Form Cms-806a - Quality Of Life Assessment - Resident Interview Page 3
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4RESIDENT INTERVIEW
6. STAFF: (F223, 241)
Has any resident or staff member ever physically
Tell me how you feel about the staff members at this
harmed you?
facility. Do they treat you with respect?
Has any resident or staff member ever taken anything
Do you feel they know something about you as a person?
belonging to you without permission?
Are they usually willing to take the time to listen when
(If yes) Can you tell me who did this?
you want to talk about something personal or a
Has a staff member ever yelled or sworn at you?
problem you are having?
(If yes) Please describe what happened.
Do they make efforts to resolve your problems?
Can you tell me who did this? Did you report this to
someone?
(If yes) How did they respond?
7. ADLs: (F216, 311, 312)
Do you feel that you get help when you need it?
(Tailor this question to what you have observed and what is
Do staff encourage you to do as much as you can for
noted in the MDS about ADL capabilities of this resi-
yourself?
dent.) For example: I see that your care plan calls for
you to dress with a little help from staff. How is that
working for you?
8. DECISIONS: (F154, 242, 280)
If you are unhappy with something, or if you want to
Here at this facility, are you involved in making choices
change something about your care or your daily
about your daily activities?
schedule, how do you let the facility know?
Are you involved in making decisions about your nursing
Do you feel the staff members listen to your requests
care and medical treatment?
and respond appropriately?
(If not, probe to determine what these choices and decisions
If the staff are unable to accommodate one of your
are, and relate this information to necessary restrictions
requests, do they provide a reasonable explanation of
that are part of the resident's plan of care.)
why they cannot honor the request?
Do you participate in meetings where staff plan your
Can you choose how you spend the day?
activities and daily medical and nursing care?
Have you ever refused care or treatment (such as a bath
or certain medication)?
(If yes) What happened then?
Form CMS-806A (07/95)
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