MDS Alert

Published on Sun Mar 26, 2006 PDF

Assess, score residents' ability to turn/reposition without hands-on help.

PERFORMANCE ASSESSMENT TO EVALUATE ABILITY TO REPOSITION SELF

Resident Name: _________________________________________  Date: ___/___/___

Purpose: To determine whether a resident is capable of independently repositioning him- or herself. This assessment should be conducted by a licensed nurse.

Instructions: Ask the resident to "please turn to one side in bed." Be prepared to offer the resident the minimum level of human assistance possible, according to a standardized graduated assistance protocol:

•  Level 0: Request only, no physical assistance required

•  Level 1: No physical assistance but encouragement, verbal cues, prompting, or instructions on how to perform the activity (e.g., "Reach for the siderail, hold the siderail and pull yourself over on your side")

•  Level 2: Verbal cues required plus minimal manual guidance to start the movement (e.g., "Please move your hand toward the siderail")

•  Level 3: Partial physical assistance (e.g., take hand and move to siderail to start turn)

•  Level 4: Unable to turn to the side without complete physical assistance

Repeat the assessment for turning to the other side.
Record results for right and left turns below:

Interpretation: For each side, rate resident as "independent" if performance falls within Level 0 or 1, and "dependent" for performance at higher levels. If the resident is rated as "Independent" for BOTH right and left sides, consider the resident as "able to move." If the resident is rated as "dependent" for EITHER side, consider the resident as "unable to move."

Other: This assessment takes about six minutes per resident to conduct. Inter-rater reliability is excellent and stability of results is good (1). The assessment should be repeated whenever there is change in the resident's condition and at periodic intervals (e.g., quarterly).

Source: The Anna & Harry Borun Center for Gerontological Research