| 1. Sense of Initiative/Involvement |
| Intent: To assess degree to which the resident is |
| involved in the life of the nursing home and takes |
| initiative in activities. |
| Process: Selected responses should be confirmed by the |
| resident's behavior (either verbal or nonverbal) over the |
| past seven days. The primary source of information is the |
| resident. Secondarily, staff members who have regular |
| contact with the resident should be consulted (for |
| example, nursing assistants, activities personnel, social |
| work staff, or therapists if the person receives active |
| rehabilitation). Also, consider how resident's cultural |
| standards affect the level of initiative or involvement. |
| Definition: At ease interacting with others--Consider how |
| resident behaves during time you are together, as well as |
| reports of how resident behaves with other residents, |
| staff, and visitors. Does resident try to shield |
| himself/herself from being with others? Does he/she spend |
| most time alone? How does he/she behave when visited? |
| At ease doing planned or structured activities--Consider |
| how resident responds to such activities. Does he/she |
| feel comfortable with the structure or restricted by it? |
| At ease with self-initiated activities--These include |
| leisure activities (for example, reading, watching TV, |
| talking with friends), and work activities (for example, |
| folding personal laundry, organizing belongings). Does |
| resident spend most of his/her time alone, or does |
| resident always look for someone to find something for |
| him/her to do? |
| Establishes his/her own goals--Consider statements |
| resident makes like, "I hope I am able to walk again," or |
| "I would like to get up early and visit the beauty |
| parlor." Goals can be as traditional as wanting to learn |
| how to walk again following a hip replacement, or wanting |
| to live to say goodbye to a loved one. Some things may |
| not be stated |
| Involvement in life of the facility--Consider whether |
| resident partakes of facility events, socializes with |
| peers, discusses activities. |
| Resident accepts invitations into most group |
| activities--Is resident willing to try group activities |
| even if later, deciding the activity is not suitable and |
| leaving? Does resident regularly refuse to attend group |
| programs? |
| 2. Unsettled Relationships |
| Intent: To indicate the quality and nature of the |
| resident's interpersonal contacts (that is, how resident |
| interacts with staff members, family, and other |
| residents). |
| Process: During routine nursing care activities, observe |
| how the resident interacts with staff members and with |
| other residents. Do you see signs of conflict? Talk with |
| direct-care staff (for example, nursing assistants, |
| dietary aides who assist in the dining room, social work |
| staff, or activities aides) and ask for their |
| observations of behavior that indicate either conflicted |
| or harmonious interpersonal relationships. Consider the |
| possibility that the staff members describing these |
| relationships may be biased. |
| Definition: Covert/open conflict with and/or repeated |
| criticism of staff--Resident chronically complains about |
| some staff members to other staff members; resident |
| verbally criticizes staff members in therapeutic group |
| situations, causing disruption within the group; or |
| resident constantly disagrees with routines of daily |
| living. (Note: Checking this item does not require any |
| assumption about why the problem exists or how it could |
| be remedied.) |
| Unhappiness with roommate--Includes frequent requests for |
| roommate changes, grumbling about roommate spending too |
| long in the bathroom, or complaints about roommate |
| rummaging in another's belongings. |
| Unhappiness with residents other than roommate--Includes |
| chronic complaints about the behaviors of others, poor |
| quality of interaction with other residents, lack of |
| peers for socialization. This refers to conflict or |
| disagreement outside of the range of normal criticisms or |
| requests (that is, beyond a reasonable level). |
| Openly expresses conflict/anger with family or close |
| friends--Includes expressions of feelings of abandonment, |
| ungratefulness, lack of understanding, or hostility |
| regarding relationships with family/friends. |
| Absence of personal contact with family/friends--Absence |
| of visitors or telephone calls from significant others in |
| the last seven days. |
| Recent loss of close family member/friend--Includes |
| relocation of family member/friend to a more distant |
| location, even temporarily (for example, for the winter |
| months); incapacitation or death of a significant other; |
| a significant relationship that recently ceased. |
| 3. Past Roles |
| Intent: To indicate recognition or acceptance of feelings |
| regarding role or status now that the person is in the |
| nursing home. |
| Definition: Strong identification with past roles and |
| life status--This may be indicated, for example, when |
| resident enjoys telling stories about own past; or takes |
| pride in past accomplishments or family life; or prefers |
| to be connected with prior lifestyle (for example, |
| celebrating family events, carrying on life-long |
| traditions). |
| Expresses sadness/anger/empty feelings over lost |
| roles/status--Resident expresses feelings such as "I'm |
| not the man I used to be" or "I wish I had been a better |
| mother to my children" or "It's no use; I'm not capable |
| of doing the things I always liked to do." Resident cries |
| when reminiscing about past accomplishments. Be careful |
| not to take the reaction out of context. |
| Process: Discuss past life with resident. Use |
| environmental cues to prompt discussions (for example, |
| family photos, grandchildren's letters or artwork). This |
| information may emerge from discussions around other MDS |
| topics (for example, Customary Routine, Activity |
| Pursuits, ADLs). Direct-care staff may also have useful |
| insights relevant to these items. |
| 1. Sad or Anxious Mood |
| Intent: To identify the presence of behaviors that may be |
| interpreted as physical or verbal expressions of sadness |
| or anxiety. |
| Definition: A distressed mood characterized by explicit |
| verbal or gestural expressions of feeling depressed or |
| anxious (or a synonym such as feeling sad, miserable, |
| blue, hopeless, empty, or tearful). This may be a |
| disorder of mood which is usually, but not always, |
| accompanied by a painful mood of such magnitude that it |
| calls for relief because it is severely, or |
| unnecessarily, distressing or threatening to physical |
| health and life, or interferes with functional |
| performance and adaptation. These symptoms may be |
| preceded by anger or withdrawal. |
| Process: Determine if resident expressed signs of a sad |
| or anxious mood over the past 30 days. Draw on your own |
| interactions with the resident. Pay particular attention |
| to statements of direct-care staff, social workers, and |
| licensed personnel who may have evaluated the resident in |
| this area. Does the resident cry or look dejected |
| (unhappy) when no one is talking with him/her? When you |
| talk with the resident, does he/she sound hopeless, |
| fearful, sad, anxious? Does the resident report feelings |
| of worthlessness, guilt? Does the resident appear |
| withdrawn, apathetic, without emotion? |
| If you are unsure, seek confirming information from |
| others who regularly come in contact with the resident |
| (for example, activities professionals, social workers, |
| or family members). |
| 2. Mood Persistence |
| Intent: To identify a persistent sad/anxious mood that |
| has existed on each day over the last seven days and was |
| not easily altered by attempts to "cheer up" the resident. |
| Process: Normally, these moods apply to one or more of |
| the indicators mentioned above of sad/anxious mood. |
| 3. Problem Behavior |
| Intent: To identify the presence of problem behaviors in |
| the last seven days that cause disruption to facility |
| residents or staff members, including those that are |
| potentially harmful to the resident or disruptive in the |
| environment, even though staff and residents appear to |
| have adjusted to them (for example, "Mrs. R's calling out |
| isn't much different than others on the unit; there are |
| many noisy residents.") |
| Definition: Wandering--Movement with no identified |
| rational purpose; resident appears oblivious to needs or |
| safety. This behavior must be differentiated from |
| purposeful movement--for example, a hungry person moving |
| about the unit in search of food; pacing. |
| Report on the most disruptive resident behavior across |
| all three shifts. Code "1" if the described behavior |
| occurred less than daily and "2" if the behavior occurred |
| daily or more frequently. |
| 4. Resident Resists Care |
| Intent: Identify problem behaviors related to delivering |
| care/ treatment to the resident. These behaviors are not |
| necessarily positive or negative; they provide |
| observational data. They may prompt further investigation |
| of causes in the care-planning process (for example, fear |
| of pain, fear of falling, poor comprehension, anger, poor |
| relationships, eagerness to participate in care |
| decisions, past experience with medication errors and |
| unacceptable care, desire to modify care being provided). |
| Process: Consult medical record and primary staff |
| caregiver. How does the resident respond to staff |
| members' attempts to deliver care to him/her? Signs of |
| resistance may be verbal and/or physical (for example, |
| verbally refusing care, pushing caregiver away, |
| scratching). |
| 5. Behavior Management Program |
| Intent: Determine if a behavior-management program is in |
| place wherein staff members identified causal factors and |
| developed a plan of action based on that understanding. |
| There must be evidence of structure and continuity of |
| care in the program (for example, written documentation). |
| This category does NOT include behavioral management by |
| physical restraints or psychoactive drugs, if these are |
| the only interventions used. |
| Process: Consult medical record (including current care |
| plan); consult primary caregiver. |
| Examples |
| Mrs. S has been observed on numerous occasions to hit, |
| shove, and curse the woman seated next to her at each |
| meal. After observing the pattern of Mrs. S's behavior |
| for several days, staff noticed that her tablemate was in |
| the habit of moving toward Mrs. S to take food from her |
| tray. As a result of their observations, the primary |
| nurse made a change in seating arrangements. (Note: |
| Although staff might have increased the amount of food |
| provided at meals, the real issue was the taking of food; |
| Mrs. S would not want to share with others, no matter how |
| much food she was given.) Mrs. S does not tend to ask |
| staff for help when she is annoyed; she takes direct and |
| aggressive action on her own. Now that staff understand |
| this behavior, they are aware of the need to be vigilant. |
| Code "1" for Yes. |
| Provisions were made for safety monitored wandering for |
| Mr. V (including use of "secure bands" that activate an |
| alarm if he wanders away from a designated area). Mr. V |
| does not really disturb others (he does not go into |
| others' rooms). Without this "band," however, staff lost |
| track of him and he was in danger of harming himself if |
| he got off the unit (a busy street is very near his |
| unit). Code "1" for Yes. |
| 6. Change in Mood |
| Intent: Determine whether the resident's mood changed in |
| the past 90 days, that is, onset of recent mood problem |
| or changes in a longstanding problem. Changes may have |
| been expressed verbally or demonstrated physically; they |
| include increased/decreased number of signs/symptoms, or |
| increase/decrease in the frequency, intensity, or |
| persistence of sad or anxious mood. |
| Examples |
| Mrs. D has a long history of depression. Two months ago |
| she had an adverse reaction to a psychoactive drug. She |
| expressed fears that she was going out of her mind and |
| was observed to be quite agitated. Her attention span |
| diminished and she stopped attending group activities |
| because she was disruptive. After the medication was |
| discontinued, these feelings and behaviors improved. She |
| is better than she was, but still has feelings of |
| sadness. Code "1" for "Improved." Mrs. D is now better |
| than her worst status in the 90-day period, but she has |
| not fully recovered. (Note: If the mood problem was no |
| longer present due to the continued efficacy of the |
| treatment program, the correct code would also be "1" |
| (Improved).) |
| Mrs. Y has bipolar disease. Historically, she has |
| responded well to lithium and her mood state has been |
| stable for almost a year. About two months ago, she |
| became extremely sad and withdrawn, expressed the wish |
| that she were dead, and stopped eating. She was |
| transferred to a psychiatric hospital. For the last 30 |
| days (following readmission), Mrs. Y has improved and her |
| appetite is restored. Code "1" for Improved. |
| 7. Change in Problem Behavior |
| Intent: Determine if problem behaviors or resistance to |
| care increased/decreased in number, frequency, or |
| intensity in the past 90 days--that is, onset of recent |
| behavior problems or changes in a more longstanding |
| problem. |
| Changes can occur in many different areas, including (but |
| not limited to) wandering, verbal or physical abuse, |
| socially inappropriate behavior, or resistance to care. |
| Changes can be exhibited as increases/decreases in the |
| number of signs/symptoms and/or change in the frequency |
| or intensity of the behavior(s). |
| Process: Review nursing notes, medical records, and |
| consult with primary staff caregiver. |