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Dignity and Respect
Self-Determination
Information and Communication
Planning and Implementing Care
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 left 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. 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 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-weight bearing.
100
Mr. Olson has an indwelling foley catheter. It is 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 assist with peri-care. How do you correctly code self-performance and support for personal hygiene?
What is independent/no set up or physical help? Rationale: The resident was independent in tasks of personal hygiene. Peri-care is capture/documented in the ADL of toilet use.
200
Mrs. Wyldestyle has requested she be laid down in bed after lunch. One 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 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 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 and hold the hand grips on the lift during the transfer; (VHS policy requires 2 team members assist when using any mechanical lift)
200
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 the mouth), or performs part of the activity for the resident. How do you correctly does self-performance and support for eating?
What is extensive/one person physical assist? Rationale: One team member is supporting some of the weight which meets the definition of extensive; limited assist is non-weight bearing.
200
Mr. Stevens requested to used 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 up 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 team 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
One team member must assist Mr. K. to zip his pants, hand him a washcloth, and remind him to wash his hands after using the toilet. 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-weight bearing assistance in the task of zipping his pants.
300
Mrs. Tyler has always loved Halloween. 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 team member assists her in donning her costume. Her adult daughter is giong to help her pass candy to the children and pushes Mrs. Tyler in her wheelchair 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? Rationale: Since the daughter is NOT and 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 wheelchairs. 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 was able to assist by bending her knees and pushing with her legs during the repositioning. How do you correctly code self-performance and support for bed mobility?
What is extensive assist/2+person physical assist? Rationale: Resident required weight-bearing assistance, but not total assist, with 2 team members.
400
Mrs. Hill is able to transfer from the bed to the chair when she uses her walker. The team member places the walker near the bed & then assists the resident by guiding her (non-weightbearing) as she transfers. How would you correctly code the self performance and support for the ADL of transfers?
What is limited assist/one person physical assist Rationale: Resident requires team member to set up her walker & provide non-weightbearing assistance when she is ready to transfer.
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 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 the ADL of eating? How would you code the ADL of eating?
What is extensive assistance/one person physical assist? Rationale: Resident partially participated in the task, however one staff member provided weight bearing assistance with some portion of the meal.
400
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.
400
Mr. Becker had a private duty aide with him during the entire night shift due to his fall risk. The private duty aide provided repositioning assistance by cueing him to turn from side to side approx. every 2 hours. How would you correctly code self performance and support for the ADL of bed mobility?
What is activity did not occur? Rationale: To capture assistance provided, it must be provided by the facility staff. The private duty aide is not a facility team member.
500
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 person physical assist Rationale: Two team members provided all the weight bearing assistance with the task. Resident was unable to participate in the task.
500
Resident Katy Miller is physically debilitated due to her diagnosis of multiple sclerosis. Two team members must physically lift and transfer her from the bed to a reclining chair daily using a mechanical lift. Katy is unalbe to participate in any way. How do you correctly code self performance and support for transfers?
What is total dependence/two person physical assistance Rationale: The resident was unable to assist and two team members provided total weight bearing assistance for the ADL task of transfers.
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. You needed to hold the glass and position the straw in her mouth while she drinks. What is the correct code for the ADL of 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-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 to her pericare, wash her hands and adjust her clothing herself each time. How do you correctly code the ADL of toileting?
What is extensive assist/one person physical assist? Rationale: Transferring is included in the ADL task of toileting and weight bearing assistance was provided due to her non-weightbearing status.
500
Mrs. Patrick has slid to the foot of the bed one time during your shift. You are another team member had to physically lift and reposition her back up to the head of the bed. Mrs. Patrick was unable to bed her legs or push up to assist the team members with the reposition. How do you correctly code bed mobility based on the assistance you provided?
What is total assist/2 person physical assist. Rationale: Mrs. Patrick did not participate in the task and 2 team members physically had to perform the task.