ALTCS Medical Assessment

Definitions:
Assistive Devices
Devices that are designed, made, or adapted to help a person perform a particular task. Examples: walkers, canes, handrails, wheelchairs.
Hands-on Assistance
Physical contact to support a person so that the activities of daily living can be carried out without fall or injury.
Purposeful Movement
The act of intentionally moving from one place to another.
Set-up
Involves placing the assistive device where the customer can reach. Examples include charging an electric wheelchair or adjusting the wheelchair safety belt.
Supervision
Observing the customer and being readily available to provide assistance, including giving verbal cues or reminders.

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3: Total Dependence
Example:
The caregiver reports she pushes the customer in his wheelchair every day because he is too weak to move himself due to Multiple Sclerosis (MS). The customer is unable to stand on his own, so when no one is around, he lays in bed unable to move.

Score of 2: Hands-on Assistance
Example:
The customer has severe shortness of breath that gets worse as the day goes on. He self-propels his wheelchair only for the first trip of the day to the dining room. Due to fatigue and shortness of breath, his spouse pushes him in the wheelchair for all other mobility for the remainder of the day.

Score of 1: Supervision, Limited Hands-on or Occasional Hands-on Assistance
Example:
The customer reports that she walks unsteadily and has fallen three times in the past 30 days due to dizziness. Since these falls, she always uses a walker, and her spouse supervises all mobility to prevent further falls.

Score of 0: Independent
Example:
The customer reports that he has spina bifida, which has led to weak leg muscles and uneven hips. He is unable to walk because of his condition. He is able to maneuver around his home using a motorized wheelchair. His caregiver offers to plug in the chair for him, but he declines the offer and charges it himself without problems.

Definitions:
Assistive Devices
Devices that are designed, made, or adapted to help a person perform a particular task. Examples: walkers, canes, handrails, wheelchairs.
Bedfast
Confined to a bed due to illness or injury.
Physical Guidance
Means physical contact that helps the customer start or complete a task but does not involve bearing any of the customer’s weight. Examples include:Pulling the customer up from a seated or laying position; Physically guiding the customer; Physically steadying the customer.
Physical Lift
Actively bearing some part of the customer’s weight during movement or activity
Set-up
Means placing assistive devices for the customer’s use, and includes locking any brakes for safe transferring activity.
Supervision
Observing the customer and being readily available to provide assistance, including giving verbal cues or reminders.

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3: Total Dependence
Example:
The CNA reports that the customer is bedfast. He is paralyzed from the chest down and does not have enough upper body strength to participate in transfer activities. Caregivers turn and position the customer every two hours, but he is not currently being moved from the hospital bed.

Score of 2: Hands-on Assistance
Example:
The customer’s husband reports that a Hoyer lift is used to transfer his wife out of bed each morning. She holds onto a bar on her hospital bed and shifts her bottom from side to side to assist in the transfer. A Hoyer lift is then used to transfer the customer from her bed to a wheelchair. The customer reaches out and holds onto the wheelchair arm to help guide her into the wheelchair. The Hoyer lift is also used to transfer the customer back into her bed each time. The customer is transferred using a Hoyer lift due to severe morbid obesity and venous insufficiency.

Score of 1: Supervision, Limited Hands-on or Occasional Hands-on Assistance
Example:
The customer reports that she gets out of bed on her own every day. The customer’s sister is with her from 5pm until 8pm every evening. Once the customer is in bed and before leaving each night, the sister puts the customer’s walker right next to the bed and makes sure it is locked. In the morning, the customer uses the walker for support to lift herself out of bed. She uses the walker throughout the day to stabilize herself when she gets in and out of her chair.
The customer becomes more fatigued and unsteady at the end of the day, so her sister supervises transfers from 5 p.m. until she helps the customer into bed. When the customer goes to bed, the sister holds her arm and guides her onto the bed, then lifts the customer’s legs into bed. The customer is already weak due to chemotherapy and needs more help at the end of the day.

Score of 0: Independent
Example:
The customer lives by himself. He has a high-rise bed so he is able to get in and out on his own without fear of falling. He notes that his dining room chair is lower, and he struggles to come to a stand. He holds onto the table for support and gets in and out of the chair on his own. He has a lift chair in the living room, which makes it easy for him to get in and out of. The customer has not had any falls in the past 90 days.

Definitions:
Assistive Devices
Devices that are designed, made, or adapted to assist a person to perform a particular task. Examples: grab bars, long-handled loofah, shower chair
Limited Hands-On Assistance
Physical contact to support a person so that the activities of daily living can be carried out without fall or injury.
Occasional Hands-On Assistance
When the customer needs hands-on help to complete an entire task less than daily.
Stand-by Assistance
The presence of another person within arm’s reach with the purpose of maintaining one’s safety
Supervision
Observing the customer and being readily available to provide assistance, including giving verbal cues or reminders.

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3: Total Dependence
Example:
The customer states that she became paralyzed six months ago in a car accident and has lost the use of her limbs. The customer is given a shower two to three times per week. Her caregiver transfers her onto a chair in the shower using a Hoyer lift. The caregiver washes, rinses and dries the customer’s body and hair. The caregiver then uses the Hoyer lift to transfer the customer out of the tub.
Explanation: The customer relies completely on someone else for all of her bathing needs

Score of 2: Hands-on Assistance
Example:
The customer is a 94 year old male who lives by himself. He said that he bathes three days per week, but is unable to get in and out of the shower on his own. A CNA comes to the home on the days that he bathes and sets the water temperature. The CNA then holds onto the customer’s arm and torso to ensure a safe transfer in and out of the shower. The CNA sets the water temperature and lathers a washcloth with soap. The customer is able to wash his upper torso. The CNA washes the customers back, legs and feet. The CNA dries the customer’s body with a towel.
Explanation: The customer receives hands-on assistance transferring in and out of the shower each time; and receives moderate hands-on assistance, washing his back, legs, and feet, each time. The customer needs assistance with two of the three criteria every time justifying the score of 2.

Score of 1: Supervision, Limited Hands-on or Occasional Hands-on Assistance
Example:
The customer’s nurse reports that the customer was recently diagnosed with dementia. Every morning the nurse reminds the customer that it is time to take a bath. The nurse fills the tub with water and makes sure that it is a safe temperature. The customer gets in the tub on her own. Once seated, the nurse leaves the bathroom to give the customer privacy. The customer is able to wash her entire body with a soapy washcloth prepared and placed on the edge of the tub by her nurse. The nurse comes back to the bathroom after 15 minutes and holds onto the customer’s arm to safely pull her to a stand. The nurse wraps a towel around the customer, and the customer dries herself off. The customer has had her hair washed and styled every Friday for the past 15 years. She does not wash her hair on the other days.
Explanation: The customer receives daily reminders when it is time to take a bath. She requires set-up, which includes filling the tub with water and making sure the water temperature is safe. The customer bathes safely without assistance and supervision, but needs limited hands-on assistance getting out of the tub.

Score of 0: Independent
Example:
The customer has a full-time caregiver at his home due to early onset Alzheimer’s disease and the risk of forgetting things or getting lost. The caregiver reports that the customer showers daily and does not need any help with his bathing routine. He does not need to be reminded and does not get any reminders. He gets in and out of the shower, and wash, rinse, and dry himself. The caregiver said that she is always in the home when the customer showers but is not in the bathroom with him.
Explanation: The customer is able to complete his bathing routine independently.

Definitions:
Anti-embolism stockings (TED Hose)
Specialized hosiery designed to help reduce the threat of blood clots forming in the legs. They improve blood circulation in the leg veins by applying graduated compression
Assistive Devices
Mechanical aids, such as zipper pulls, long-handled shoe horns, stocking aids, Velcro fasteners; and adaptive clothing, such as elastic waist pants, slip-on shoes or non-tie shoes
Cooperation
Includes actions that allow the caregiver to perform a task for the customer, but are not an actual part of the task
Example: The customer raises his arms, but the caregiver threads hands and arms through shirt sleeves and pulls the shirt down.
Limited Hands-On Assistance
Hands-on help needed to do a portion of the task each time, but not needed for the entire task each time.
Occasional Hands-On Assistance
When the customer needs hands-on help to complete an entire task less than daily.
Physical Participation
The customer’s active participation, not just being passive or cooperative. This includes the ability to complete a small portion of the task
Example: The caregiver holds shirt so sleeves are easy to get to. The customer threads her arms through and tugs her shirt into place.
Set-up
Includes laying clothes out for the customer, placing shoes where the customer is able to put them on easily, and placing assistive devices within reach
Supervision
Observing the customer and being readily available to provide assistance, including verbal cues or reminders and set-up activities

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3: Total Dependence
Example:
The customer is in the advanced stages of Lou Gehrig’s disease. He needs help daily dressing and undressing because he has lost a lot of his motor skills. To get dressed, the customer raises his arms and his wife threads his hands and arms through the shirtsleeves, pulls the shirt over his head and then pulls it down. She then slides on the customer’s pants and pulls them up, puts the customer’s socks and shoes on for him, and ties the shoes. To get undressed, the customer raises his arms and his wife pulls the shirt over his head and guides his arms out of the shirtsleeves. As the customer lies on the bed, she pulls his elastic pants down over his hips as she rolls the customer from side to side. She removes his shoes and socks each time.
Explanation: The customer receives a combination of full hands-on by the caregiver for BOTH dressing and undressing.

Score of 2: Hands-on Assistance
Example:
The customer says her hands are very shaky due to tremors. Each day the CNA puts a dress over her head. The customer pushes her arms through the dress sleeves as the CNA guides the dress over her arms. The customer pulls the dress down once it’s over her head and arms. The CNA puts the customer’s socks and shoes or slippers on her every day. The customer does not wear a bra or underwear and never wears anything with fasteners due to her hand tremors. The CNA helps the customer undress by pulling the dress up above the customer’s hips. The customer is then able to slide her arms out of the dress and over her head. The customer can slide her slippers or shoes off, and the CNA removes her socks.
Explanation: The customer needs hands-on assistance from her CNA to put on her dress, socks, and shoes. The customer is able to actively participate by pushing her arms through the dress sleeves and pulling her dress down once over her head and arms. The customer needs similar hands-on assistance when undressing, and actively participates by sliding her shoes or slippers off, and taking her dress off once the CAN lifts the dress over her hips.

Score of 1: Supervision, Limited Hands-on or Occasional Hands-on Assistance
Example:
The customer’s nurse reports that the customer was recently diagnosed with dementia. Every morning the nurse reminds the customer that it is time to take a bath. The nurse fills the tub with water and makes sure that it is a safe temperature. The customer gets in the tub on her own. Once seated, the nurse leaves the bathroom to give the customer privacy. The customer is able to wash her entire body with a soapy washcloth prepared and placed on the edge of the tub by her nurse. The nurse comes back to the bathroom after 15 minutes and holds onto the customer’s arm to safely pull her to a stand. The nurse wraps a towel around the customer, and the customer dries herself off. The customer has had her hair washed and styled every Friday for the past 15 years. She does not wash her hair on the other days.
Explanation: The customer receives daily reminders when it is time to take a bath. She requires set-up, which includes filling the tub with water and making sure the water temperature is safe. The customer bathes safely without assistance and supervision, but needs limited hands-on assistance getting out of the tub.

Score of 0: Independent
Example:
The customer has a full-time caregiver at his home due to early onset Alzheimer’s disease and the risk of forgetting things or getting lost. The caregiver reports that the customer showers daily and does not need any help with his bathing routine. He does not need to be reminded and does not get any reminders. He gets in and out of the shower, and wash, rinse, and dry himself. The caregiver said that she is always in the home when the customer showers but is not in the bathroom with him.
Explanation: The customer is able to complete his bathing routine independently.

Definitions:
Anti-embolism stockings (TED Hose)
Specialized hosiery designed to help reduce the threat of blood clots forming in the legs. They improve blood circulation in the leg veins by applying graduated compression
Assistive Devices
Devices that are designed, made, or adapted to assist a person to perform a particular task. Examples: universal ADL cuffs; adapted holders and long handles for toothbrushes, razors, and hairbrushes; electric razor; tube dispenser for toothpaste.
Grooming
The process of tending to one’s appearance.
Oral Care
Cleaning the mouth and teeth, including dentures, of food debris and dental plaque. For people without teeth or dentures, oral care includes cleaning the mouth and gums.
Set-up
Scoring for set-up involves more than simply making grooming items available. Examples of set-up include: putting toothpaste on a toothbrush and cleaning up after each use, adding a new razor blade to a razor and cleaning up after each use, setting up adaptive holders and long handles for toothbrushes, razors, hair brushes.
Shaving
To remove hair from the face, legs, or underarms by cutting it close to the skin with a razor.

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3: Total Dependence
Example:
The CNA reports that the customer is bedfast and is unable to participate in grooming tasks because he is in a coma. A soft toothbrush is used daily to clean the customer’s teeth. The CNA explained that the customer is positioned with his head turned to the side to prevent aspiration during oral care. The CNA also reported that the staff will comb the customer’s hair two to three times per week and shave his face weekly.
Explanation: The customer receives a combination of full hands-on by the caregiver for BOTH dressing and undressing.

Score of 2: Hands-on Assistance
Example:
The spouse reports that the customer removes her dentures before she goes to bed every night. He sets up the denture cup with cleaning tablets and puts the dentures in the cup. Each morning, when she wakes up, he places her dentures in her mouth. She suffers from dementia and does not remember how to place her dentures in her mouth. Spouse reports that his wife attempts to comb her hair, but she is only able to comb the front of her hair. He combs the sides and back of her hair each time. He does this every day. She has limited range of motion due to severe arthritis and is not able to reach the sides and back of her hair. The customer has no shaving needs.

Score of 1: Supervision, Limited Hands-on or Occasional Hands-on Assistance
Example:
The customer’s wife reports that the customer was recently diagnosed with multiple sclerosis. He has tremors in his hands which makes it difficult for him to complete his grooming tasks. His toothbrush and hairbrush both have adaptive holders, which do help him keep his hands steady. The wife said that the customer is still able to brush his hair, which is kept short for convenience. Although the toothbrush holder helps and he can brush his front teeth, he is not able to brush the back and bottom teeth, so she brushes them for him. These tasks are completed every morning. He is at risk of cutting himself when shaving because of the tremors, so his wife lathers his face with shaving cream and shaves his face and neck once a week.

Score of 0: Independent
Example:
The customer lives by herself and reports that all her grooming supplies are readily available on her bathroom counter. She said that she has limited grip in her hands due to severe arthritis. She has an assistive device, a universal ADL holder, which she straps around her hand to secure her toothbrush and brush into place. She can brush her teeth, which she does daily. She combs her own hair daily. She said without this device she would not be able to complete her grooming tasks. She said that she does not shave her underarms or legs because she prefers not to.

Definitions:
Assistive Utensils
Utensils that are designed, made, or adapted to help a person with eating. Examples: curved utensils, universal cuff utensil holder, bendable utensils, weighted utensils
Mechanically altered diet
Food prepared with the purpose of changing the consistency to make it easier for a person to eat by mouth. Examples: soft foods, pureed foods, ground meat, thickened liquids
Parenteral Nutrition
A method of getting nutrition into the body through the veins
Serving Food
Bringing food to a person
Set-up
Actions taken before a meal to make it easier for a person to eat. Examples include: opening milk cartons, cutting food, clockwise arrangement for the visually impaired, cutting or pureeing of food. Set-up does NOT include: serving food, delivering a meal, preparing food (for example, cooking).
Stand-by Assistance
The presence of another person within arm’s reach required to prevent injury during the performance
Tube Feeding
Nutrition administered through a tube. Examples include nasogastric (NG) tube, gastrostomy (g-tube) or jejunostomy (j-tube).

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3: Total Dependence
Example:
The customer’s hospice nurse reports that the customer is fed by a caretaker for each meal due to weakness from advanced cancer. The customer eats three small meals a day. The caregiver cuts all food into small pieces; sets the meal in front of the customer; and uses a spoon to bring each bite of food to the customer’s mouth. The customer is only able to open her mouth, chew and swallow the food.

Score of 2: Hands-on Assistance
Example:
The customer’s caregiver reports that the customer needs help eating every day. The caregiver cuts up food into bite-size pieces. During each meal, the customer uses thick-handled silverware to feed herself for about five to ten minutes, and then asks the caregiver to feed her due to tremors in the arms and hands from stage three Parkinson’s disease. The caregiver holds a cup with thickened liquids up to the customer’s mouth and the customer drinks from a straw every time due to swallowing difficulty caused by Parkinson’s disease.

Score of 1: Supervision, Limited Hands-on or Occasional Hands-on Assistance
Example:
The caregiver reports that the customer needs assistance with setting up each meal due to rheumatoid arthritis. The caregiver plates the food, opens a carton of milk and places both on a tray with a cup before bringing it to the customer. Once the tray is in front of the customer, the caregiver needs to pour the milk into the cup and cut the customer’s food into small pieces. After this is done the customer can eat without further assistance.

Score of 0: Independent
Example:
The customer reports that he lives alone and receives Meals on Wheels during the week, but not on weekends. During the week, every time a meal is delivered the Meals on Wheels volunteer sets the food on a tray in front of the recliner where the customer sits. The customer opens containers and cuts food without issue. As soon as the volunteer leaves, he feeds himself. On Friday extra meals are delivered to last for the next two days. On Saturday and Sunday, the customer heats a meal in the microwave when he is hungry and eats three times a day. He gets himself a drink each time he is thirsty and drinks from a cup without any issues.

Definitions:
Assistive Devices
Devices that are designed, made, or adapted to assist a person to perform a particular task. Examples: grab bars, raised toilet seat, self-wipe toilet aide, safety rails, bedside toilet
Catheter
A flexible tube inserted through a narrow opening into a body cavity, particularly for removing fluid from the bladder. Common types of catheters: Foley, Suprapubic, Straight or Intermittent, Nephrostomy tube
Ostomy
A surgical procedure that creates an opening, called a stoma, from an area inside the body to the outside. This procedure changes the way urine or stool exits the body. Common types of ostomies: Colostomy, Ileostomy, Jejunostomy, Nephrostomy
Set-up Activities
Ensuring assistive devices are in place; emptying bedpans, commode chairs, and urinals.
Stand-by Assistance
The presence of another person within arm’s reach with the purpose of maintaining one’s safety
Supervision
Observing the customer and being readily available to provide assistance, including verbal cues or reminders and set-up activities

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3: Total Dependence
Example:
The customer’s mother reports that the customer has physical limitations due to paralysis. Each time the customer needs to use the restroom, a family member picks her up and puts her on the toilet. Then the family member cleans her, picks her up off the toilet, adjusts her clothes, and flushes the toilet. The customer is unable to participate at all.
Explanation: The customer is completely dependent on someone else for her toileting needs. The customer is not able to participate at all.

Score of 2: Hands-on Assistance
Example:
The customer’s brother reports that the customer gets assistance using the toilet each time due to a recent below the knee amputation on his right leg. The brother holds the customer’s arm as he guides him down onto the toilet so he does not fall. The customer is able to clean himself adequately. The brother pulls the customer up to a standing position and steadies the customer so that he does not lose his balance. The customer needs help adjusting his clothing due to balance issues. Once he is in a standing position and steady, the customer flushes the toilet and washes his hands. The brother stays within arm’s reach until the task is completed due to continued fall risk.
Explanation: The customer receives limited hands-on assistance each time for transferring on and off the toilet and adjusting clothing. Even though he is only receiving limited hands-on assistance, he needs standby assistance every time for safety. The standby assistance each time justifies a score of 2.

Score of 1: Supervision, Limited Hands-on or Occasional Hands-on Assistance
Example:
The customer’s brother reports that the customer is forgetful. The customer has a history of rashes and infections from not cleaning himself after a bowel movement. He has to be reminded to flush the toilet every day and clean himself after every bowel movement. Once reminded, the customer flushes the toilet and cleans himself adequately. The customer is able to transfer onto the toilet each time. The customer’s brother pulls the customer up by the arm to come to a stand due to arthritic knees. He provides this assistance every time. The customer washes his hands after toileting.
Explanation: The customer needs supervision by getting verbal reminders to flush and clean himself. He receives limited hands-on assistance to transfer off the toilet each time.

Score of 0: Independent
Example:
The customer’s brother reports that the customer toilets independently. The customer is able to transfer safely on and off of the toilet, wash his hands, and adjust his clothing. Due to the customer’s delusion that his feces will turn into snakes if he flushes the toilet, he refuses to flush the toilet. So, his brother flushes the toilet when he refuses. The customer does flush the toilet after urinating.
Explanation: The customer is independent with the entire task most of the time. She is offered limited hands-on assistance, but it is less than the majority of the time.

Definitions:
Bladder Continence
The customer’s ability to voluntarily control the discharge of body waste from the bladder
Bowel Continence
The customer’s ability to voluntarily control the discharge of body waste from the bowel.
Stress Incontinence
The customer’s inability to prevent the escape of small amounts of bowel or bladder contents during activities such as coughing, sneezing, lifting, or laughing.

Definitions:
Bladder Continence
The customer’s ability to voluntarily control the discharge of body waste from the bladder
Bowel Continence
The customer’s ability to voluntarily control the discharge of body waste from the bowel.
Stress Incontinence
The customer’s inability to prevent the escape of small amounts of bowel or bladder contents during activities such as coughing, sneezing, lifting, or laughing.

Definitions:
Deterioration
A new or increased loss of independence in ADLs or continence as compared to 90 days before the PAS.

Definitions:
Disorientation
The loss of one’s bearings; a state of mental confusion or impaired awareness of time, place, or identity.
Orientation
Awareness of one's environment related to place, time, and people.

Definitions:
Disorientation
The loss of one’s bearings; a state of mental confusion or impaired awareness of time, place, or identity.
Orientation
Awareness of one's environment related to place, time, and people.

Definitions:
Central Vision
The field of vision that allows a person to see shapes, colors, and details clearly and sharply.
A person who loses central vision often feels like they are missing fine details or seeing blurred spots in the center part of their field of vision.
Field of Vision
The entire area that a person is able to see when their eyes are fixed in one position.
Monocular Vision
A condition in which one eye is blind, or one eye is unable to register images in coordination with the other eye.
Tunnel Vision
Loss of peripheral vision but still having central vision, resulting in a constricted, circular field of vision.

Definitions:
Chemical Restraints
A medication prescribed specifically to stop or reduce the wandering behavior
Pacing
Walking back and forth within an area due to restlessness, lack of exercise, stress, or anxiety, which does not pose a safety risk to self or others.
Physical Intervention
A physical device or barrier that prevents the customer from going beyond the physical borders of his environment to prevent the wandering behavior. For example, placement in a locked memory unit to prevent the wandering behavior. OR Hands-on assistance to stop the wandering behavior from occurring. For example, stepping in front of the person or leading them by the hand
Verbal Redirection with difficulty
Spoken direction or requests, or verbal redirection of the customer’s focus that takes a great deal of time and effort but eventually succeeds.
Verbal Redirection with ease
Spoken direction or requests, or verbal redirection of the customer’s focus that the customer responds to quickly and easily.

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
The caregiver, the customer’s daughter, reports the customer wanders through the house at night. The customer goes into other family members’ rooms every night collecting items and stacking them on the floor in the hallway to take on her “trip”. The caregiver confirms that there is no trip scheduled.
The customer and other family members have tripped over the piled items at night. The injuries were mostly minor, except for the customer fracturing her wrist.

Score of 2 of 3
Example:
The customer’s wife explains that the customer has moderate dementia. He walks down the street in the evening about three times each week after his daughter visits for dinner. The customer’s wife said that when she is cleaning up after dinner, he leaves his house to “go home.” He gets lost and walks into the street. The wife is afraid he won’t make it home due to his confusion.

Score of 1 of 3
Example:
The customer lives in a skilled nursing facility. The CNA reports that the customer wanders in and out of other residents’ rooms several times a week. He goes through drawers and closets “looking for buried treasures”. The CNA said that the customer’s behavior does not usually pose a safety risk. However, twice in the past month this has resulted in arguments with another resident that became physical.

Score of 0
Example:
The daughter says the customer used to wander the house every night, collecting items from other rooms and stacking them on the hallway floor to get ready to “go visit her daughter.” The customer only has one daughter and lives with her. The daughter was concerned that someone would trip and fall over the piles. This behavior has not occurred in over 4 months.

Definitions:
Chemical Restraints
A medication prescribed specifically to stop or reduce the wandering behavior
Pacing
Walking back and forth within an area due to restlessness, lack of exercise, stress, or anxiety, which does not pose a safety risk to self or others.
Physical Intervention
A physical device or barrier that prevents the customer from going beyond the physical borders of his environment to prevent the wandering behavior. For example, placement in a locked memory unit to prevent the wandering behavior. OR Hands-on assistance to stop the wandering behavior from occurring. For example, stepping in front of the person or leading them by the hand
Verbal Redirection with difficulty
Spoken direction or requests, or verbal redirection of the customer’s focus that takes a great deal of time and effort but eventually succeeds.
Verbal Redirection with ease
Spoken direction or requests, or verbal redirection of the customer’s focus that the customer responds to quickly and easily.

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
Every night the caregiver turns on the hallway light so that she can see the random piles. She then takes her mother’s arm and leads her back to her bedroom, puts her in bed, sings a lullaby until she falls back to sleep, and then closes the bedroom door.

Score of 2 of 3
Example:
When the customer tires or gets lost walking, he asks his neighbors where his house is, even when he is right in front of it. The neighbors are aware of his condition and take him by the arm each time to take him back to his house.

Score of 1 of 3
Example:
When this behavior occurs, a staff member quietly tells the customer that it is time to go back to his room. The customer appears confused, so each time the caregiver holds the customer by his arm and walks him slowly back to his room.

Score of 0
Example:
The customer’s daughter said that ever since her mother was prescribed Risperidone, which the customer takes every evening, not only has the wandering behavior stopped but she also sleeps through the night.

Definitions:
Chemical Restraints
A medication prescribed specifically to stop or reduce the self-injurious behavior.
Physical restraints
Physical restraints

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
The customer is diagnosed with Asperger’s and is not DD eligible. His mother reports that when he gets overstimulated, he bangs his head against the wall or floor at least once a day. She said that this behavior has caused bruising, frequent headaches, and dizziness.

Score of 2 of 3
Example:
The group home staff reports that the customer has hallucinations that tell her to slap herself. As a result, the customer repeatedly slaps her head and face three or four times a week. The staff reports that the customer often bruises her face. The staff reports that 45 days ago she was slapping herself in the head every day, but since she was prescribed medication, the behaviors have decreased.

Score of 1 of 3
Example:
The customer’s mother reports that the customer scratches his forearms with a paperclip which have left several scars. His mother describes the cuts as mostly “superficial,” but the scratches cause bleeding and scarring. The customer only scratches himself when he is by himself, so she is not sure how often he is scratching but he has told her he remembers doing it at least three times in the past month. He told her it helps him deal with his emotions when nothing else works.

Score of 0
Example:
The customer’s husband reports that his wife had been burning herself on her stomach with candle wax. He did not become aware of this behavior until six months ago. When he asked her about it, she said that she used to burn herself several years ago after a traumatic event but stopped when she met him. About six months ago, she had an event that reminded her of her past trauma, and she started to burn herself again. The behavior lasted for two months.

Definitions:
Chemical Restraints
A medication prescribed specifically to stop or reduce the self-injurious behavior.
Physical restraints
Physical restraints

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
The group home staff reports that the customer takes a daily dose of Quetiapine that was prescribed to reduce the self-injurious behavior. In addition, the three or four times a week they see the customer hurting herself, they hold her arms down to her sides to stop the behavior.

Score of 2 of 3
Example:
Every time this behavior happens, two staff members calmly approach the customer. They ask him why he is upset. The customer yells and screams and tells them that he is “sick of everything.” They continue talking with him for several more minutes until the customer tires. Shortly after the customer was taken to the ER, the staff members put up a punching mat on the wall. The customer has agreed that if he “has” to punch the wall he will do so on the mat.

Score of 1 of 3
Example:
The mother said when she sees this behavior, her first reaction is to ask the customer to stop, but he usually doesn’t. She then asks him, “Do you want to rock now, or would you rather swing?” The question distracts him, and he stops the head banging immediately.

Definitions:
Chemical Restraints
A medication prescribed specifically to stop or reduce aggressive behavior
Physical restraints
Physical devices that stop or reduce movement to protect a customer from injuring themselves or others.
Physical Intervention
Immediate hands-on assistance, provided by a caregiver to stop the aggressive behavior.
Verbal Redirection with difficulty
Verbal redirection given by a caregiver that takes a great deal of time and effort to reduce the aggressive behavior, but the customer eventually complies
Verbal Redirection with ease
Verbal redirection given by a caregiver that the customer responds to quickly and easily to reduce the aggressive behavior

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
The customer’s mother reports that the customer was in a serious motor vehicle accident just over a year ago, which resulted in a traumatic brain injury (TBI). The mother reports that, among other things, he is easily agitated which results in aggressive behavior. She said that every day for the past 90 days, the customer has hit, pinched, punched, or slapped both her and her husband at least once a day. This behavior has resulted in bruises and welts for both the mother and father. On one occasion, the father slapped the customer in the face to stop the behavior. None of the aggressive behaviors resulted in seeking medical attention.

Score of 2 of 3
Example:
The customer’s daughter reports that the customer has Alzheimer’s disease. The daughter reports that before her mother’s memory started to decline, she was very sweet and never “raised a hand to me or the rest of my family.” In the past year, the daughter reports the customer is easily agitated and when upset, she will raise her cane up in the air swings it at anyone who comes near her. The daughter reports that if the customer did hit someone it would hurt. The daughter is also concerned that the customer has poor balance and could fall when she starts swinging her cane. This behavior occurs at least five times a week when a family member attempts to approach the customer to pick up items from the trashcan that she has thrown on the floor.

Score of 1 of 3
Example:
The customer’s wife reports that her husband had his right leg amputated below the knee six months ago. She said that he has been depressed ever since and has been drinking heavily. When he drinks too much, he gets very angry. Since his surgery, she said he becomes “out of control” and starts yelling at her, approximately once a month. The more he yells, the angrier he gets. He then starts throwing his empty bottles at her. She reports that he has never actually hit her with a bottle, probably because he is “too drunk to throw well.” But, during these episodes he has thrown a beer bottle through the sliding glass door and multiple times has hit the living room wall, smashing glass all over the floor and carpet.

Score of 0
Example:
The customer reports that her husband died six months ago. She said she has never felt so much grief in her life and she “kind of lost it for a while.” The customer is diagnosed with bipolar disorder. In the first couple of months after her husband died, she was not sleeping and became “manic and explosive.” During this time, she admits to hitting a “lady in the store with my cart because she was walking too slowly.” She also threw a garbage can at her neighbor because “he looked at me weird.” After these incidents, she was prescribed a new medication for the aggression and has not had any outbursts in the last 90 days.

Definitions:
Chemical Restraints
A medication prescribed specifically to stop or reduce aggressive behavior
Physical restraints
Physical devices that stop or reduce movement to protect a customer from injuring themselves or others.
Physical Intervention
Immediate hands-on assistance, provided by a caregiver to stop the aggressive behavior.
Verbal Redirection with difficulty
Verbal redirection given by a caregiver that takes a great deal of time and effort to reduce the aggressive behavior, but the customer eventually complies
Verbal Redirection with ease
Verbal redirection given by a caregiver that the customer responds to quickly and easily to reduce the aggressive behavior

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
The customer’s wife reports that there is no reasoning with him when he has had too much to drink. She is scared that one day he might hit her. She said when he becomes violent, she calls the police. On one occasion he was arrested for disorderly conduct when four of her neighbors called the police. On the other occasions the police have had to physically restrain the customer until he calms. She said that she has not pressed charges because, “he is going through so much right now.”

Score of 2 of 3
Example:
The customer’s daughter said that her mother started taking items out of trashcans in the home about two months ago. The daughter said when she or a family member ask her what she is doing, she always says the same thing, “I have to find my kitten.” The daughter said whenever a family member tries to approach her; she becomes agitated and startled and raises her cane. The daughter or another family member will try to calmly talk with customer, but this only makes things worse. They have tried to leave her alone until she stops throwing garbage on the floor, but the customer slipped on a banana peel once when they tried this. Now they stay further than cane distance away to make sure the customer is safe. It takes over 10 minutes to redirect the customer into the TV room, by telling her that it is time to watch “The Price is Right.”

Score of 1 of 3
Example:
The spouse reports that on the occasion when he was transported to the hospital, his wife was taken to the ER and given a dose of Seroquel to reduce her agitation. Now, when she becomes agitated, he moves at least ten feet away from her and tries to redirect her by calmly asking if she would like a snack. Sometimes this works and she calms down and sits in her recliner while he makes her snack. Other times she will say, “I don’t know you. You are trying to poison me.” When this happens, he keeps his distance, but puts on a CD of her favorite songs. Even at her most agitated, the music calms her. He knows she is calm when she sits down in her recliner chair and stops pacing around the house. He then approaches her chair and asks if she would like a snack. Her common response is, “yes, dear that would be very nice.”

Definitions:
Self-advocacy
Speaking up for oneself and one’s views or interests

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
The customer’s daughter reports that her father has a cognitive impairment from a traumatic brain injury (TBI) sustained four months ago after being shot in the head. He now lives with her. Since his accident, the customer resists changing his clothes because he thinks he has already changed, which has resulted in ulcers on his buttocks from wearing soggy, soiled clothing. He also will not take his blood pressure medication because he thinks she is trying to poison him. These behaviors happen daily.

Score of 2 of 3
Example:
The customer’s daughter reports that her father has a cognitive impairment from a traumatic brain injury (TBI) sustained four months ago after being shot in the head. He now lives with her. Since his accident, the customer resists changing his clothes because he thinks he has already changed, which has resulted in ulcers on his buttocks from wearing soggy, soiled clothing. He also will not take his blood pressure medication because he thinks she is trying to poison him. These behaviors happen daily.

Score of 1 of 3
Example:
The customer lives with his brother. His brother said that the customer struggles with alcoholism, and goes days without showering, changing his clothes, and grooming. This behavior happens one to two times a month. When the brother reminds the customer to do these tasks, the customer says, “leave me alone, I’m not in the mood.” Two months ago, the customer was seen by a mental health provider, and was prescribed a daily anti-depressant in hopes of improving his mood, and to help with his lack of self-care.

Score of 0
Example:
The customer lives by himself. He said that his sister comes over once a week and brings him healthy, homemade dishes, but he refuses to eat these saying he is fine with his sandwiches and frozen meals.

Definitions:
Self-advocacy
Speaking up for oneself and one’s views or interests

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 3 of 3
Example:
The brother said that the customer’s therapist created a daily hygiene routine for him to follow. The brother reminds and encourages the customer three times a week to follow the routine. The customer is also taking a daily anti-depressant. Per brother, the combination of daily medication and reminders to follow the hygiene routine has decreased the customer’s resistance from weekly to one or two times a month.

Score of 2 of 3
Example:
The customer’s daughter reports that it is very difficult to convince her father to change his clothes. Every morning she reminds him that it is time to get dressed. He gets upset and paces back and forth, shaking his head. He continues to refuse and says he has already changed. She will eventually give up. The only day she can get him to change his clothes is on Sunday. She reminds him that it is time to get ready for church and sets out his “Sunday” outfit. He then changes his clothes. She is unable to get him to take his medication, so she mixes it up in his oatmeal each morning.

Score of 1 of 3
Example:
The nurse reports that, for oral care, the staff gently remind the customer that they only want to clean her dentures and promise not to hurt her. The verbal reassurance relieves her anxiety, and she allows the staff to remove and clean her dentures. For bathing, the staff tell the customer that her daughter is coming to visit, which she is. The customer says, “Oh, well I want to look pretty for my guest.” The customer then allows the staff member to help her with bathing.

Score of 3 of 3
Example:
The customer is diagnosed with obsessive-compulsive disorder (OCD) and has a morning routine that she needs to complete in a specific order. For example, she needs to brush her hair exactly 200 strokes. If she loses count or hears someone talking during the time that she is brushing her hair, she will start over. If a family member tells her that she is going to be late for school, she will yell and cry and say she cannot go until she is done and must start all over. This behavior is disruptive to the customer and the other members of her family because they are often late to appointments, work, and school. This behavior happens every morning.

Score of 2 of 3
Example:
The customer moved into a group home two months ago. The staff report that the customer is diagnosed with schizophrenia. The staff said that the customer hides her soiled clothing after incontinent episodes three times a week. They have found soiled clothing in the pantry, refrigerator, bathroom cabinets, and under her bed causing health concerns for the other residents and staff. The residents, staff, and visitors have complained of the home smelling badly because of this. When the soiled clothing is found, the staff must immediately stop what they are doing to disinfect the area.

Score of 1 of 3
Example:
The customer is diagnosed with Alzheimer’s disease and lives in a nursing home. Approximately, three times a month he makes sexually explicit and inappropriate remarks to the female residents. The women tell him to stop, but when they do the customer laughs and continues to make inappropriate remarks. The female residents have told the staff that this behavior makes them feel very uncomfortable. The behavior always happens during scheduled group movie time.

Score of 0
Example:
The customer moved into a skilled nursing facility four months ago. He is diagnosed with Huntington’s disease. The staff reports that when the customer first was transferred to the SNF he would have loud conversations and laugh hysterically with his imaginary friend. It happened every night and woke up the other residents in the facility.

Score of 3 of 3
Example:
The staff reported this behavior to the customer’s psychiatrist shortly after she moved in. The psychiatrist prescribed a daily dose of Haldol to reduce the behavior. The staff report that the behavior was happening daily when the customer first moved in, but as soon as she started taking the medication it has reduced to three times a week.

Score of 2 of 3
Example:
During the group movie time, the staff watch the customer closely and confront him immediately after he starts making inappropriate comments. The staff ask him to apologize to the women, but he refuses and says, “it’s a free country.” The staff eventually stop the argument by redirecting him verbally three to five times before he complies.

Score of 1 of 3
Example:
The customer’s family knows the exact time that the customer starts to brush her hair, and they know how long it usually takes her. They have created a time schedule and allow an extra 15 minutes for her to complete this task. They also are quiet during this time so that the customer is not disrupted. The customer still yells and cries every morning and is often late for school. But when the family reminds her to stick to her schedule, she stops crying and takes responsibility for her behavior.