Residents by Location Form - Instructions

Instructions for completing the Residents by Location Form

If you have any questions please contact:___________________________________

Survey Date:

Facility Identifier (ID):

Location Name:

Location Type:

Number of beds in Location:

This information will be completed by the EIP Team

#

Information required

Definition and instructions

SECTION A: Complete section A for all residents of your facility on the day of the survey

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CDC Resident ID number

All residents are allocated a unique ID number. This will be completed on the forms by the EIP Team.

1

Room, bed number

Enter the room and/or bed number for every bed in this location, for example 1,2,3 or 1a, 1b,etc.

2

Resident name

Enter the name of the resident assigned to the bed on the day of the survey. If a bed is not assigned to a resident write in “UNASSIGNED”

Note: Room/bed number and resident name are used for data checking purposes, and will not be saved in any databases or sent to CDC.

3

Admission date

Enter the residents’ admission date using the mm/dd/yyyy format. The admission date is the date that a person enters the facility and is admitted as a resident.

4

Present in the facility

Enter Y if resident was present in your facility by 8:00am on the survey date. Enter N if they were not. If Resident Name is completed as “Unassigned” enter N.

Example: If the resident is present in the facility on the survey date, but was admitted to your facility that day enter N.

SECTION B: Only complete Section B if column 3 is marked Y.

5

Age (in years)

Enter the age of the resident in years on the day of the survey.

6

Race/Ethnicity

Enter the race/ethnicity of the resident – select one of the following response options;

American Indian or Alaska Native

Black or African American

Native Hawaiian/other Pacific Islanders

Asian

White

Hispanic or Latino

7

Male gender

Enter Y if resident is male and N if the resident is female.

8

Short Stay

Enter Y if on the day of the survey the resident is considered a short stay resident, as defined by the CMS Minimum Dataset (MDS). Short stay is when the expected length of stay ≤100 days. Enter N if the resident is a long stay resident (the expected length of stay >100 days.

9

Diabetes

Enter Y if on the day of the survey the resident has previously been diagnosed by with diabetes by a physician or other healthcare provider. Diabetes includes persons with type I or type II (includes “insulin-dependent”, “adult-onset”, and “non-insulin dependent.”), glucose intolerance, and new-onset diabetes. Some common abbreviations for diabetes include: DM, AODM, IDDM, NIDDM.

Enter N if they have not. Diabetes does not include residents noted to be “pre-diabetic”. Pre-diabetic persons should be entered N.

10

Receiving dialysis

Enter Y if on the day of the survey the resident requires ongoing, chronic dialysis treatment, either hemodialysis or peritoneal dialysis, in your facility or at an outpatient dialysis center.

Enter N if they do not.

11

Wheelchair bound or bedridden

Enter Y if on the day of the survey the resident requires a wheelchair for movement or is bedridden.

Enter N if the resident can walk independently, or can walk with the use of canes, crutches, or uses a walker.

12a

Indwelling urinary catheter (Foley catheter)

Enter Y if on the day of the survey the resident has an indwelling urinary catheter (a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system. This device may also be called a Foley catheter.

Enter N if they do not.

12b

Use of other urinary device (not a Foley)

Enter Y if on the day of the survey the resident requires the use of a urinary drainage device other than an indwelling urinary catheter. This includes suprapubic catheters (a drainage tube inserted through the skin of the lower abdomen directly into the bladder), condom catheters (a drainage tube connected to the shaft of the penis using an external attachment device), and urostomy or nephrostomy tubes (drainage tubes placed through the skin directly into the ureters or renal collecting system).

Enter N if they do not.

For residents who receive intermittent catheterization or “straight” catheterization (also known as “in and out’ catheterization), enter N.

13

Central line

Enter Y if on the day of the survey the resident a central line, can also be called a central venous catheter, in place. A central line or central venous catheter is a long tube inserted through the skin into a large vein and ends near the heart. They used to give medicines, fluids, nutrients, or blood products. Some types includes; peripherally inserted central catheter (PICC) or PICC line, Tunneled catheter, or Implanted Port which is entirely under the skin. Enter N if they do not.

14

Tracheostomy tube

Enter Y if on the day of the survey the resident has a tracheostomy tube in place (a tube placed through an opening in the neck to provide an airway and to remove secretions from the lungs). Enter N if they do not.

15

Ventilator

Enter Y if on the day of the survey the resident is using a ventilator (a device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation). Do not include Individuals intermittently on a device to assist respiration (for example, only at night). Enter N if they do not.

16

Percutaneous Gastrostomy / Jejunostomy (PEG or PEJ) Tube

Enter Y if on the day of the survey the resident has a percutaneous Gastrostomy / Jejunostomy (PEG or PEJ) Tube (a tube that is passed into the stomach (PEG tube) or upper intestine (PEJ tube) through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. Enter N if they do not.

17

Pressure ulcer

Enter Y if on the day of the survey the resident has a pressure ulcer. Pressure ulcers in all locations on the body and of all stages should be included, even stage 1 characterised by discoloration of intact skin (non-blanching erythema) and non-stageable pressure ulcers. Enter N if they do not.

18

Receiving wound care

Enter Y if on the day of the survey the resident is receiving wound care, either provided by facility staff or contracted wound care services. Enter N if they do not.

SECTION C: The following section it to be completed by the Nursing Home Team Leader or the EIP Team.

19

Receiving systemic antimicrobial

To complete this question, obtain and review a copy of the facility Medication Administration Record (MAR) for the 7 days before and 7 days after the survey date. A copy of the MAR used should be given to the EIP Team.

Enter Y if on the day of the survey or the day before, the resident is on a course of systemic antibiotics(s). Include all oral (PO), rectal, intramuscular (IM) and intravenous (IV) treatment with antibacterials and antifungals, drugs for treatment of tuberculosis, antivirals, or antibiotic treatment by inhalation (aerosol therapy). Include medications that are administer by staff, and any that may be self-administer by residents.

Enter N if they are not. If the resident is receiving antimicrobials for topical use (cream, ointment, or drops) or antiseptics enter N.

20a

Condition that may indicate the presence of any infection

Enter Y if on the day of the survey or the day before, the resident has a condition listed in the table below that may indicate the presence of an infection. Enter N if they do not.

20b

If 20a=Y, conditions present

Using the code assigned to each condition, please list those that are present

Sources: Common Infections in the Long-term Care Setting. AMDA: The Society for Post-Acute and Long-Term Care Medicine - Clinical Practice Guideline.

Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents

of Long-Term Care Facilities: 2008 Update by the Infectious Diseases Society of America.

Table: Condition changes that may indicate the presence of Infection
Code	Nonlocalizing signs and symptoms
A	Change in ability to perform Activities of Daily Living (ADLs)
B	Change in intake of food or fluids
C	Change in mental status (e.g., increased confusion or lethargy)
D	Change in skin temperature or color
E	Change in sleep pattern
F	Change in vital signs (pulse rate, respiratory rate, blood pressure)
G	Fever or hypothermia
H	Dizziness
I	Fall or deterioration in balance or gait
J	Generalized pain; myalgia
Code	Localizing signs and symptoms
K	Lower respiratory tract symptoms: Increased coughing, shortness of breath, lung sounds
L	Upper respiratory tract symptoms: Sore throat, nasal congestion
M	Gastrointestinal (GI) symptoms: New onset of diarrhea, new or worsening stool incontinence, new vomiting, abdominal pain
N	Urinary tract symptoms: Suprapubic or flank pain or tenderness; painful urination; dysuria
O	Wound characteristics (erythema, pus)
P	Skin/soft tissue symptoms: Redness, swelling, tenderness
Q	Mucosal: Puffy, red eyes; excessive tearing
Code	Laboratory or diagnostic testing performed
R	A complete blood cell (CBC) count
S	Urinalysis or urine cultures
T	Pulse oximetry
U	Stool collected for Clostridium difficile (CDI, C. diff) testing

Last update 02.09.2016 Page 5 of 5