Quality of Care and Quality of Life Indicator (QCLI) Dictionary - sorted by Care Area Care Area: QP205 QCLI Name: Abuse Prohibition (Resident Observation) Threshold-Small Samples: >0.0% Definition: Use the Abuse Prohibition investigative protocol to complete this task on every QIS on which the Abuse care area is investigated. Threshold-Not Small Samples: >0.0% Data Source: Resident Observation Numerator Denominator Updated: 10/18/2010 Residents in the Census Sample AND "Are staff treating the resident in a manner that may indicate abuse (yelling at resident, striking resident, treating resident in a rough manner, etc.)? " =1-Yes Exclusions No response to the "Are staff treating the resident in a manner that may indicate abuse" item. Comments None. Residents in the Census Sample with a valid response to the "Are staff treating the resident in a manner that may indicate abuse" item. CMS (07/2012) Dictionary Page 4 of 110
Quality of Care and Quality of Life Indicator (QCLI) Dictionary - sorted by Care Area Care Area: QP236 QCLI Name: Abuse Prohibition (Family Interview) Threshold-Small Samples: >0.0% Definition: Use the Abuse Prohibition investigative protocol to complete this task on every QIS on which the Abuse care area is investigated. Threshold-Not Small Samples: >0.0% Data Source: Family Interview Numerator Denominator Updated: 10/18/2010 Family Interview residents AND "Have you ever noticed any staff member being rough with, talking in a demeaning way or yelling at [resident's name] or any other resident?"=1-yes AND "Did you report it?"=1-yes AND "Did facility staff act promptly to investigate and correct the situation?"=0-no Exclusions Residents who are interviewable, residents who refuse to be interviewed, and residents who are unavailable for an interview. OR No response to the "noticed any staff member being rough with resident" item. Comments None. Family Interview residents with a valid response to the "noticed staff member being rough with resident" item. CMS (07/2012) Dictionary Page 5 of 110
Quality of Care and Quality of Life Indicator (QCLI) Dictionary - sorted by Care Area Care Area: QP253 QCLI Name: Abuse Prohibition (Resident Interview) Threshold-Small Samples: >0.0% Definition: Use the Abuse Prohibition investigative protocol to complete this task on every QIS on which the Abuse care area is investigated. Threshold-Not Small Samples: >0.0% Data Source: Resident Interview Numerator Denominator Updated: 10/18/2010 Residents in the Census Sample AND ("Have you ever been treated roughly by staff?"=1-yes OR "Has staff yelled or been rude to you?"=1-yes OR "Do you ever feel afraid because of the way you or some other resident is treated?"=1-yes) Exclusions Comments None. Residents in the Census Sample with a valid response to at least one of the three abuse items, "Have you ever been treated roughly by staff?", "Has staff yelled or been rude to you?", or "Do you ever feel afraid because of the way you or some other resident is treated?". Residents who are not interviewable, residents who refuse to be interviewed, and residents who are unavailable for an interview OR No response to all of the three abuse items, "Have you ever been treated roughly by staff?", "Has staff yelled or been rude to you?", or "Do you ever feel afraid because of the way you or some other resident is treated?". CMS (07/2012) Dictionary Page 6 of 110
RESIDENT INTERVIEW & RESIDENT OBSERVATION Facility Name: Facility ID: Date: Surveyor Name: Resident Name: Resident ID: Admit Date: Resident Room: Ask screening questions similar to the following: 1. Are you from around here, the area, etc? 2. Tell me a little about yourself. 3. How long have you been here? 4. What is the food like here? Resident Interview Proceed with the interview questions below if you are comfortable that the resident is interviewable. A Cognitive Status 1) Is the resident able to be interviewed? Not Interviewable Interviewable Resident refused interview Resident is unavailable for an interview If the resident is interviewable, proceed to the Resident Interview section on the following page. If the resident is not interviewable, refuses, or is unavailable (after repeated attempts to interview) proceed to the Resident Observation section on the following page (the resident is excluded from the resident interview). Notes: FORM CMS-20050 (7/2012)
RESIDENT INTERVIEW & RESIDENT OBSERVATION B Choices QP234 Resident Interview 1) Do you choose when to get up in the morning? If No: What time do you get up? What time would you like to get up in the morning? 2) Do you choose when to go to bed at night? If No: What time do you go to bed? What time would you like to go to bed? 3) Do you choose how many times a week you take a bath or shower? If No: How many times a week do you get a bath or shower? How many times a week would you like to bathe? 4) Do you choose whether you take a shower, tub, or bed bath? If No: What type of bathing are you receiving? What would you like to receive? 5) Can you have visitors anytime during the day or night? If No: What are the visiting restrictions? C Dignity QP212 1) Do staff treat you with respect and dignity? If No, Tell me some examples about when staff did not treat you with respect and dignity. The focus of this question is how well staff interacts with the resident. N/A, the resident is independent with ADLs N/A, the resident is independent with ADLs N/A, the resident is independent with ADLs N/A, the resident is independent with ADLs Resident Observation A Cleanliness/Grooming/Oral QP075 QP216 1) Based on general observations, did you see any of the following? (Mark all that apply) A: Unpleasant body odor (other than signs of incontinence) B: Skin unclean (i.e., food on face and hands) C: Eyes are matted D: Mouth contains debris, or teeth/dentures not brushed, or mouth odor, or dentures not in place E: Teeth broken/loose, or inflamed/bleeding gums, or problems with dentures F: Hair is uncombed and not clean G: Facial hair not removed or unshaven H: Fingernails are unclean and untrimmed I: Clothing and/or linens are soiled (other than signs of incontinence) J: Glasses are dirty or broken K: None of the above B Incontinence QP260 1) Are there signs of incontinence, such as odor and/or wetness? C Dressing QP074 1) Based on general observations, did you see any of the following? (Mark all that apply) A: Clothing in poor repair, improper fit, or worn inappropriately B: Inappropriate foot coverings (i.e., shoes without non-skid soles) C: None of the above FORM CMS-20050 (7/2012) 2
RESIDENT INTERVIEW & RESIDENT OBSERVATION D Activities QP208 Resident Interview 1) Do you participate in any of the activity programs here? 2) Do the organized activities meet your interests? 3) Do you receive assistance for things you like to do, such as supplies, batteries, books? (Facility should have items available for residents to use.) 4) Are there activities offered on the weekends, including religious events? 5) Are there activities available in the evenings? Do not wish to participate Resident Observation D Activities QP096 (Complete for residents who are not interviewable due to cognitive screening. Do not complete for residents who are interviewable, have refused to be interviewed, or are unavailable.) 1) Did you observe the resident in activities during the two days of Stage 1? (This is not limited to group activities or scheduled activities.) 2) Is the resident actively participating in the activities or does staff encourage the resident to participate? Comments (skip to E) E Building and Environment QP201 1) Is this a comfortable building in which to live? (Comfortable includes appropriate temperature, lighting, and noise levels.) 2) Is the facility clean? E Contractures QP077 QP076 1) Does the resident have a contracture? (Defined as a condition of fixed high resistance to passive stretch of a muscle.) If unable to determine ask staff member. 2) Does the resident have splint devices in place? (Answer "No" if device not present or is incorrectly applied.) (skip to F) F Participation in Care Plan QP210 1) Have you been involved in decisions about your daily care? FORM CMS-20050 (7/2012) 3
RESIDENT INTERVIEW & RESIDENT OBSERVATION Resident Interview G Abuse QP253 1) Have you ever been treated roughly by staff? 2) Has staff yelled or been rude to you? 3) Do you ever feel afraid because of the way you or some other resident is treated? If the resident answers Yes, ask who, what, when, where, how often? H Interaction with Others QP246 1) Have there been any concerns or problems with a roommate or any other resident? 2) Has the staff addressed the concern(s) to your satisfaction? I Personal Property QP194 1) Were you encouraged by staff to bring in any personal items? If No: Do you wish to have items brought in? 2) Have you had any missing personal items? If Yes: What is still missing and how long has it been missing? 3) Did you tell staff about the missing item(s)? If Yes: Who did you tell about the missing item? If the answer is "Yes," then ask question 4. 4) Has staff told you they are looking for your missing item(s)? If No, do you know who or which department is supposed to be looking for your missing item? (skip to I) N/A, the resident is a short-stay resident Resident Observation F Abuse QP205 1) Are staff treating the resident in a manner that may indicate abuse (yelling at resident, striking resident, treating resident in a rough manner, etc.)? G Skin Problems/Conditions (other than pressure ulcers) QP261 1) Were any of the following observed? (Mark all that apply) A: Abrasions and/or lacerations B: Bruises C: Skin Tears D: Burns E: None of the above H Potential Restraints QP092 QP089 1) Does the resident have a potential restraint in place (physical device or equipment that may potentially restrict a resident s movement and/or access to her/his body)? (skip to I) 2) Which potential restraints are being used? (Mark all that apply) A: Potential limb restraint B: Potential trunk restraint C: Chair potentially prevents rising D: Bed side rails (excludes beds with only one ¼ rail that is on the side of the bed against the wall) E: Other (e.g., mittens), please describe 3) Is the device correctly applied? (Such as potential trunk and limb restraints. See Section L below for bed side rails.) FORM CMS-20050 (7/2012) 4
RESIDENT INTERVIEW & RESIDENT OBSERVATION J Pain QP255 Resident Interview 1) Do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief? I Pain QP129 Resident Observation 1) Were any of the following observed? (Mark all that apply) A: Vocalization of pain: constant muttering, moaning, groaning B: Breathing: strenuous, labored, negative noise on inhalation or expiration C: Pained facial expressions: clenched jaw, troubled or distorted face, crying D: Body language: clenched fists, wringing hands, strained and inflexible position, rocking E: Movement: restless, guarding, altered gait, forceful touching or rubbing body parts F: None of the above K Food Quality QP249 1) Does the food taste good and look appetizing? 2) Is the food served at the proper temperature? L Hydration QP258 1) Do you receive the fluids you want between meals? N/A, does not take fluids orally J Hydration QP182 1) Does the resident demonstrate physical signs of dehydration (i.e., dry, cracked lips and/or dry mouth; exhibits signs of thirst, etc.)? FORM CMS-20050 (7/2012) 5
RESIDENT INTERVIEW & RESIDENT OBSERVATION M Sufficient Staff QP232 Resident Interview 1) Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? N Oral Health QP254 QP256 1) Do you have mouth/facial pain with no relief? 2) Do you have any chewing or eating problems (could be due to: no teeth, missing teeth, oral lesions, broken or loose teeth)? 3) Do you have tooth problems, gum problems, mouth sores, or denture problems? 4) Does staff help you as necessary to clean your teeth? 5) How often are your teeth/dentures/mouth cleaned (routine oral hygiene)? O Privacy QP204 1) Does staff provide you privacy when they work with you, changing your clothes, providing treatment? 2) Do you have privacy when on the telephone? 3) If you would have a visitor, do you have a private place to meet? N/A, do not need assistance (Skip to O) Daily Weekly Monthly Never N/A, do not use telephone K Positioning QP233 Resident Observation 1) Were any of the following observed? (Mark all that apply) A: Sagging mattress while lying in bed B: Bed sheets tucked tightly over toes holding the feet in plantar flexion C: Legs and/or feet hanging off the end of a too-short mattress D: No padding between bony prominences (residents not able to position themselves) E: Wheelchair too big or too small (i.e., seat too long/short, seat too high/low) F: Uncomfortable geri-chair positioning, hyperflexion of the neck, sliding down in the chair, no support for the legs G: Dangling legs and feet (that do not comfortably reach floor and/or without needed foot pedals in place) H: Leaning to the side without support to maintain an upright position I: Lack of needed head or torso support J: Lack of arm/shoulder support K: Resident observed in the same position for long periods of time when in the wheelchair or in bed (Resident is not repositioned in chair at least every hour and in bed at least every two hours) L: None of the above L Potential Accident Hazards/Bed Side Rails QP218 1) If the bed side rails are in the up position, do the bed side rails fit the bed properly to prevent the resident from being caught between the side rails and mattress? N/A, side rails are not observed in the up position FORM CMS-20050 (7/2012) 6
RESIDENT INTERVIEW & RESIDENT OBSERVATION P Exercise of Rights QP250 Resident Interview 1) Have you been moved to a different room or had a roommate change in the last nine months? 2) Were you given notice before a room change or a change in roommate? Q Personal Funds QP199 1) Do you have a personal funds account with the facility? 2) Does the facility let you know how much money you have in your account? 3) Can you get your money when you need it, including on weekends? (Skip to Q) (Skip #2 & 3) Do Not Know (Skip #2 & 3) Do Not Know Do Not Know M Resident s Room Resident Observation 1) Were any of the following observed? (Mark all that apply) A: Odor in resident s room QP221 B: Walls, floors, ceilings, drapes, or furniture are not clean or are in disrepair QP222 C: Environment does not accommodate individual needs and preferences QP147 D: Lighting levels are inadequate or uncomfortable QP223 E: Room temperatures are uncomfortable or unsafe QP224 F: Sound levels are uncomfortable QP225 G: Bedrooms are not equipped to assure full privacy (i.e., curtains, moveable screens, private rooms, etc.) QP151 H: Clean bed/bath linens are not available or are in poor condition QP152 I: Evidence of insects or rodents in bedrooms or bathrooms QP226 J: None of the above 2) Were any of the following observed? (Mark all that apply) A: Electric cords, extension cords, or outlets are in disrepair or used in an unsafe manner QP228 B: Bed and linens are visibly soiled with stool or urine QP260 C: Resident care equipment is unclean, in disrepair or stored in an improper or unsanitary manner QP140 D: Ambulation, transfer or therapy equipment are unclean or in unsatisfactory condition QP229 E: Safety equipment in bedroom or bathroom is inadequate (i.e. grab bars, slip surface) QP230 F: Call system in room or bathroom is not functioning. Call light not within reach for residents capable of using it QP231 G: None of the above FORM CMS-20050 (7/2012) 7
RESIDENT INTERVIEW & RESIDENT OBSERVATION Resident Observation N Dignity QP266 1) Based on general observation, did you see any of the following? (Mark all that apply) A: Staff dressed resident in institutional fashion such as a hospital type gown during the day B: Clothes labeled with the resident s name visible C: Staff failed to knock and/or request permission to enter the room or wait to receive permission to enter D: Staff failed to explain the service or care they are going to provide E: Staff failed to include the resident in conversations while providing care or services F: Staff used a label for the resident (e.g., feeder or honey ) G: Staff posted confidential clinical or personal care instructions in areas that can be seen by others H: Staff failed to treat the resident respectfully when providing care to the resident s roommate; I: Staff failed to treat the resident with respect and dignity during care and services, such as: Making disapproving comments such as What do you want now? Mimicking or making fun of the resident Displaying disapproving behavior (rolling their eyes, or sighing) J: Staff failed to provide visual privacy of the resident s body while transporting him/her through common areas, or uncovered in their rooms but visible to others K: Staff failed to cover a urinary catheter bag or any other type of body fluid collection device L: Staff failed to respond to the resident s call for assistance in a timely manner M: Any other identified dignity concerns (document concerns) N: None of the above O Sedation 1) Is the resident excessively sedated? FORM CMS-20050 (7/2012) 8
Facility Name: Facility ID: Date: Surveyor Name: The Abuse Prohibition task is completed only if the resident-level Care Area, Abuse, is investigated in Stage 2. If concerns regarding abuse are identified offsite (e.g., complaints) or are identified during any part of the survey, initiate both the Abuse Care Area for the resident(s) and Abuse Prohibition for the facility. Interview/Review Notes Policies and Procedures Review Obtain and review the facility s written policies to determine that they include the following key components: Screening of potential new hires; Training of employees (both new employees and ongoing training for all employees); Prevention policies and procedures; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of residents during investigations; and Reporting of incidents, investigations, and facility response to the results of their investigations. Evaluate how each component of the policies and procedures is operationalized. If the answers to the following questions are not obvious from the policies, interview the individual responsible for coordinating the policies and procedures. If this person is interviewed, ask how do they: Monitor staff providing and/or supervising the delivery of resident care and services to ensure that care/service is provided as needed to make certain that neglect of care does not occur. Determine which injuries of unknown origin should be investigated as alleged occurrences of abuse. Ensure that residents, families, and staff feel free to communicate concerns without fear of reprisal. FORM CMS 20059 (11/2010)
Interview/Review Notes Facility Handling of Alleged Violations Review written evidence of the facility s handling of a minimum of three alleged violations (if any exist) since the previous standard survey or the previous time this review was done by the State. Include all residents who triggered the Abuse Care Area in the review of the facility s handling of alleged violations. (If less than three (3) residents triggered and the facility has additional allegation, select additional residents to fulfill the minimum of three residents.) Determine whether the facility implemented adequate procedures for: Reporting: Reports any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. Ensures that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Ensures that results of all investigations are reported to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident. Investigating: has evidence that all alleged violations are thoroughly investigated. Protection of the resident during the investigation: prevent further potential abuse while an investigation is in progress, and; Provision of corrective action: takes appropriate corrective action for verified violations. Determine whether the facility re-evaluated and revised applicable procedures as necessary. FORM CMS 20059 (11/2010) 2
Interview/Review Notes Resident/Family Interviews Interview several residents and families regarding their awareness of to whom and how to report allegations, incidents, and/or complaints, unless this information has already been obtained. Name of Person Interviewed Date/Time Interviewed Aware Not Aware Name of Person Interviewed Date/Time Interviewed Aware Not Aware Name of Person Interviewed Date/Time Interviewed Aware Not Aware Name of Person Interviewed Date/Time Interviewed Aware Not Aware FORM CMS 20059 (11/2010) 3
Interview/Review Notes Direct-care Staff Interviews Interview at least five (5) direct care staff, representing all three shifts, including activity staff and nursing assistants, to determine whether each staff member is: Trained in, and knowledgeable about, how to appropriately intervene in situations involving residents who have aggressive or catastrophic reactions. Knowledgeable regarding what, when, and to whom to report, according to the facility policies. 1. Name of Staff Interviewed Date/Time Interviewed Discipline Shift 2. Name of Staff Interviewed Date/Time Interviewed Discipline Shift 3. Name of Staff Interviewed Date/Time Interviewed Discipline Shift 4. Name of Staff Interviewed Date/Time Interviewed Discipline Shift 5. Name of Staff Interviewed Date/Time Interviewed Discipline Shift FORM CMS 20059 (11/2010) 4
Interview/Review Notes Front-line Supervisor Interviews Interview at least three (3) front-line supervisors of staff who interact with residents (Nursing, Dietary, Housekeeping, Activities, Social Services). Determine how they monitor: Provision of care/services; Staff/resident interactions; Deployment of staff to meet the residents needs; and Potential for staff burnout, which could lead to resident abuse. 1. Name of Supervisor Interviewed Date/Time Interviewed Discipline Shift 2. Name of Supervisor Interviewed Date/Time Interviewed Discipline Shift 3. Name of Supervisor Interviewed Date/Time Interviewed Discipline Shift FORM CMS 20059 (11/2010) 5
Interview/Review Notes Pre-screening of New Employees Obtain a list of all employees hired within the previous four (4) months, and select five (5) employees from this list. Ask the facility to provide written evidence that the facility conducted pre-screening of the five (5) employees based on the regulatory requirements at 42 CFR 483.13(c). Determine whether the facility has NOT employed individuals meeting either of the following criteria: Who have been found guilty of abusing, neglecting, or mistreating residents by a court of law, or Who have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents, or misappropriation of their property. 1. Name of New Employee Hire Date Written Evidence of Pre-screening Yes No 2. Name of New Employee Hire Date Written Evidence of Pre-screening Yes No 3. Name of New Employee Hire Date Written Evidence of Pre-screening Yes No 4. Name of New Employee Hire Date Written Evidence of Pre-screening Yes No 5. Name of New Employee Hire Date Written Evidence of Pre-screening Yes No FORM CMS 20059 (11/2010) 6
Determination of Compliance 1. Did the facility follow the requirements for: Employment of individuals Reporting, and Investigation of alleged violations? Yes No F225 2. Did the facility develop and implement policies and procedures in the areas of screening, training, prevention, identification, investigation, protection, and reporting? Yes No F226 FORM CMS 20059 (11/2010) 7