Show:
BED MOBILITY
TRANSFER
EATING
TOILET USE
ADL HODGEPODGE
100
Mr. Claus is resting in bed and has been laying on his right side for the past 2 hours. According to his care plan, he is to be encouraged to reposition approx. every 2 hours. On your shift, you reminded him to turn to the other side 1 time and to his back 1 time. How do you correctly code self performance and support for bed mobility?
What is supervision/no set up or physical help. Rationale: Resident completed the ADL with oversight, encouragement or cueing; eyes are on the resident, only talking (cueing) was provided & no touch or hands on the resident.
100
During your shift, across the room, you observed your resident, Mr. F. Banks rising from his dining room chair and leaving the dining room table without any team member assistance. How do you correctly code self performance and support for transfers?
What is independent/no setup or physical help from staff Rationale: Resident completed the ADL with no help or supervision from staff; no hands on resident/no touch/no oversight provided
100
The team member supports some of the weight of the resident’s hand while helping the resident to eat (e.g. lifting a spoon or a cup to mouth), or performs part of the activity for the resident. How do you correctly code self performance and support for eating?
What is extensive/one person physical assist Rationale: team member is supporting some of the weight which meets the definition of extensive; limited assist is non-weightbearing
100
Mr. Olson has an indweling foley catheter. It's the end of your shift and you empty his catheter bag. How do you correctly code self performance and support for toilet use?
What is activity did not occur? Rationale: Coding for toilet use does not include emptying of the catheter bag.
100
During your shift, Mr. Smith was independent with brushing hair & teeth, shaving, washing face & hands. He required extensive assistance with peri-care. How do you correctly code self performance and support for personal hygiene?
What is independent/no setup or physical help? Rationale: The resident was independent in tasks of personal hygiene. Peri-care is captured/documented in the ADL of toilet use.
200
Mrs. Wyldestyle has requested she be laid down in bed after lunch. Team member assisted her by lifting her legs into bed. How do you correctly code self performance and support for bed mobility?
What is extensive assistance/1 person physical assist Rationale: One team member supports some of the resident's weight during the task by lifting her extremities (legs).
200
Mr. Austin has Parkinson's disease and needs weightbearing assist of 2 team members to transfer using the sit/stand lift. During your shift, you & another team member transferred Mr. Austin from his bed to wheelchair using the sit/stand lift. He was able to hold the hand grips during the transfer. How do you correctly code self performance and support for transfers?
What is extensive/2+persons physical assist Rationale: Extensive assist is defined by the resident involved in the activity; the resident was able to bear weight & hold the hand grips on the lift during the transfer; (VHS policy requires 2 team members assist when using any mechanical lift)
200
It is meal time and you are present in the dining room. You are delivering meals to the residents as they arrive. Mrs. Wild arrives to her table. You deliver her meal to her and she requires no assistance. However you remain in the dining room observing all the residents as they finish eating. How do you correctly code self performance and support for eating?
What is independent/No set up Rationale: Mrs. Wild required no help or staff oversight at any time during her meal. She also required no set up or physical help. To code "supervision" the team member would need to provide "direct supervision or cueing" to her. Just observing the entire dining room is not "direct supervision".
200
Mr. Stevens requested to use his urinal while he was in bed. You handed him his urinal and returned later to empty it. How do you correctly code self performance and support for toilet use?
What is independent/set help only? Rationale: Resident completed the ADL of toileting without cues or instruction from the team member; set up assistance of handing him the urinal was provided.
200
On your shift, Mr. Smith is on a walk to dine program. One staff member assists Mr. Smith with guided maneuvering while the other staff member follows along with a wheelchair for safety purposes. How do you correctly code self performance and support for locomotion on unit?
What is limited assist/ one person physical assist? Rationale: The resident required limited assist of 1 staff member, the second person is not touching the resident.
300
Mrs. Wyldestyle has slid down in bed during your shift and needs to be moved up in bed. Because of her dementia and inability to follow directions, you and another team member used a turning sheet to move her up in the bed without any assistance from the resident. How do you correctly code self performance and support for bed mobility?
What is total dependence/two persons physical assist Rationale: Two team members provided all the weight bearing assistance with the task. Resident was unable to participate in the task.
300
At breakfast, Mrs. Wyldestyle is anxious to go to the dining room for her bacon. You must bring the wheelchair next to the bed and then remind her to hold on to the wheelchair and position her body slowly. How do you correctly code self performance and support for transfers?
What is supervision/set up help? Rationale: Resident completed the ADL with staff cueing; no touch or hands on resident; team member "set up" the wheelchair next to the resident for the transfer
300
Mrs. D. receives all of her nourishment via a gastrostomy tube. She did not consume any food or fluid by mouth. How do you correctly code self performance and support for eating?
What is total dependence/one person physical assist? Rationale: The resident did not participate in eating and/or administering of her tube feedings. She required full staff performance of these functions.
300
Team members must assist Mr. K. to zip his pants, hand him a washcloth, and remind him to wash his hands after using the toilet daily. How do you correctly code self performance and support for toileting?
What is limited assistance/one person physical assist? Rationale: Resident was highly involved in the ADL activity; 1 team member provided non-weightbearing assistance in the task of zipping his pants
300
Mrs. Tyler has always loved Halloween and being a resident of the nursing home has not changed her mind about this fun holiday. The facility is having a party and she wants to dress up. Due to her past CVA she is no longer able to dress herself. One of the CNAs assists her in donning her costume. Her adult daughter is going to help her pass candy out to the children and pushes Mrs. Tyler in her wheel chair down to the lobby area with her foot pedals on the w/c. How do you correctly code self performance and support for Locomotion Off Unit?
What is activity did not occur. Raionale: Since the daughter is not an employee of the facility, team members should code "activity did not occur" Important note: We must be cautious when non employees are pushing our residents in their wheel chairs. We need to ensure that they are following our safety policy and have foot pedals on at all times while pushing.
400
On your shift, Mrs. Davis has slid to the foot of the bed. You and another team member had to physically lift and reposition her toward the head of the bed. According to her care plan, Mrs. Davis is able to assist by bending her knees and pushing with her legs during the reposition. During the reposition, she was able to bend her knees and push with her legs. How do you correctly code self performance and support for bed mobility?
What is extensive assist with 2 personal physical assist Rationale: Resident was involved in the activity of pushing up in bed but required weight-bearing assistance, but not total assist, of two team members.
400
Mrs. Anderson is a post CVA and needed to transfer from the bed to wheelchair on your shift. You and another CNA used a mechanical lift to transfer her and Mrs. Anderson was unable to provide any assistance. How do you correctly code self performance and support for transfers?
What is total dependence/two persons physical assist Rationale: team members provided all of the weight bearing for the ADL; resident was unwilling/unable to participate. (VHS policy requires 2 staff members when using a mechanical lift)
400
Mr. Solomon begins eating each meal daily by himself. After he had eaten only his bread, he stated he was tired and unable to complete the meal. One staff member physically supported his hand to bring the food to his mouth and provided verbal cues to swallow the food. The resident was then able to complete the meal. How do you correctly code self performance and support for eating?
What is extensive assistance/one person physical assist? Rationale: Resident partially participated in the task daily at each meal, but one staff member provided weight-bearing assistance with some portion of each meal.
400
Mrs. Wyldstyle lives in the memory support household and has "urinary dribbling". Because she likes to use the bathroom independently, she doesn't routinely change her incontinence product. During your shift, Mrs. Wyldstyle used the bathroom independently. As her assigned team member, you noted she did not have her pad in place and you assisted her with placement of the pad. How do you correctly code self performance and support for toilet use?
What is limited assistance/one person physical assist? Rationale: Limited assist includes other non-bearing assistance being provided to the resident by changing/placement of incontinence pad.
400
Mr. Becker had a private duty aide with him all night on the night shift. When the CNA repositioned him in bed every 2 hours, the resident did not participate at all. How do you correctly code self performance and support for bed mobility?
What is activity did not occur? Rationale: To capture assistance provided it must be performed by the facility staff
500
Mr. Jack just returned from therapy and has asked for assist in laying down. When assisting him to bed, you placed your hand on his back guiding him to a lying position. You also positioned a pillow under his legs as requested. He was able to move his legs to assist with pillow placement. How do you correctly code self performance and support for bed mobility? How do you correctly code self performance and support for bed mobility?
What is limited assistance/one person physical assist? Rationale: Resident was highly involved in the activity (placement of hand on the back and placement of pillow under his legs); one team member provided only guided maneuvering of limbs and other non-weightbearing assistance.
500
Mrs. H. is able to transfer from the bed to chair when she uses her walker. On your shift, you placed the walker near her bed and then assisted the resident with guided maneuvering as she transferred. How do you correctly code self performance and support for transfers?
What is limited assist/one person physical assist? Rationale: Resident required the team member to set up her walker and provide non-weight-bearing assistance when she was ready to transfer.
500
It is 2am and you have just assisted Mrs. Brown to/from the bathroom. She is back in bed and you have offered her a drink. For her to drink, you need to hold the glass and position the straw in her mouth while she drinks. How do you correctly code self performance and support for eating?
What is total dependence/one person physical assist Rationale: full staff performance was required to hold the glass and position the straw for the entire task
500
Mrs. Rubble is a post right ankle fracture and has orders for non-weight bearing to her right foot. This is also stated on her care plan. During your shift you took her to the bathroom 2 times and each time you physically transferred her from the wheelchair to toilet and then back from the toilet to the wheelchair. She was able to do her peri care, wash her hands and adjust her clothing herself each time. How do you correctly code self performance and support for toileting?
What is extensive assistance/one person physical assist Rationale: Transferring is included in the ADL task of toileting and you provided weight bearing assistance due to her non-weightbearing status.
500
This self performance includes: Resident is involved in the activity and team member(s) provide weight bearing support. Examples of weight bearing support can include: hands on assistance, weight bearing in nature, lifting of an extremity, supporting weight of his/her body or extremity, pushing/meeting resistance of body or body part.
What is Extensive assistance?