Annual Compulsory Education Community rai Annual Compulsory Education

What is rai – hc? Resident Assessment Instrument A system that informs & guides comprehensive planning of care & services in community settings Focuses on the individual’s functioning & quality of life by assessing needs, strengths, & preferences Facilitates referrals when appropriate Gives an outcome based assessment of the person’s response to care &/or services provided

What is a tracking tool? Records relevant information about a client for eight (8) days prior to a case manager’s RAI – HC assessment Communicates valuable information to the case manager of the care that is provided to the client Assists in care plan development Notifies the case manage of the client’s status Is a consistent tool in all supportive living sites

Note: LPN time includes Medication Passes, wound care, etc Who completes the tool? LPNs/HCAs who work in supportive living (SL3, SL4, & SL4D) facilities & assist/observe clients in their daily routines Must be accurately completed as this tool forms the client’s care plan Complete with honesty & is to reflect your work with the client May be audited at any time by BSF management & Alberta Health Services for accuracy Note: LPN time includes Medication Passes, wound care, etc

When will you use the tool? The case manager will set a date & time to start tracking (communicated to the RN/LPN who will then initiate the tool) You record your observations, assistance, & care provided for eight (8) days The assessment cannot have missing spaces. This means that tracking must be completed at all times No guessing on assessments If there is a change in the client’s status let the case manager know in addition to the program manager & director of care

Describe pain & skin conditions in comments section What is tracked? Moods & Behaviours Physical Functioning Nutrition & Hydration Bathing Locomotion (Indoor & Outdoor) Continence (Bladder & Bowel Control) Problem Conditions/Symptoms Skin Condition Pain R All that apply Describe pain & skin conditions in comments section

DO NOT confuse personality traits with actual moods Moods may be expressed verbally or non-verbally Client has feelings of sadness, anger, anxiety, or depression ie: VERBAL – client may say “Life is not worth living.” ie: NON-VERBAL – client is frowning or teary All moods must be recorded regardless of why, why, &/or when it is displayed DO NOT confuse personality traits with actual moods

behaviours All behaviours have meaning & this must be recorded All behaviours must be recorded regardless of when, why, &/or where it is displayed Pacing is not wandering Wandering can be done in a wheelchair Client may move without any obvious purpose Client swings out at others i.e. verbally abusive – client has screamed at or threatened others i.e. physically abusive – can include swinging out with intent to hit

Behaviours continued… Questions to ask: Were these behaviours easily altered? Was the client easily removed or re-directed from the situation? Basically ask if you were successful in re-directing the client &/or preventing one client from hitting or pushing another person Very important to code as this could be the cause of other problems Note: Pacing is not included in wandering. If the pacing is disruptive to others include this as “client was socially inappropriate or disruptive.” The same statement may be used with hoarding.

Activities of daily living (ADL) self-performance Record what the client actually does on their own or what help is needed in activities of daily living This category includes: Transfers Mobility in bed Locomotion (How the client moves around) Dressing the upper & lower body Eating Toileting Personal Hygiene Bathing

Activities of daily living (ADL) self-performance Continued… What to record/code (Choose one of the following): Did not require help Required supervision, cueing, encouragement, or set-up help Required “hands on” help & touches resident Activity did not occur Mobility in bed would also include “recliners” as there are clients/residents who prefer to sleep in their chair. Some days or shifts client can do more for himself than others. Record what actually occurs.

Primary modes of locomotion The aid or device the client most often uses to get around both indoors & outdoors What to record/code (Choose one of the following): No assistive device Cane Walker/Crutch(es) Scooter Wheelchair (includes electric wheelchair) Activity did not occur (i.e. outdoors) If not too sure what to code, think about what the client uses more than 50% of the time

Bladder continence (Control) Incontinence includes any level of dribbling or wetting of urine Leaking indwelling catheter = incontinence R All that apply Bladder Devices Incontinent Product Do not include panty liners &/or pad placed on the bed routinely if the client is never or rarely incontinent Note: Leaking or bypassing of catheter should be reported right away to nursing supervisor as per policy

Bladder continence (Control) Does not include the client’s ability to toilet themselves Leaking ostomy = incontinence Record each time a client has a bowel movement (BM) What would you record if the ostomy leaks? Note: Leaking ostomies should be reported to the nursing supervisor as per policy

Note: New, sudden, or continued symptoms should be reported right away Problem Conditions Diarrhea – frequent watery stools Difficulty urinating or urinating 3 or more times at night Vomiting Chest Pain Dizziness or light-headedness Hallucinations – Seeing/hearing/touching/smelling things that are not really there Note: New, sudden, or continued symptoms should be reported right away

Describe pain & location in the comment section Complains of pain – may be verbal &/or non-verbal i.e. wincing or favoring the affected site Complains of pain in more than one area Change in behaviour i.e. clients with dementia R All that apply – then describe in comment section Very important to assess & record/code as it could be a sign of other issues Describe pain & location in the comment section

Weigh client once over the eight (8) day period (bath day) Nutrition/hydration Percentage of food eaten at meal &/or snacktime 75-100 50-75 25-50 0-25 Client did not drink/eat all/almost all of food/drink Enteral Tube Feeding CHECK R All that apply or % Weigh client once over the eight (8) day period (bath day)

Skin conditions Itchiness Rash Bruises Skin tears/cuts Scrapes Open sores Burns R All that apply & describe in comment section

Reminders Accurately record observations, assistance, & care provided Report any sudden changes &/or concerns Record your time spent with the client Round time off to the nearest increment of 10 minutes Add up minutes at the end of your shift before rounding off Sign your initials at the end of your shift Add any comments regarding any unusual event(s) – be sure to document the date & time it happened