Long-Term Care Survey Alert

Help the team make decisions about whether residents can do the same.

1. Ability to Process Information

3=  Understands, processes and follows complex directions.
2=  Understands and follows basic directions (i.e., ADL's).
1=  Understands and follows one-step directions.
0=  Unable to understand or follow any directions.

SCORE:

2. Ability to Recognize that Choice Exists

3=  Receives information and understands relevance of choices in relation to own values and beliefs.
2=  Receives information and recognizes choices exist but is unable to relate choices to one's values and beliefs.
1=  Unable to distinguish which information is relevant to making choices.
0=  Unable to recognize relevant information nor understands choices exist.

SCORE:

3. Memory Recall
3=  Short-term and long-term memory are intact.
2=  Moderately impaired: recalls time of day (i.e., am or pm), month and/or year.
1=  Severely impaired: recalls 2 of the following: time of day, month and/or year.
0=  Incomprehensible language.

SCORE:

4. Ability to Reason

3=  Consistent ability to reason and express decision making.
2=  Inconsistent ability to reason and express decision making.
1=  Minimal ability to reason and express decision making.
0=  Not capable of reasoning.

SCORE:

5. Understands Consequences of Decisions

3=  Fully understands and expresses consequences of decisions.
2=  Understands there are consequences to decisions but unable to fully define them.
1=  Does not recognize there are consequences to decisions.
1=  Does not recognize there are consequences to decisions.
0=  Unable to understand situation or consequences.

SCORE:

TOTAL SCORE

Resident Name: _________________________________________ Resident # _______ Unit _______ Room # _______

SCORING (For decision making)

13-15  Full decision making capacity. (Resident can make all decisions independently.)

7-12   Limited decision making capacity. (Lacks ability to make one or more complex decisions independently   but still possess at minimum the capability to designate a power of Attorney. Facility must determine   decision making capability on a decision by decision basis. Surrogate will be involved in complex   decision making.)

0-6   None. (Unable to make decisions but may express preferences, i.e., food, clothing, and daily routine.)

SIGNATURES OF ID TEAM MEMBERS

Signature and Credentials                                                                            Date 
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_________________________________________________________________  _________________________

_________________________________________________________________  _________________________

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Comments: _______________________________________________________________________________________

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Resident Name: _________________________________________ Resident # _______ Unit _______ Room # _______

Source:  Masonic Village at Elizabethtown