ADL Self-Performance
Resident performs ADL even when staff is not present and w/o any physical or verbal help at all
Independent
Resident did not do an activity, or someone other than staff performed the activity (ie-feeding, changing, turning)
Activity Did Not Occur
Moves to or from the lying position. Turns side to side, positions body while in type of furniture the resident prefers to sleep in.
Bed Mobility
The staff member physically lifted the resident's hand and assisted to bring the food to his mouth.
Extensive Assist, 1 Person Physical Assist
Bearing any of the resident's weight, even light lifting to help steady self to maintain balance or assisting to place feet in bed, assisting to lift hand holding a spoon
Extensive Assist
Handing resident their cane or walker, locking wheelchair brakes, cutting food, opening containers, giving cup
Moves from chair to bed, bed to chair, chair to chair, etc. Stands from a sitting position or sits from a standing position.
Transfer
The resident required the assistance of two staff members to turn, and sit up/lie down in bed. The resident was not able to help at all.
Dependent, 2 Person Assist
Guiding the resident, touching them but not lifting or bearing any weight
Limited Assist
Resident gathers his/her own supplies
No Set Up or Physical Help From Staff
Eats and Drinks; receives tube feeding, IV nutrition or IV fluids.
Eating
The staff member assisted resident by zipping his pants.
Limited Assist, 1 Person
Resident not willing/able to help at all, not even one time.
Dependent
Support Provided coded when staff helped resident to do ADL (ie-lifted one leg into bed)
1 Person Physical Assist
Uses the toilet room, commode, bedpan, urinal or brief; manages ostomy or catheter; adjust clothes
Toilet Use
The resident's tray was given to him. He opened all the packages and cut his own meat, etc. The resident performed his own set up and ate without assistance.
Independent, No Setup or Physical Help From Staff
Resident needs observation, encouragement, verbal cues, reminders or step-by-step instructions from staff to complete the activity
Supervision
Support Provided coded for transfer by Hoyer lift, 1 person helped resident stay in chair while another pushed w/c or showered resident, or 2 people required to pull resident up in bed.
2 person assist
450 days x $20/day lost due to under-coding of ADLs= $9000/month or $108,000/year.
Financial Impact of Improper/Inaccurate Documentation
The resident remained in the bed the entire shift and did not transfer at all.
Activity Did Not Occur