BED MOBILITY
Mrs. Palmer 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 left side 1 time and to his back 1 time. How do you correctly code his performance
What is Supervision or touching assistance?
During your shift, across the room, you observed your resident, Mr. Shepard rising from his dining room chair and leaving the dining room table without any team member assistance. How is this documented
What is INDEPENDENT?
Mr. Hines is able to feed himself without assistance for most of the meal but needs encouragement and cueing to finish.
How do you document for eating?
What is SUPERVISION or TOUCHING ASSISTANCE
Mr. Reeves has an indwelling foley catheter. It is the end of your shift and you empty his catheter bag.
For Urinary Continence, you document N/A.
True or False
What is FALSE?
Correct answer: Continence Not Rated due to Indwelling Catheter
Mr. Magnus walks 50 feet with the therapist providing trunk support. He also requires a second helper, the rehabilitation aide, who provides supervision and follows closely behind with a wheelchair for safety. Mr. T walks the 50 feet with two turns with the assistance of two helpers.
What is DEPENDENT?
Remember: If 2 staff are needed, it is documented as Dependent
Mr. Gibbs had a stroke that resulted in paralysis on his right side and is recovering from cardiac surgery. He requires the assistance of two certified nursing assistants when rolling onto his right side and returning to lying on his back and also when rolling onto his left side and returning to lying on his back.
How would you document this?
What is DEPENDENT?
Mr. Mallard has Parkinson's disease and needs weight bearing assist of 2 team members to transfer using the sit/stand lift. During your shift, you and another team member transferred Mr. Austin from his bed to the wheelchair using the sit/stand lift. He was able to hold the hand grips during the transfer.
How is this documented?
What is DEPENDENT
Mr. Knight has dropped his fork twice and you have had to provide a new fork to him, the only other thing you did for Mr. k was to remind him to drink his coffee. How do you code for eating?
What is SUPERVISION or TOUCHING ASSISTANCE?
Mr. Quinn always requests to use his urinal while on the night shift. You hand him his urinal and return later to empty it.
How is this documented?
What is CONTINENT.
Mr. Fielding has limited mobility resulting from his multiple and complex medical conditions. He prefers to wash his body while sitting in front of the sink in his bathroom. A helper assists with washing, rinsing, and drying Mr. Y’s arms/hands, upper legs, lower legs, buttocks, and back.
What is SUBSTANTIAL / MAXIMAL ASSISTANCE?
Mrs. David has slid down in bed during your shift and needs assistance to be moved up in bed. You and another team member used a turning sheet to move her up in the bed without any assistance from the resident. During the rest of the night shift, she repositions on her side and back by herself after being reminded. How do you correctly code for Roll left and right?
What is SUPERVISION or TOUCHING ASSISTANCE?
Remember: Roll left and right does not include being moved up in bed.
At breakfast, Mrs. Franks 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. What level of performance is this?
What is SUPERVISION or TOUCH ASSISTANCE?
Mrs. Todd receives all of her nourishment via a gastrostomy tube. She does not consume any food or fluid by mouth due to difficulty swallowing and risk for aspiration. How much assistance do you document for Mrs. Todd?
What is N/A NON-APPLICABLE?
Colonel Bell is able to adjust his clothes before using the toilet, after toileting he washes himself but needs help to zip his pants.
Document toileting hygiene as ____________.
What is PARTIAL TO MOERATE ASSISTANCE
Mrs. Macy has peripheral neuropathy in her upper and lower extremities. Each morning, Mrs. R needs assistance from staff to place her lower limb into, or to take it out of (don/doff), her lower limb prosthesis. She needs no assistance to put on and remove her underwear or slacks.
What is PARTIAL to MODERATE ASSISTANCE?
Rationale: performs less than half the effort of lower body dressing (with a prosthesis considered a piece of clothing). The helper lifts, holds, or supports Mrs. R’s trunk or limbs, but provides less than half the effort for the task of lower body dressing.
The CNA answers Mrs. Ryan's call light. She is laying on her back in bed and asked to be helped to the bathroom. Mrs. Ryan recently fractured her left hip and is able to lift her torso using the trapeze as the CNA lifts her legs and moves them to the side of the bed, keeping good alignment and then provides back support as Mrs. Ryan releases the trapeze and sits on the side of the bed
How is lying to sitting on the side of the bed documented?
What is LYING TO SITTING AT THE SIDE OF THE BED?
Mrs. Morrow is able to transfer from the bed to the chair when she uses her walker. The team member places the walker near the bed & locks the W/C. The resident completes the rest of the transfer without help
How is this documented?
What is SET-UP OR CLEAN UP ASSISTANCE
Mrs. Bishop begins eating each meal daily by herself. After she had eaten only her toast, she stated she was tired and unable to complete the meal. One staff member fed her and provided verbal cues to swallow the food. The resident ate 100%.
How do you document eating?
What is SUBSTANTIAL/MAXIMAL ASSISTANCE?
Mrs. West is cognitively and physically imparied. On your shift, Mrs. West was incontinent of bowel and bladder one time. You and one other team member provided peri-care while the resident remained in bed. How would you correctly code self performance and support for the ADL of toileting?
What is total dependence/2+ person physical assist? Rationale: Resident did not participate in the task and required 2 team members to provide total care for toileting.
Mrs. Benoit was admitted to the SNF for a neurologic condition and experiences visual impairment and fine motor coordination and endurance issues. She requires setup for retrieving her socks and shoes, which she prefers to keep in the closet. Mrs. F often drops her shoes and socks as she attempts to put them onto her feet or as she takes them off. Often a certified nursing assistant must first thread her socks or shoes over her toes, and then Mrs. Benoit can complete the task. Mrs. Benoit needs the certified nursing assistant to initiate taking off her socks and unstrapping the Velcro used for fastening her shoes.
This would be documented as Partial/moderate assistance.
True or False?
What is FALSE?
The correct answer is Substantial/maximal assistance.
Mr. Snow needs reminders to reposition himself in bed, otherwise he sleeps on his back all night. After reminders he is able to reposition himself independently. Tonight Mr. Snow needed assistance of one CNA to turn onto his side in bed.
How do you document this?
What is SUPERVISION OR TOUCH ASSISTANCE?
Mrs. Mann is sitting on the side of the bed. She stands and pivots into the chair as the CNA provides contact guard (touching) assistance. The nurse reports that one time Mrs. Mann only required verbal cues for safety but usually requires touch assistance.
What do you document for transfer?
What is PARTIAL TO MODERATE ASSISTANCE?
Mr. A eats all meals after set up without any physical assistance or supervision from staff. He has a gastrostomy tube (G-tube), but it is no longer used, and it will be removed later today.
How do you document eating?
What is SET UP ASSISTANCE
Mrs. Parsons is a post right ankle fracture and has orders for non-weightbearing to her right foot. During your shift, you took her took her to the bathroom two times and each time, provided weight bearing assistance transferring her from the wheelchair to the toilet and back. She was able to complete her pericare, wash her hands and adjust her clothing herself each time.
How do you correctly code toileting hygiene?
What is INDEPENDENT?
We document the resident's ________ level of assistance?
What is USUAL?