 and R_C10e≠1 | |
R_C12a3 | Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to... Stand or be on feet for about two hours? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
R_C10d≠1 and R_C10e≠1 | |
R_C12a4 | (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] ...) Sit for about two hours? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
All residents | |
R_C12a5 | (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...) Stoop, bend, or kneel? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
R_C10d≠1 and R_C10e≠1 | |
R_C12a6 | (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...) Reach up over head? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
All residents | |
R_C12a7 | (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...) Use fingers to grasp or handle small objects? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
All residents | |
R_C12a8 | (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...) Lift or carry something as heavy as 10 pounds, such as a bag of groceries? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
All residents | |
R_C12a9 | (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...) Push or pull a large object like a living room chair? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
All residents | |
R_C12a10 | (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...) Go out to do things like shopping, movies, or sporting events? |
1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN'T DO AT ALL--HEALTH REASON 6 DOES NOT DO--OTHER REASON |
R_C10d≠1 and R_C10e≠1 | |
R_C14 | In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors? | 1 CONTINUE | ||
R_C14a | HAND R SHOWCARD (In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Refusing to take prescribed medicines at the appropriate time or in the prescribed dosage |
1 OFTEN 2 SOMETIMES (INCLUDES 1 TIME) 3 NEVER 4 RESIDENT DOES NOT TAKE ANY PRESCRIBED MEDICATIONS 5 FACILITY DOES NOT HANDLE RESIDENTS' MEDICATIONS |
All residents | |
R_C14c | (In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Creating disturbances or being excessively noisy by knocking on doors or yelling or being verbally abusive? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14cc | (In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Wandering or moving aimlessly about in the building or on the grounds? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14d | (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Refusing to bathe or clean (himself/herself)? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14e | (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Rummaging through or taking other peoples belongings? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14f | (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Damaging or destroying property? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14g | (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Verbally threatening other persons including staff or other residents? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14h | (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Being physically aggressive towards other persons including staff or other residents? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14i | (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Removing clothing in public? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C14j | (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Making unwanted sexual advances towards staff or other residents? |
1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never |
All residents | |
R_C15 | Does a physician ever prescribe medications to help control [RESIDENT INITIALS] behavior or to reduce agitation? | 1 YES 2 NO |
R_C14a-j = 1 or 2 in any of these questions | |
R_C16 | HAND R SHOWCARD The following services may be offered by facility staff or provided at the facility by non-facility staff. Please look at this Showcard and tell me if [RESIDENT INITIALS] uses any of these services. SELECT ALL THAT APPLY |
1 SPECIAL DIETS 2 ASSISTANCE WITH ACTIVITIES OF DAILY LIVING 3 ASSISTANCE WITH A BATH OR SHOWER AT LEAST ONCE A WEEK 4 SKILLED NURSING SERVICES 5 BASIC HEALTH MONITORING SUCH AS BLOOD PRESSURE AND WEIGHT CHECKS 6 SOCIAL AND RECREATIONAL ACTIVITIES WITHIN THE FACILITY 7 SOCIAL AND RECREATIONAL ACTIVITIES OUTSIDE THE FACILITY 8 INCONTINENCE CARE 9 TRANSPORTATION TO MEDICAL APPOINTMENTS 10 TRANSPORTATION TO STORES AND ELSEWHERE 11 PERSONAL LAUNDRY 12 LINEN LAUNDRY SERVICES 13 SOCIAL SERVICES COUNSELING 14 NONE OF THE ABOVE |
All residents | |
R_C17a | HAS THIS RESPONDENT ALSO COMPLETED EITHER THE FACILITY QUESTIONNAIRE OR ANOTHER RESIDENT'S QUESTIONNAIRE? | 1 YES 2 NO |
||
R_C17 | The next few questions are about you. How long have you worked at this facility? |
1 6 MONTHS OR LESS 2 MORE THAN 6 MONTHS BUT LESS THAN ONE YEAR 3 AT LEAST ONE YEAR TO LESS THAN TWO YEARS 4 TWO YEARS OR MORE |
R_C17a = 2 | |
R_C18 | HAND R SHOWCARD Please look at this card and tell me which best describes your position at this facility. |
1 RN 2 LPN 3 CERTIFIED MEDICATION AIDE 4 NURSING ASSISTANT/CNA/ PERSONAL CARE AIDE 5 ACTIVITY DIRECTOR OR STAFF 6 OWNER, ADMINISTRATOR, EXECUTIVE DIRECTOR, ASSISTANT DIRECTOR, DIRECTOR OF OPERATIONS, OR MANAGER 7 SOME OTHER POSITION |
R_C17a = 2 | |
R_CEND | Thank you. These are all the questions I have for you regarding this resident. Now I need to check my records if there are any other selected residents for whom you were identified as a caregiver. | 1 CONTINUE |
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