Data Collection Instruments

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Improving Quality of Care in Long-Term Care

Data Collection Instruments

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Appendix A
Data Collection Instruments

Implementing a Program to Prevent Injurious Falls in Assisted Living
List of Research Measures with Administration Time by Type of Respondent
Respondent: Research
staff only

Measures

Facility
Facility
Physician
staff
resident
Time to administer (minutes)
15

A. Facility Information

(administrator)

B. Resident Interview
Mini Mental Status Exam

Demographic and medical information

5-10

Geriatric Depression Scale (5 or 15 item)

Symbol Digit Modalities Test

C. Staff Interview
Resident Functional and Medical Status

3 (DCG)*

Resident Cognitive status: MDS-COGS

5 (DCG)*

Staff Demographics

2 (DCG)*

D. Chart Abstract
Medical history (chart review)

Current medications

9
9

Falls history (chart, report review)
E. Resident Physical Assessment
Assistive devices

Balance:
Activity Specific Confidence Scale (ABC)
balance self-confidence
Standing Balance tests

Dynamic balance tests

2
2

Lower extremity impairment:
10-Foot Walk Test

Timed chair rise

3 minute walk

Additional physical assessment measures:
Grip strength
Timed up and go test
F. Physician Interview
*DCG = Direct caregiver

1
1.5
15

PHYSICIAN QUESTIONNAIRE
THIS PROTOCOL WILL BE ADMINISTERED TO ALL PHYSICIANS WHO HAVE PATIENTS WHO RESIDE
IN THE STUDY SITES. IT WILL BE ADMINISTERED IN-PERSON, AT BASELINE AND ONE YEAR.

This interview is part of a project in several assisted living facilities, in which we are seeking to learn
about the prevention and management of falls in this population. The interview itself is to learn from
physicians who work in assisted living facilities about the issue. There are not right or wrong answers to
this survey; it is designed to identify how the physician fits into the overall picture of falls management,
and what physicians think about the topic. The interview will last between 20 minutes and half an hour.
It will ask questions about yourself, your practice, what you think about risk factors for falls, screening
for falls, and treatment of patients who fall. We very much appreciate your participation and, if you are
interested, will provide you with a report of the project when it is completed.
To begin, I’d like to get some information about you and your practice, so we can describe the
participants in this project. .
DEMOGRAPHICS
1. What type of medical degree do you have?

( ) MD

( ) DO

2a. What is your specialty? ( ) FP ( ) IM ( ) IM subspecialty (name): ________________________
2b. Do you have the Certificate of Special Competency in Geriatric Medicine from the American
Board of Internal Medicine or the American Board of Family Medicine?
( ) yes ( ) no
2c. Have you been certified by the American Medical Directors Association (AMDA)?
( ) yes ( ) no
3. Did you attend a US medical school? ( ) US

( ) Non-US

4. In what year did you graduate? 19 ___ ___
5. Gender (do not ask): ( ) Male ( ) Female
6. In what year were you born? 19 ___ ___
7. Are you:

( ) Hispanic or Latino ( ) Not Hispanic or Latino

8. Are you?

( ) American Indian/Alaska Native
( ) Asian
( ) White ( ) Black or African American
( ) Native Hawaiian or other Pacific Islander ( ) Other _____________

For the following questions, please estimate what percent of your overall patients—not just those in
assisted living -- are ….
9. Patients over age 65

______ %

10. Patients residing in nursing homes

______ %

11. Patients who are Medicare beneficiaries

______ %

12. Patients who are Medicaid recipients

______ %

13. Patients whose racial/ethnic background is non-white ______ %
14. Patients residing in assisted living facilities

______ %

KNOWLEDGE ABOUT FALLS PREVENTION
A. Please consider the following with regard to their importance in an assessment of falls risk among
older adult patients who live in assisted living facilities.
I will say a word or several words – such as “number of medications” – and you will state whether it is
not at all important, a little important, moderately important, important, or very important as a
consideration in falls risk assessment.
How important is … in falls
Not at all
risk assessment?
important
1. Number of medications a
1
patient is taking
Whether or not the patient is on …
2. an antipsychotic
1
medication
3. an antianxiety medication
1
4. an antidepressant
1
5. a sleeping pill or other
1
hypnotic
Whether or not the patient has….
6. Diabetes mellitus
1
7. Urinary incontinence
1
8. Parkinson’s disease
1
9. Arthritis
1
10. Depressive symptoms
1
11. Confusion
1
12. Cognitive problems
1
13. Vision problems
1

A little
important
2

Moderately
important
3

Very
Important
4

Extremely
Important
5

2
2
2

3
3
3

4
4
4

5
5
5

2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5

3
3
3
3

4
4
4
4

5
5
5
5

Whether or not the patient has a history of…..
14. Stroke
15. Myocardial infarction
16. Falls
17. Fractures

1
1
1
1

2
2
2
2

B. Please consider the following activities as a potential strategy for reducing the risk of falls among
older adults patients who live in assisted living facilities.
I will say a word or several words – such as “cardiovascular disorder treatment” – and will ask you to
state how important it is that it should be considered as a strategy for reducing the risk of falls.
The response options are the same as before.
How important is it that …
should be considered as a
strategy for reducing the risk of
falls in assisted living patients?
1. Gait, balance and exercise for
moderate risk patients
2. Medication modification
3. Postural hypotension
treatment
4. Environmental hazard
modification
5. Cardiovascular disorder
treatment
6. Physical therapy for moderate
risk patients

Not at all
important

A little
important

Moderately
important

Highly
Important

Very
Highly
Important

1
1

2
2

3
3

4
4

5
5

IMPORTANCE OF FALLS PREVENTION
To what extent to you consider the following statements false or true, using the responses completely
false, mostly false, somewhat false, somewhat true, mostly true, or completely true.
To what extent is it true that …

Completely
false

Mostly
false

Somewhat
false

Somewhat Mostly
true
true

Completely
true

1. My patients in assisted
living facilities are concerned
about falls and preventing
falls.
2. I believe that falls are a big
problem for elderly patients in
assisted living facilities.
3. My patients in assisted
living facilities have so many
other medical problems that
falls prevention seems less
important.
4. Physicians are paid to
diagnose and treat medical
problems rather than assess the
risk of falls among their
patients in assisted living
facilities.
5. The quality of patient care
will be severely compromised
if a physician is oblivious to
the need to assess and manage
the risk of falls among elderly
patients in assisted living
facilities.
6. Responsibility lies with the
primary care physician to alert
and educate the assisted living
facility and staff about a
patient’s risk for falls and what
can be done to reduce this risk.
7. Responsibility lies with the
assisted living facility and its
staff to identify a patient’s risk
for falls and what should be
done to reduce this risk.

SELF-EFFICACY REGARDING ABILITY TO PREVENT FALLS IN PATIENTS
How do you rate your comfort or skill in the following areas – poor, fair, good, or excellent?

1. Assessment of falls risk in a new admission to a longterm care facility.
2. Assessment of an elderly patient who has fallen.
3. Assessment of an elderly patient who has had multiple
falls.
4. Medications for a given condition that are most likely
to increase the risk of falls.
5. Medications for a given condition that are least likely
to increase the risk of falls.
6. When to order physical therapy or physical exercise to
reduce the risk of falls.
7. Conditions to be fulfilled for a physical therapist to be
reimbursed for falls-related care in a patient residing in
an assisted living facility.
8. Your familiarity with the literature on steps that
assisted living facilities can take to reduce the risk of
falls.

Poor

Fair

Good

Excellent

1
1

2
2

3
3

4
4

BELIEF IN OTHER’S ABILITY TO PREVENT FALLS
For the following questions, please consider the role of others (staff at assisted living facilities,
physical therapists, the patient himself/herself) in efforts to prevent falls among your patients
residing in assisted living facilities.
I will make a statement and you will use the false through true categories that we used earlier -completely false, mostly false, somewhat false, somewhat true, mostly true, or completely true.
To what extent is it true that …
1. High staff turnover in
assisted living facilities
hampers falls prevention
efforts.
2. The assisted living facilities
where I see patients are
familiar with ways to prevent
falls among elderly residents.
3. The staff at assisted living
facilities do not have sufficient
time to implement falls
prevention programs.
4. The assisted living facilities
where I see patients have the
ability to implement a falls
prevention program.
5. The assisted living facility –
its leadership, management
and staff – has primary
responsibility for assessing the
risk and preventing falls
among their elderly residents.
6. It is unrealistic to expect
staff at assisted living facilities
to learn how to prevent falls
among the elderly residents.
7. Assisted living staff are
often unfairly blamed for falls
among the elderly residents.
8. I do not know whose
responsibility it is to assess the
risk for falls among my elderly
patients in assisted living
facilities.

Completely
false
1

Mostly
false
2

Somewhat
false
3

Somewhat Mostly Completely
true
true
true
4
5
6

OUTCOME EXPECTATIONS
For the following activities, please consider their potential effectiveness in reducing falls among
elderly patients residing in assisted living facilities.
The response options are not at all effective, a little effective, moderately effective, effective, and very
effective.
How effective do you think … is in
reducing falls among assisted living
patients?
1. Comprehensive review of all
medications for potential adverse
side effects
2. Physical therapy for patients at
moderate falls risk
3. Physical exercise for patients at
moderate falls risk
4. Thorough baseline assessment of
residents for the risk for falls
5. Teaching assisted living facility
staff how to assess the risk of falls
6. Teaching assisted living facility
staff how to manage the risk of falls
7. Involving management at the
highest levels of an assisted living
facility in efforts to reduce falls
8. Targeting efforts on high risk
residents

Not at all
effective

A little
effective

Moderately
effective

Highly
Effective

Very
Highly
Effective
5

NEED MORE INFORMATION ABOUT PREVENTING FALLS
The following question asks about your own priorities in terms of continuing education or additional
independent learning.
Please rate the following topics in terms of your own need for or interest in additional information or
training as not at all a priority, a low priority, a moderate priority, a high priority, or a very high priority.
To what extent is information about … your
priority for additional information?
1. Coding and billing for assisted living visits
2. Coding and billing office visits
3. Assessment and management of dementia
4. Assessment, prevention and management
of falls
5. Assessment, prevention and management
of incontinence
6. Medications that should either not be
prescribed or prescribed with caution in older
people
7. The role of physical therapy in reducing
the risk for falls among elderly patients
8. The role of physical exercise in reducing
the risk for falls among elderly patients

Not at
all a
priority
1
1
1
1

A low
priority

A high
priority

2
2
2
2

A
moderate
priority
3
3
3
3

4
4
4
4

A very
high
priority
5
5
5
5

Resident Name: ___________________________
(Black out after completion, ID check)

Collaborative Studies of Long-Term Care:
Falls Prevention Program in Assisted Living
E. Physical Assessments
(PHY)
3-2-2007

Facility ID:

Resident ID:

Interviewer ID:
Date
completed:
M

Developed / adapted for the Collaborative Studies of Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Do not use without permission

BLANK

I. Assistive Devices
Now I would like to ask you a few questions about any assistive devices you use to help
you walk.
1a. Over the past 7 days, have you used an assistive device, like a cane or a walker, to walk or move from
place to place?

0 No

1 Yes 7 Don’t know

1b. What types of assistive device(s) have you used over the past 7 days?

If yes, where do you usually use this device?
1. Walker

0 No

1 Yes

2. Hemi-walker

0 No

1 Yes

3. Broad quad cane

0 No

1 Yes

4. Narrow quad cane

0 No

1 Yes

5. Cane

0 No

1 Yes

6. Crutches

0 No

1 Yes

7. Wheelchair

0 No

1 Yes

8. Motorized skooter

0 No

1 Yes

0 No

1 Yes

9. Other device, specify:
__________________________

1c. If “yes” to any of the above devices, which one do you use most often: _______________

1d. Do you use furniture in your living area to help you walk from one location to another?

0 No

1 Yes

2. Do you spend all or most of the day in a chair because of a health or physical condition?

0 No

1 Yes
3

II. Readiness for Testing
Before we ask you to complete several everyday activities such as rising from a chair
and walking, I would like to take your blood pressure and ask you a few questions about
how you feel today .

BP: ___ ___ ___ Systolic ___ ___ ___Diastolic

Do you have ANY pain today?

0 No

1 Yes

2a. If yes, is this usual for you?

0 No

1 Yes

If yes, where:___________________

Have you had any dizziness today?

0 No

1 Yes

Have you had any headaches today?

0 No

1 Yes

Have you had any recent surgical or medical procedures?

0 No

1 Yes

III. Standing Balance Assessment
Instructions: Participants should wear shoes with no or low heels. After giving instructions to
the resident, demonstrate each position. Stress that if the resident feels it would be unsafe to try,
he/she should not attempt to do it. If the activity is not being done properly, demonstrate it again
and repeat instructions, but do not give more trials if the resident fails. Stand next to the
participant to guard for balance loss. Assistive devices are NOT allowed.
Administer these tests next to a chair or table for support. The participant may use support of the
chair/table to assume the position. As soon as the support is released start timing. Stop after 10
seconds or when the participant moves a foot or grabs for support (table, chair etc). Record the
time to the nearest tenth second.
Use the following codes for all balance assessments (Sections II. & III.):
93:
94:
95:
96:
98:

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

Participant Instructions:
This test will assess your standing balance I would like you to try to stand in
different positions. First I will show you each movement then I want you to try it.
If you feel unsafe please tell me. Do you have any questions before we begin?

1. Semi-tandem stand
Instructions:
I would like you to stand with the side of the heel of one foot
touching the side of your other foot. Please watch while I demonstrate. You
may use your arms, or move your body to maintain your balance, but try not to
move your feet. Hold this position until I say stop.

If the participant DID NOT hold the semi-tandem position for 10 seconds go on to test the
side-by-side stand. If the participant was successful (held for 10 seconds), test full tandem
stand and single leg stand.

1. Semi-tandem stand: ____ ____ .____seconds

2. Side by side stand
Instructions:
I would like you to stand with your feet together. Please watch while I
demonstrate. You may use your arms, or move your body to maintain your
balance, but try not to move your feet. Hold this position until I say stop.

2. Side by side stand: ____ ____ .____seconds

3. Full tandem stand
Instructions:
I would like you to stand with the heel of one foot in front of and touching the
toes of your other foot. Please watch while I demonstrate. You may use your
arms, or move your body to maintain your balance, but try not to move your
feet. Hold this position until I say stop.

3. Full tandem stand: ____ ____ .____seconds

4. Single Leg Stand
Instructions:
I want you to stand on one leg. You may choose which foot you stand on.
Watch while I demonstrate. You may not touch your free leg to the standing
leg. Try not to put your foot on the floor. Do you have any questions? When
you are ready, pick up one of your feet from the floor and hold it until I say
stop.

____ ____ .____seconds

III. Dynamic Balance Tests
1. PICK UP PENCIL
Place a pencil on the floor approximately 12 inches in front of the resident’s dominant foot.
Time from the command “go” until the resident is standing erect with the pencil in hand.

Resident Instructions:
When I say, “go”, I want you to bend over pick up the pencil from the floor and
stand back up. Watch me as I demonstrate”. Demonstrate. “ Are you ready? Go”.
Time from the command “go” until the resident is standing erect with the pencil
in hand.
Use the following codes for Section III.1 & 2.:

993:
994:
995:
996:
998:

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

1. Time to complete:

____ ____ ____ .____seconds

2. 360o TURN
• Place a piece of masking tape on the floor to mark a starting position.
• The resident stands with arms at his/her side and feet comfortably apart and pointing straight ahead

at the tape.
• Start timing from the word Go and stop when the resident’s shoulders are square facing you again.

Record the time to complete the turn to a tenth of a sec.
• Have the resident do two trials. The resident will complete two trials one to the left and one to the

right.

Resident Instructions:
When I say go, I want you to turn around at your normal pace making sure to go in a
complete circle and take steps as you turn. Make sure you end up facing me. I’ll show
you. (demonstrate the turn).
We’ll do two trials one to the left and one to the right. First you will turn to your right.
When I say 'go' start turning. Ready, go. Guard the resident for balance loss.

2. Time to complete:

2a. Right ____ ____ ____ .____seconds

2b. Left ____ ____ ____ .____seconds
7

IV. 10-Foot Walk Test
If the participant usually walks with an assistive device, they should use it for the test.
• Measure out 10 feet on the floor and mark these lines with masking tape. This is the walking path

for timing walking speed.
• Measure and mark 3 feet before and after the walking path lines. These are the start and finish lines.
• Have the participant stand at the start line.
• Instruct the participant to walk to the finish line (the line 3 feet past the end of the walking path).
• Walk with the participant (slightly behind and to the side). Begin timing when the participant's foot

crosses the line at the beginning of the 10 foot path and stop the watch when the foot first crosses
the ending path line.
• Record the time to tenths of a second
• Complete two trials

1. Comfortable Walking Pace (2 trials).
Resident Instructions:
I want you to walk from here to ______ (give destination past the finish line) at your
normal comfortable pace when I say, "go". Keep walking until I say stop.
Ready, go.

Be sure to say "Ready, go" in a neutral tone of voice so that the participant does not
feel like it is a race.
Use the following codes for Section IV:

993:
994:
995:
996:
998:

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

1.a. Trial 1: ____ ____ ____. ____
1.b. Trial : ____ ____ ____. ____

V. Timed Chair Rise
1. Single chair rise
Have the participant sit erect in a standard height chair with the chair back against the wall.
Ask the participant to fold both arms across his or her chest.
Instruct the participant to stand up one time without using arms. Record whether or not he
was able to do this. If the participant was NOT able to get up with arms folded, do not test
the repeated chair rise.

When I say go, I want you to stand up without using your arms.
Demonstrate.
1. Completed chair rise:

0 No

1 Yes

2. Repeated chair rise.
If the participant was successful with the single chair rise, test the repeated chair rises and
time to tenth of a second.

When I say go, I want you to stand up and sit down as quickly as you can
until I tell you to stop.
Demonstrate.
Start timing from the command “go” until the participant is in the final seated position for the
fifth chair rise. Record the time it takes the resident to complete the task and the number of
complete chair rise repetitions (0-5)

2a. Time to complete repeated
chair rise:

____ __ __ ____ .____seconds

Use the following codes for Section V, 2a.:

993:
994:
995:
996:
998:

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

2b. Number completed:
Use the following codes for Section V, 2b.:

93:
94:
95:
96:
98:

____ ____ completed

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused
9

VI. 3-minute Walk
During this test, residents are asked to walk a predetermined course at a comfortable, selfselected pace, using whatever assistive device is normally used by the resident. The resident is
allowed to rest but the clock continues running during any rest stops. Measure the walking path
you will ask the resident to take in 20-50 foot increments. Be sure there are chairs place
strategically for the resident to rest, if necessary.
Resident Instructions:
I want you to walk from here to ______ at your normal comfortable pace when I
say, "go". Keep walking until I say stop. Ready, go.

Use the following codes for Section VI1.:

993:
994:
995:
996:
998:

___ ___ ___feet

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

Use the following codes for Section VI.2.:

93:
94:
95:
96:
98:

1. Distance covered:

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

2. Number of stops: ___ ___ stops

VII. Grip Strength
Have the participant sitting at a table in a straight back chair, with hips all the way at the back of the
chair. Hand not being tested should rest in lap. The participant’s forearm (dominant hand) should be
resting on top of the table with the elbow at the edge. The forearm should be in neutral rotation, elbow
flexed, and shoulder slightly flexed. Position the dynamometer grip at Position 2 (marked). Hand the
participant the dynamometer. The tester will hold the dynamometer to help stabilize it in a vertical
position.
Resident Instructions:
This is a test of your grip strength. Grip strength gives us an indication of how
strong the other muscles in your body are.
I want you to squeeze this device as hard as you can for 3 seconds. The
dynamometer won’t move when you squeeze it. You will do three trials. Between
each trial you will rest for 30 seconds. Are you ready? Squeeze.
Count to 3 as the participant squeezes the dynamometer.
Allow 30 seconds of rest between each trial so the muscles do not fatigue.
Record scores in pounds.

Use the following codes for Section VII:

93:
94:
95:
96:
98:

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

1. Number of pounds:

Trial 1: _____ _____ pounds
Trial 1: _____ _____ pounds
Trial 1: _____ _____ pounds

VIII. Timed "UP & GO" Test
The TUG test, measured in seconds, is the time taken by an individual to stand up from a standard chair
(approximate seat height of 46 cm, arm height 65 cm), walk a distance of 3 meters (approximately 10 feet),
turn, walk back to the chair, and sit down again. The subject wears his/her regular footwear and uses his
customary walking aid (none, cane, or walker). No physical assistance is given.
Administration:
Participants start with their back against the chair, their arms resting on the arm rests, and their walking
aid at hand if needed.
Resident Instruction:
When I say go please stand up and walk as quickly and as safely as possible
cross the line on the floor, turn around, walk back and sit in the chair.
Practice: Have the participant walk through the test once for practice before being timed in order to
become familiar with the test.
Use a stop-watch to time the performance and watch closely for balance problems. Residents may have
particular problems getting up out of the chair and turning around.
Record:
Start timing from the go command and end when the resident sits in the seat of the chair.
Time in seconds to tenths of a second.
Use the following codes for Section 8 :

993:
994:
995:
996:
998:

Attempted but unable
Interviewer felt unsafe
Resident felt unsafe
Resident unable
Refused

1. Walking speed ___ ___ ____. ___seconds

Resident Name: ___________________________
(Black out or erase after completion, ID check)

Collaborative Studies of Long-Term Care:
Falls Prevention Program in Assisted Living
D. Chart Abstract
(ABS)
3-2-2007

Facility ID:

Resident ID:

Interviewer ID:
Date
completed:
M

Developed / adapted for the Collaborative Studies of Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Do not use without permission

I. Resident Demographic and Medical History

1. Date resident admitted to facility?

2. Resident date of birth?

____ ____

____ ____ ____ ____

Month

Day

Year

____ ____

____ ____ ____ ____

Month

Day

Year

II. Medication Use
Record all medications administered in the last week. Photocopy chart, if possible, and staple to this form.
Medication #

Medication Name

Dose

Administration
If given regularly,
# times/day

0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

If PRN, # of
times/past week

III. Comorbid Conditions
Check thoroughly through chart for any of the following conditions, past or present. Note any confusing or very
specific language.

Yes

Heart disease

High blood pressure

Chronic lung disease

Stroke

Yes

4a. If yes, year of last stroke ___ ___ ___ ___
5.
6.

Mini-stroke

Depression

Orthostatic hypotension

Chronic back pain

10. Cancer, other than skin cancer

11. Diabetes

12. Arthritis, or other musculoskeletal disorders

14. Parkinson’s disease

15. Altered mobility or gait

16. Visual impairment

17. Hearing impairment

18. Dizziness

19. Dehydration

20. Blackouts

21. Seizures

22. Headaches

13.

Dementia or Alzheimer’s Disease (includes Vascular, Binswanger’s disease,
Pick’s disease, Lewy Body disease, Creutzfeldt-Jakob disease, Huntington’s Chorea,
Alcoholic dementia, Organic Brain Syndrome, Chronic Confusion, Senile Dementia)

IV. Other Medical Diagnoses
Record any other medical diagnoses listed in medical records, past or present. Photocopy chart, if possible, and
staple to this form.

Diagnosis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

V. Falls and Fracture History
Carefully check the resident’s chart for the following falls information.
1. List dates of all falls in the last year. Describe fall and any injury that occurred as a result of the fall.
Date
[mm/dd/yyyy]

Description of fall, location, circumstances, and resulting injury and
treatment.

2. Has the resident:

Yes

Date (if indicated)

a. Had a hip fracture in the last 6 months?

b. Ever had a hip fracture?

__ __/__ __ /__ __ __ __

c. Had any other fracture in last 6 months?
Describe:

__ __/__ __ /__ __ __ __

VI. Assistive devices
1. Does this resident use any of the following:
1. Walker

0 No

1 Yes

2. Hemi-walker

0 No

1 Yes

3. Broad quad cane

0 No

1 Yes

4. Narrow quad cane

0 No

1 Yes

5. Cane

0 No

1 Yes

6. Crutches

0 No

1 Yes

7. Wheelchair

0 No

1 Yes

8. Motorized skooter

0 No

1 Yes

9. Other device, specify:

0 No

1 Yes

1. Catheter stand

0 No

1 Yes

2. Oxygen

0 No

1 Yes

3. Other attached device, specify:

0 No

1 Yes

__________________________

VII. Attachment of equipment
1. Does this resident use any of the following:

____________________________

VIII. Physician Contact Information
Physician contact information
1. Last name:
2. First name:
3. Degree
4. Mailing address:
a.Street 1:
b. Street 2:
c. Other:

5. City/state/zip:

City __________________________State: ___ ___ Zip ___ ___ ___ ___ ___

6. Phone:

(___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

7. Fax

(___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Resident Name: __________________________
Staff Name:________________________
(Black out after completion, ID check)

Collaborative Studies of Long-Term Care:
Collaborative Studies of Long-Term Care:
Falls Prevention Program in Assisted Living
Screening for Mental Well-Being
inC.
Assisted
Living
Staff Interview
(STF)
B. Staff Interview
3-2-2007
(STF)

Facility ID:

Resident ID:

Staff ID:

Interviewer ID:
Date
completed:
M

Developed / adapted for the Collaborative Studies of Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Do not use without permission

I. Physical Activities of Daily Living (MDS-ADL)

These first questions address activities of daily living. I’ll be asking about resident’s
level of performance over the last seven days, and here are the answer categories I’d
like you to use. Show Cue Card C.

0 = INDEPENDENT
No help or oversight-OR-Help/oversight provided only 1 or 2 times during last 7 days.
1 = SUPERVISION
Oversight, encouragement or cueing provided 3 or more times during last 7 days-OR-Supervision
plus physical assistance provided only 1 or 2 times during last 7 days.

2 = LIMITED ASSISTANCE
Resident highly involved in activity; received physical help in guided maneuvering of limbs, or
other non-weight-bearing assistance 3 or more times-OR-More help provided only 1 or 2 times
during last 7 days.

3 = EXTENSIVE ASSISTANCE
While resident performed part of activity, over last 7-day period, help of following type(s)
provided 3 or more times:

• Weight-bearing support
• Full staff performance during part (but not all) of last 7 days
4 = TOTAL DEPENDENCE
Full staff performance of activity during ENTIRE 7 days.
8 = ACTIVITY DID NOT OCCUR during entire 7 days.

1. Over the last seven days, what has resident’s level of performance been for the following activities (not
including set-up)? Read item, then ask: for this activity, would you say that resident has been Independent, or
has he/she required Supervision, Limited Assistance, Extensive Assistance, or has he/she been Totally
Dependent, or has the activity not occurred over the last seven days?
Independent Supervision

a. Bed Mobility: How he/she moves to and from
lying position, turns side to side, and positions
body while in bed.

Limited Extensive
Total
Assistance Assistance Dependence

Did not
Occur

d. Dressing: How he/she puts on, fastens, and takes
off all items of street clothing, including
donning/removing prosthesis.

e. Eating: How he/she eats and drinks (regardless
of skill).

f. Toilet Use: How he/she uses the toilet room (or
commode, bedpan, urinal): transfers on/off
toilet, cleanses, changes pad, manages ostomy or
catheter, adjusts clothes.

g. Personal Hygiene: How he/she maintains
personal hygiene, including combing hair,
brushing teeth, shaving, applying makeup,
washing/drying face, hands, and perineum
(EXCLUDE baths and showers).

b. Transfer: How he/she moves between surfaces to/from bed, chair, wheelchair, standing position
(EXCLUDE to/from bath/toilet).
c. Locomotion on Unit: How he/she moves
between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, selfsufficiency once in chair.

2. Over the last seven days, how has resident taken a full-body bath/shower, sponge bath, and/or transferred
in/out of tub/shower? (EXCLUDE washing of back and hair; code for most dependent.)

Independent-no help provided

Supervision-oversight help only

Physical help limited to transfer only

Physical help in part of bathing activity

Total dependence

Activity itself did not occur during entire 7 days

3. During the last seven days, was resident chairfast all or most of the time?

0 No 1 Yes

4. During the last seven days, was resident bedfast all or most of the time?

0 No 1 Yes

5. How would you describe resident’s bladder continence in the past two weeks?

Continent: complete control

Usually continent: incontinent episodes once a week or less

Occasionally incontinent: two or more times a week, but not daily

Frequently incontinent: tended to be incontinent daily but some control present
(e.g., on day shift)

Incontinent: had inadequate control; multiple daily episodes

6. How would you describe resident’s bowel

continence in the past two weeks?

0
1
2

Continent: complete control

Frequently incontinent: tended to be incontinent daily but some control present (e.g.,
on day shift)

Incontinent: had inadequate control; multiple daily episodes

Usually continent: incontinent episodes once a week or less
Occasionally incontinent: two or more times a week, but not daily

7. Is this resident able to go to the bathroom alone or does the resident need
assistance?
8. Over the past 7 days has this resident used an assistive device, like a cane or
a walker, to walk or move from place to place?

0 No 1 Yes
0 No 1 Yes

8b. What types of assistive device(s) were used over the past 7 days?

1. Walker

0 No

1 Yes

2. Hemi-walker

0 No

1 Yes

3. Broad quad cane

0 No

1 Yes

4. Narrow quad cane

0 No

1 Yes

5. Cane

0 No

1 Yes

6. Crutches

0 No

1 Yes

7. Wheelchair

0 No

1 Yes

8. Motorized skooter

0 No

9. Other device

0 No

1 Yes
1 Yes

II. Depressive Symptoms
A. Do you believe [resident name] is often sad or depressed?

0 No 1 Yes

B. Cornell [only ask if resident has cognitive impairment]

During the LAST SEVEN DAYS did you notice that [resident’s name]:
Unable to
None Mild Severe Evaluate
1. Was anxious, or had an anxious expression, or has been worrying
constantly?

2. Had a sad expression, a sad voice or has been tearful?

3. Lacked reactivity to pleasant events?

4. Was easily annoyed, short tempered or irritable?

5. Seemed restless, or wrung his/her hands, or pulled his/her hair or
otherwise agitated?

6. Had slow movements, or slow speech or slow reactions?

7. Had many physical complaints? (Score 0 if intestinal complaints only)

8. Seemed less interested in his/her usual activities than he/she did in the last
month?

9. Was eating less than usual?

10. Lost weight? (Score 2 if >5 lbs. in one month)

11. Lacked energy or got tired more easily than he/she did in the last
month?

12. Had lower mood or seemed sadder in the morning on most days?

13. Had difficulty falling asleep?

14. Woke up many times during the night?

15. Woke up earlier than usual?

16. Said that life is not worth living, or had suicidal wishes or had an attempt at
suicide?

17. Blamed him/herself unnecessarily, or had feelings of failure or poor selfworth?

18. Expected the worst?

19. Expressed beliefs about his/her financial situation, or physical illness or
losses that were untrue?

III. MDS-COGS
1. Over the last seven days, was this resident comatose or in a persistent vegetative state with no discernable
consciousness? (Check one)

No; resident was NOT comatose or in a persistent vegetative state

Yes; resident was comatose or in a persistent vegetative state

2. Over the last seven days, how would you describe this resident’s:
a. short-term memory? How well does the resident recall
information after 5 minutes? (Check one)

0 Memory Okay

1 Memory Problem

b. long-term memory? How well does the resident recall
information that has long past? (Check one)

0 Memory Okay

1 Memory Problem

3. Over the last seven days, could this resident recall the following items? (Check one for each item)
a. Current season

1 Can Recall

0 Cannot Recall

b. Location of own room

1 Can Recall

0 Cannot Recall

c. Staff names/faces

1 Can Recall

0 Cannot Recall

d. That he/she is in an assisted living facility

1 Can Recall

0 Cannot Recall

4. How would you describe this resident’s cognitive skills for daily decision-making? (Check one)

0
1
2
3

Independent – decisions are consistent and reasonable
Modified Independence – some difficulty in new situations only
Moderately Impaired – decision poor; cues/supervision required
Severely Impaired – never/rarely made decisions

5. How would you describe this resident’s ability to make himself/herself understood or express information,
however he/she is able? (Check one)

0
1
2
3

Understood
Usually understood – difficulty finding words or finishing thoughts
Sometimes understood – ability is limited to making concrete requests
Rarely/never understood

6. How would you describe this resident’s ability to understand others’ verbal information content, however
he/she might be able? (Check one)

0
1
2
3
6

Understood
Usually understands – may miss some part/intent of message
Sometimes understands – responds adequately to simple direct communication
Rarely/never understands

7. On a scale of 1 to 4, where 1 is “not very well at all” and 4 is “very well”, how well would you say you know
about this resident’s health and function? (Check one)

Not very well at all

Fairly well

Pretty well

Very well

IV. Relationship History
1. How long have you known this resident, both before and after
they came to live at the facility?

___ ___
Years

2. How long have you provided cared for this resident? [Note: only
report days if respondent has known resident less than 1
month]

___ ___

Months

___ ___
Years

___ ___

Days

___ ___

Months

Days

V. Staff Information
1. What is your job title at this facility?

_________________________________

2. How long have you been in this current position?

___ ___ years ___ ___months

3. How long have you worked at this facility?

___ ___ years ___ ___months

4. What is your highest level of education completed?

1 Junior High or Middle School
2 Some high school
3 High school grad or GED
3 2-year college or associate’s degree
4 Some college (no degree)
5 4-year college degree or higher

5a. Which of the following certifications or licensures do you hold?
Check all that apply:
1. RN

0 No 1 Yes

2. LPN

0 No 1 Yes

3. CNA or Certified Personal Care Assistant

0 No 1 Yes

4. Medication assistant

0 No 1 Yes
7

6. What is your sex? [DO NOT ASK]

7. What year were you born?

8. Is English your first language?

1 Male

Female

___ ___ ___ ___
0 No 1 Yes
If NO, what is:____________________]

9. What of the following best describes your race?
[check one]

1 American Indian or Alaska Native
2 Asian or Pacific Islander
3 Black or African American
4 White
5 Other

10. Are you Latina or Latino?

0 No 1 Yes

Do not ask the following item. This is meant to capture the interviewer’s own perspective.
1. Overall, how confident are you about the accuracy of
the respondent’s replies?

1 = Not at all confident
2 = A little confident
3 = Quite confident
4 = Very confident

Resident Name: ____________________________________
(Black out or erase after completion, ID check)

Collaborative Studies of Long-Term Care:
Falls Prevention Program in Assisted Living
B. Resident Interview
(RES)
3-2-2007

Date
completed:
M

Facility
ID:
Resident
ID:
Interviewer
ID:

Developed / adapted for the Collaborative Studies of Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Do not use without permission

I. Mini-Mental State Exam
Now I would like to ask you some questions that use your memory and
concentration. Please listen carefully until I have finished reading the each
question before you respond. Please try to answer each question even if you are
not sure of your answer. Do you have any questions?
(Use the following codes for the remaining
questions)

1=Correct response
0=Incorrect response
6=Can’t do (physically unable)
8=Refused (won’t answer/attempt

Record Answer

Correct

Incorrect

Can’t
do

Refused

1. What is the year?....................................................

________________

2. What is the season?

________________

3. What is the date? ..................................................

________________

4. What is the day of the week?

________________

5. What is the month? ..............................................
6. Can you tell me where we are right now? For
instance, what state are we in?
7. What town/city are we in? .....................................

________________

8. What county are we in?

________________

9. What floor of the building are we on? ...................

________________

10. What is the name of this facility?

________________

11. I am going to name three objects. After I have said
them I want you to repeat them. Remember what they
are, because I am going to ask you to name them again
in a few minutes. Please repeat the three items for me.
“Apple”…”Table”…”Penny”…

Correct

Incorrect

Can’t
do

Refused

A. APPLE:

B. TABLE:

C. PENNY:

(Score first try. Repeat objects until all are learned, up to six
times.)

12. Can you subtract 7 from 100, and then subtract 7 from the answer you get, and
keep subtracting 7 until I tell you to stop?
RECORD NUMBERS:
(93)
(86)
(79)
(72)
(65)

Code number correct
(0-5):

Code if applicable: 6=Can’t do
8=Refused to respond

13. Now I am going to spell a word forwards, and I want you to spell it backwards.
The word is WORLD, W-O-R-L-D. Spell “world” backwards.
(Repeat instructions if necessary, but not after resident begins spelling)
PRINT LETTERS:
(D)

(L)

(R)

(O)

Code number correct
(0-5):

(W)
Code if applicable: 6=Can’t do
8=Refused to respond

Use the following codes for the remaining
questions:

14. Now what were the three objects I asked you to
remember?

1=Correct response
0=Incorrect response
6=Can’t do (physically unable)
8=Refused (won’t answer/attempt

Correct

Incorrect

Can’t
do

Refused

A. APPLE:

B. TABLE:

C. PENNY:

Correct

Incorrect

Can’t
do

Refused

(Show wristwatch)
15. What is this called?

WATCH:

(Show pen)
16. What is this called?

PEN:

17. I’d like you to repeat a phrase after me. Listen carefully until I finish and
repeat this phrase: “No ifs, ands, or buts” (Allow only one trial)

18. Read the words on this card and then do what it says.
(Show resident "Close your eyes" cue card A.)

20. Here is a drawing. Please copy the drawing on the same paper. (Show
next page) (Consider correct if the two 5-sided figures intersect to form a
4-sided figure, and if all angles in the 5-sided figures are preserved.)

21. Write any complete sentence on this piece of paper for me. (Use page _)
(Sentence should have a subject and a verb, and make sense. Spelling
and grammar errors are acceptable.)

(Read full statement and then give resident the paper.)
19. I’m going to give you a piece of paper.
When I do, take the paper in your right hand, fold
the paper in half with both hands, and put the paper
down on your lap. (Do not coach or repeat
instructions.)

A. RIGHT HAND:
B. FOLDS:
C. IN LAP:

II. Demographics
Now, I would like to ask you a few questions about you and your health.
1. What is your highest level of education completed?

1 Junior High or Middle School
2 Some high school
3 High school grad or GED
3 2-year college or associate’s degree
4 Some college (no degree)
5 4-year college degree or higher
1 Junior High or Middle School
2 Some high school

2. What of the following best describes your race? [check one]

1 American Indian or Alaska Native
2 Asian or Pacific Islander
3 Black or African American
4 White
5 Other
77 (Code if respondent says “Don’t Know”)

3. What is your ethnic background?

1 Hispanic
2 Not of Hispanic origin

4. What is your gender? (DO NOT ASK)

1 Male
2

5. What is your marital status?

Female

1 Never Married
2 Married
3 Widowed
4 Separated
5 Divorced
77 (Code if respondent says “Don’t Know”)

III. Medical History
Now I’d like to ask you about your medical history.
1. Have you ever been told by a doctor that you had:

Yes

Heart disease

High blood pressure

Chronic lung disease

Stroke

Yes

4a. If yes, year of last stroke ___ ___ ___ ___
e.
f.

Mini-stroke

Depression

Orthostatic hypotension

Chronic back pain

Cancer, other than skin cancer

Diabetes

Arthritis, or other musculoskeletal disorders

Parkinson’s disease

Altered mobility or gait

Visual impairment

Hearing impairment

Dizziness

Dehydration

Blackouts

Seizures

Headaches

2. Are you able to go to the bathroom alone or do you need assistance?

0 No

1 Yes

IV. Pain

Not at all

A little

Moderately

Quite a bit

Extremely

1a. In general, how much have you been
bothered by pain over the past few weeks?

1b. How much are you bothered by pain right
now?

1c. How much are you bothered by pain when
it is at its worst?

1d. How many days a week does the pain get
really bad?

(Record number from 0 to 7 days.) _______

1e. How much are you bothered by pain when
it is at its least?

1f. How much has the pain interfered with
your day-to-day activities?

2. Today, have you been given medicine for physical pain or discomfort?

Yes

3. Pain Rating Scale

Please look at this line.

(Show Pain Scale.)

This line goes from No Pain at one end to the Worst Pain possible at the other end.
Point to the place on the line that shows how much physical pain or discomfort you have
had in the past week.
(Enter the corresponding number as the score.)

3. Score: ___ ___

(00-10)

V. Self-Rated Health
Now I’d like to ask you about your current health.
1. In general, would you say your health is:

1 Excellent
2 Very Good
3 Good
4 Fair
5 Poor

3., Falls and Fractures
a. In the last 6 months, how many times have you fallen? (If > 0, ask dates):

___ ___

In the last 6 months, have you:

Yes

b. fallen and hurt yourself?

c. needed to see a doctor because of the fall?

d. been afraid that you would fall because of balance or walking problems?

e. fallen and not been able to get up without help?

f. fallen and not been able to get up without help?

g. broken your hip?

h. broken a bone other than your hip?

VI. Depressive Symptoms (5-item GDS)
The next few questions are about how you are feeling.
Choose the best answer for how you felt over the past week.

Yes

1. Are you basically satisfied with your life?

2. Do you often get bored?

3. Do you often feel helpless?

4. Do you prefer to stay home rather than going out and doing new things?

5. Do you feel pretty worthless the way you are now?

VII. Activities-Specific Balance Confidence (ABC) Scale
Interviewer Instructions
Hand the participant the response sheet with the scale on it. It is important that the tester repeats the
sentence stem “How confident are you that you could…without losing your balance or becoming
unsteady” at least every second item.

Participant Instructions:
I will ask you a series of questions about how confident you are with your balance while
performing activities that you may encounter in your daily life. For each of the following
activities, please indicate your level of confidence in doing the activity without losing your
balance or becoming unsteady. Choose a percentage between 0% and 100%. One hundred
percent means you are completely confident.
If you do not currently do the activity in question, try to imagine how confident you would be if
you had to do the activity. If you normally use a walking aid or hold on to someone or
something, rate your confidence as if you were using these supports. If you have any
questions about answering these items, please ask.

Scoring:
Ratings should consist of whole numbers 0-100 for each item. Total the ratings (range 0-1600) and then
divide the number by 16 to get the ABC score.
If the participant qualifies his/her response to items 2, 9, 11, 14, 15 with different ratings for up vs.
down, or onto vs. off, get separate ratings and use the lowest of the two (since this will limit the entire
activity, for instance likelihood of using the stairs).

For each of the following activities, please indicate your level of self-confidence by choosing a
corresponding number from the following rating scale:

0%
10
not
confident

50
60
somewhat
confident

90
100%
completely
confident

How confident are you that you will not lose your balance or become unsteady when you…
%

…walk around the house

...walk up or down stairs?

...bend over and pick up a slipper from front of a closet floor?

…reach for a small can off a shelf at eye level?

...stand on tiptoes and reach for something above your head?

…stand on a chair and reach for something above your head?

...sweep the floor?

...walk outside the house to a car parked in the driveway?

...get into or out of a car?

10 ...walk across a parking lot to the mall?
11 ...walk up or down a ramp?
12 ...walk in a crowded mall where people rapidly walk past you?
13 ...are bumped into by people as you walk through the mall?
14 ...step onto or off of an escalator while you are holding onto a railing?
15 ...step onto or off an escalator while holding onto parcels such that
you cannot hold onto the railing?
16 ...walk outside on icy sidewalks?
Total of responses:
Divide the Total of responses by 16 for the TOTAL SCORE:

VII. Symbol Digit Modalities Test (Oral version)

The next activity measures visual attention and how quickly you process information
Instruction to interviewer: Place the test form in front of the examinee and read the following verbatim.

Please look at these boxes at the top of the page. You can see that each box in the upper
row has a little mark in it. Now look at the boxes in the row just underneath the marks.
Each of the marks in the top row is different, and under each mark in the bottom row is a
different number.
Now look at the next line of boxes (examiner points to the line of boxes) just under the
top two rows. Notice that the boxes on the top have marks, but the boxes underneath are
empty. I want you to tell me what number to fill in each empty box according to the way
they are paired in the key at the top of the page.
PRACTICE:

For example, if you look at the first mark, and then at the key, you will see that the
number 1 goes in the first box. Now, what number should go in the second box? That’s
right. What number goes in the third box? (Number 2) Two, right. That is the idea.
You are to tell me which number to write in each of the empty boxes according to the
key. Now for practice, let’s do the rest of the boxes on the top line until we come to the
double line

Check to see that nature of the test is clearly understood before proceeding. If not, repeat directions with further
examples.

Now, when I say “Go” tell me which numbers to fill in like you have been doing until I
say “Stop”. When you come to the end of the first line, go quickly to the next line
without stopping, and so on. Do not skip any boxes and work as quickly as you can.
Ready? Go.
After 90 seconds say, “STOP”.
SCORING: the number of correct substitutions completed in 90 seconds. Do not include those completed for
practice.

SYMBOL DIGIT MODALITIES TEST

SDMT: ___ ___ ___

Do not ask the following item. This is meant to capture the interviewer’s own perspective.
1. Overall, how confident are you about the accuracy of
the respondent’s replies?

1 = Not at all confident
2 = A little confident
3 = Quite confident
4 = Very confident

Collaborative Studies of Long-Term Care:
Falls Prevention Program in Assisted Living
A. Facility Information
(FAC)
3-2-2007

Facility ID:
Interviewer
ID:

Master Facility
ID:

Date:
M

Developed / adapted for the Collaborative Studies of Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Do not use without permission

I. Facility Characteristics
1.

a. Is your facility’s ownership for profit, non-profit, or
government?

Profit

Non-profit

Government

Yes

1. continuing care retirement community (CCRC)?.

2. hospital?................................................................

3. nursing home?......................................................

4. residential care/assisted living facility?...............

b. Is it affiliated with a religious organization? ...............................................

c. Does the owner of your facility own other facilities? .................................

a. Is your facility owned or operated in association with a (or another):

a. How many years has this facility been in operation? [Round to nearest
whole number. If < one year, record number of months.]

___ ___ Years or ___ ___ Months

b. How many years has your facility been under its current management?

___ ___ Years or ___ ___ Months

a. How many beds does this facility have overall, and how many are occupied
today?

(1) Total

(2) Occupied

___ ___ ___

i. On average, how many admissions do you have per week
___ ___
ii. What is the average monthly rate paid by your private pay assisted living
residents?

___ ___ ___ ___

The next few questions ask for numbers of residents within certain categories. Please provide your
best estimate of these numbers. It is not necessary for you to review records for this information.
5. How many of all of your current residents are....
a. Resident Age Distribution

Number

1. 0 -18 years old

___ ___ ___

2. 19-64 years old

___ ___ ___

3. 65-74 years old

___ ___ ___

4. 75-84 years old

___ ___ ___

5. 85 - 94 years old

___ ___ ___

6. 95 years old and over

___ ___ ___

b. Resident Gender

Male

___ ___ ___

c. Resident Racial Background

1. American Indian or Alaskan Native

___ ___ ___

2. Asian or Pacific Islander

___ ___ ___

3. Black

___ ___ ___

4. White

___ ___ ___

5. Other

___ ___ ___

d. Resident Ethnicity
of Hispanic Origin
e. Incontinent of urine, that is they soak through clothes or underclothes at least twice a week or
more or wear incontinence pads (adult diapers)

___ ___ ___

f. Chairfast during the day; that is, they are confined to a chair all or most of the time because of
health or physical condition. Includes those in a wheelchair, geriatric chair or armchair in the
bedroom.

___ ___ ___

g. Bedfast all or most of the time?

___ ___ ___

h. Mentally retarded or developmentally disabled?

___ ___ ___

i. Use wheelchairs to get around in the facility?

___ ___ ___

j. Have a diagnosis of dementia? Diagnoses include: Alzheimer’s Disease (AD); Senile Dementia;
Senile Dementia of the Alzheimer’s Type (SDAT); Organic Brain Syndrome (OBS); Cerebral
Arteriosclerosis; Multi-Infarct Dementia (MID); Subcortical Dementia; Binswanger’s Disease;
Pick’s Disease; Creutzfeldt-Jakob Disease; Lewy Body Disease; Any other diagnosis that
includes dementia, such as “Alcoholic Dementia” or “Parkinson’s Disease with Dementia”; and
Dementia not otherwise specified.
k. Do not have a diagnosis of dementia, but have short-term memory problems or seem disoriented
all or most of the time? This would include, for example, residents who are not able to remember
things after a short while, residents who have difficulty remembering where their room is, or
difficulty recognizing staff names or faces, and residents who have difficulty organizing their
daily routine.

___ ___ ___

l. Require staff attention because of behavior problems?

___ ___ ___

m. Are currently receiving state financial assistance or Medicaid?

___ ___ ___

II. Facility Staff
The next questions are about the number of paid employees you have on staff. Please be thinking of the
primary position of your staff; even if a paid staff member fulfills more than one role, assign him or her to a
single primary classification. If this is a multi-level facility, only include persons who spend at least one-half of
their work time in the portion of the facility that is participating in this project.
PRESENT TIME
1. How many (1)FULL and (2) PART TIME paid staff are there in each of these positions at THE PRESENT TIME,
not including contract workers and other persons not paid by the facility?
[Ask full and part time for each row before moving onto the next row.]

Total Number Paid Staff Now

Staff Classification

1. Full Time

2. Part Time

a. Administrative Director or Assistant Director
b. Registered Nurses
c. Licensed Practical Nurses or Licensed Vocational Nurses
d. Certified Nursing Assistants or Personal Care Providers

LAST 6 MONTHS
2. How many (1)FULL and (2) PART TIME paid staff persons left this position in the LAST SIX MONTHS, not
including contract workers and other persons not paid by the facility?
[Ask full and part time for each row before moving onto the next row.]

Staff Classification

Total Number Paid Staff Last 6 months

3. Full Time

4. Part Time

a. Administrative Director/Assistant Director
b. Registered Nurses
c. Licensed Practical Nurses or Licensed Vocational Nurses
d. Certified Nursing Assistants or Personal Care Providers
3.
4.
4

How many total paid hours were worked by contract RN and LPN staff in the LAST
WEEK?
How many total paid hours were worked by contract Certified Nursing Assistants or
Personal Care Aides in the LAST WEEK?

___ ___ ___
___ ___ ___ ___

Do any of the staff I’ve just asked about work in a portion of this
facility that is not participating in this project?
How often does the assignment of specific residents to direct care
workers change?

0 No 1 Yes 9 Not applicable
1 Never
2 Less than once a month
3 Monthly
4 Two to three times a month
5 Weekly
6 More than once a week

Is daily care provided using a specialized worker perspective, where
staff fill specialized roles? An example of this perspective would be
having a direct care worker who specializes in giving baths, and is
released from other duties.

0 No 1 Yes

How many administrators has this facility had in the last 3 years?

______

Do you have a dedicated physical therapist on staff?

0 No 1 Yes

10.

Is there a physical therapist to whom you regularly refer residents?

11.

Do you have any arrangements with a pharmacist?

0 No 1 Yes

Describe:

III. Falls Reporting

How many falls do you have per year?

___ ___

How many falls do you have that require medical care each year?

___ ___

What is your falls protocol?

How do you document falls?

Do you have a falls prevention program in place? (Describe)

0 No 1 Yes

Do you have a facility-wide exercise program? (Describe)

0 No 1 Yes

This project is one of the
Collaborative Studies of
Long-Term Care

Who is conducting
this project?
The project is conducted
by the University of North
Carolina (UNC) Collaborative
Studies of Long-Term Care,
and Research Triangle Institute (RTI).

The Collaborative Studies of Long-Term Care is a

Dr. Sheryl Zimmerman, a
gerontologist and health
services researcher, and Dr.
Philip Sloane, a geriatrician,
are the UNC project investigators. Dr. Edith Walsh, from
RTI, is the project director.

tive.

All research staff are professionals who are sensitive to
the needs and experiences
of older adults and their
caregivers.
For further information…
If you have questions about this
project, feel free to contact the
individuals whose names appear
on the back of this pamphlet.
You can also call our study
offices at (919) 966-7173.

program of research to learn more about residential
care/assisted living and nursing home settings and
their role in the provision of long-term care. More
than 4000 residents, staff, and families from 350
facilities across several states have already participated in other projects conducted by this collabora-

Project Director
Edith G. Walsh, PhD., R.N.
Research Triangle
Institute International

Principal Investigators
Sheryl Zimmerman, Ph.D.
Philip Sloane, M.D., M.P.H.

Program on Aging, Disability, and Long-Term Care
Sheps Center for Health Services Research
School of Social Work
Department of Family Medicine
University of North Carolina at Chapel Hill

Collaborative Studies of Long-Term Care

Preventing Falls
in
Assisted Living
Falls are a serious problem
for older adults. This assisted
living residence is participating in a project to learn about
falls, what types of things put
people at risk for having a
fall, and how those risks

For further information, please contact:

Madeline Mitchell, M.U.R.P.
Project Manager

(919) 966-6074
Arin Ahlum Hanson
Graduate Research Assistant

(919) 843-2708

change over time.
This pamphlet describes this
project, and your role if you
decide to participate.

Background and Purpose

Who Should Participate?

Falls are a serious problem
for older adults, including
those who live in assisted
living residences. In fact,
about one-half of the people
who live in assisted living
residences experience falls.
Falls can be a serious problem and sometimes result in
injuries.

Assisted living residents will
be invited to participate in this
project if they are:
• older than 65 years.
• English speaking
• not bed bound.
• not hospice patients.

The Evaluation Project
Many factors cause people to
fall, such as bad vision, weak
muscles, poor balance, and
medications. Also, external
factors, such as low lighting
or poorly fitting shoes, can
cause falls.
The University of North Carolina and Research Triangle
Institute are conducting a
project to learn more about
risk factors for falls, and how
those factors change over
time.

This project is being done in
four assisted living residences
in North Carolina. Researchers
will visit each facility three
times over one year to assess
resident strength, balance, and
other factors. Each assessment
will take about 40 minutes.
Researchers also will review
residents’ medical charts and
documents from healthcare
providers, as well as talk to assisted living staff about resident falls risk.

Your participation will help us
understand how to
better prevent falls in
assisted living. Also, we will let
participants know if they are
at high risk of falling.
Confidentiality
All information will be kept in
strict confidence. Your
information will be combined
with that of others. It will be
impossible to identify an
individual’s responses in any
papers or presentations, since
only group totals or averages
will be used. Your confidentiality is protected by law.

Preventing Falls in Assisted Living Facilities
Administrator Interview Guide
This interview will start with introductions and informed consent. Respondents will complete a
written consent form, and you’ll leave a copy with them.
Introduce yourselves as follows:
Hello, my name is _____________, from the Research Triangle Institute in North Carolina. This
is ______________ who will be taking notes and helping me with other activities. I would like
to talk to about the “Preventing Falls in Assisted Living” project.
Once we get started, the discussion will last about 60 minutes.
I’ll ask you about how the project was implemented, how easy or difficult it was to implement,
the impact the project had on the operations of the facility, on your facility staff, and on the
residents, and your thoughts about implementing the project on a permanent basis.
We do not expect that any harm will come to you by participating in this interview. However,
you can choose not to answer any question and you can choose not to participate in the
interview. Also, if at any time during the interview you decide that you do not want to continue,
you may stop. Your participation is completely voluntary.
There are no right or wrong answers to our questions. Nothing that you tell me in the discussion
will be identified as coming from you personally. Everything we learn from you and use in the
study will be kept confidential and notes and recordings will be stored in a locked file cabinet
and on a secure computer.
With your permission, we would like to tape record the interview. This will ensure that we
capture your words, not our interpretation of them. We will destroy the tapes once our analysis
is completed. Is it OK if we tape?
This consent form also explains in more detail what I just told you. It has phone numbers for
people you can call if you have any questions. You should keep one of the forms for your
records, and I will keep the other one for mine.
Please take a few minutes to review the consent form and sign one copy.
Do you have any questions before we get started?
Operational Questions about the Quality Improvement Falls Prevention Program
1

Please describe the quality improvement program as it now exists.
a. How was it decided that these would be the components?
b. Does it differ than what was envisioned when you first began this project?
i. If so, why did it change from what was envisioned?

Which staff were involved? How were staff selected for this project? What was their
role? What was your own involvement in the project?
What resident outcome data do you routinely collect or monitor regarding falls, fallrelated injuries or risk of falls?
2.

Were volunteers involved? For what role(s)? How were they recruited? What
supervision did they need or receive? From whom?

How does this project relate to your other quality assurance and quality improvement
activities? What did your facility do in terms of falls risk assessment or falls prevention
prior to this project? How did this project fit into your previous approach?

What changes in facility practices were necessary to implement the project? [including
record keeping]. Did the project change any of your routine data collection?

Where there any costs to the facility associated with participating? Are those costs that
would be incurred in the future to continue the program or were they one time costs?

Evaluative questions
7.

Do you consider this project a success? Why or why not? What contributed to the
success of the project?

What aspects of the project do you value most? Which least? Why?
[probes: medication review, reaching physicians to change medications, risk screening,
exercise program, referrals to PT, changes to facility environment]

What feedback did you get from staff, residents, families and physicians about this
project?

10.

What aspects of this project did they value the most? Why?
[probes: medication review, reaching physicians to change medications, risk screening,
exercise program, referrals to PT, changes to facility environment]

11.

Were there any aspects of the project that they did not like? Why?

12.

What changes have occurred in staff or resident outcomes related to this project?

13.

What were the challenges to implementing this project? Were they resolved? How? Any
changes you would recommend to address these challenges in the future? (at their own
facility or in new facilities).

14.

How burdensome was it to implement this program in your facility?

15.

How important was it to have outside experts to train staff? Or to provide ongoing
technical assistance/support?

Future impact
16.

Will you be sustaining any aspects of the project in this facility? Which ones? Why or
why not? [medication review, sending info to MDs suggesting medication changes, falls
risk appraisal, exercise program, referrals to PT, training staff]

17.

If so, how do you plan to sustain these aspects? [probes: staff have been assigned new
tasks or doing something differently, falls prevention will be an ongoing part of their
QA/QI activities, will continue to use volunteers- if so, will the current volunteers
continue, or will you be recruiting new ones? How do you plan to recruit new
volunteers?]

18.

Do you anticipate making any modifications to the program? Please describe.

19.

Is your chain interested in bringing this program to other facilities? What technical
support would other facilities need to implement the program? If you needed technical
support, like training by experts, how would you pay for it?

Preventing Falls in Assisted Living Facilities
Person Implementing the Exercise Program
This interview will start with introductions and informed consent. Respondents will
complete a written consent form, and you’ll leave a copy with them.
Introduce yourselves as follows:
Hello, my name is _____________, from the Research Triangle Institute in North
Carolina. This is ______________ who will be taking notes and helping me with other
activities. I would like to talk to about the “Preventing Falls in Assisted Living” project.
Once we get started, the discussion will last about 45 minutes.
I’ll ask you about the types of residents participating in the exercise program; what
changes were observed in the participants; what worked well; what did not work well; the
barriers to resident participation; and any recommendations you have for changes to the
Preventing Falls in Assisted Living program.
We do not expect that any harm will come to you by participating in this interview.
However, you can choose not to answer any question and you can choose not to
participate in the interview. Also, if at any time during the interview you decide that you
do not want to continue, you may stop. Your participation is completely voluntary.
There are no right or wrong answers to our questions. Nothing that you tell me in the
discussion will be identified as coming from you personally. Everything we learn from
you and use in the study will be kept confidential and notes and recordings will be stored
in a locked file cabinet and on a secure computer.
With your permission, we would like to tape record the interview. This will ensure that
we capture your words, not our interpretation of them. We will destroy the tapes once
our analysis is completed. Is it OK if we tape?
This consent form also explains in more detail what I just told you. It has phone numbers
for people you can call if you have any questions. You should keep one of the forms for
your records, and I will keep the other one for mine.
Please take a few minutes to review the consent form and sign one copy.

Do you have any questions before we get started?
Consent process
45 minutes to one hour for interview

Introduction
1.

What is your role in the exercise and falls prevention program?

What is your background? Volunteer or staff member?

How did you get involved in the program?

Who else in the facility did you interact with in conducting this program?
What was the nature of the interaction?

Program Participants
8.

What types of residents participated in the exercise program?
Probes: Frail
Mobility Problems
Fairly Healthy or active
Etc.

Describe the frequency of attendance.
Same people come on regular basis
each time
A few new people attend each time

10.

Were there people who attended the exercise program that you felt were
inappropriate for the program? How did you handle those situations?

11.

What kind of difficulties did participants experience?
Probes:
getting to the location
some exercises easier to do than others
stamina issues
anxiety about participating

12.

What changes were observed in the participants?
Probes:

stamina increased
balance improved
people seemed to enjoy
level of interest in exercise increased / seemed to enjoy it
flexibility improved
effect on socialization
increased level of independence

The program
13.

How often do you have the exercise program? How long does session last?

14.

Who trained you in doing the program? Does it require a lot of training to be
able to oversee this program? What type of experience and training is
necessary?

15.

Did you receive any ongoing support from the consulting physical therapist in
conducting the exercise program? What type of support?

16.

What things worked particularly well during the program?
Probes: did any one exercise work better than another
Schedule / location
Getting people to the location
Participation level
Education component (will there be one)

17.

What things did not work well?
Probes: did any one exercise work better than another
Schedule / location
Getting people to the location
Participation level
Education component (will there be one)

18.

What types of barriers were there to residents’ participation?

19.

What support would other facilities need to implement the exercise program?

20.

Do you feel you could train someone else here at the facility to do the exercise
program?

21.

How should assisted living facilities identify and encourage other people to
conduct these programs?

22.

Any recommendations for change.

Wrap up
24.

Anything else

Preventing Falls in Assisted Living Facilities
Medication Review Staff
This interview will be conducted with whoever conducted any aspects of the medication review
or follow-up with physicians. The interview will start with introductions and informed consent.
Respondents will complete a written consent form, and you’ll leave a copy with them.
Introduce yourselves as follows:
Hello, my name is _____________, from the Research Triangle Institute in North Carolina. This
is ______________ who will be taking notes and helping me with other activities. I would like
to talk to about the “Preventing Falls in Assisted Living” project.
Once we get started, the discussion will last about 60 minutes.
I’ll ask you about the medication review process, the computer program you used as part of the
resident medication review process and about the process for following up with physicians
including what worked well and what did not work particularly well.
We do not expect that any harm will come to you by participating in this interview. However,
you can choose not to answer any question and you can choose not to participate in the
interview. Also, if at any time during the interview you decide that you do not want to continue,
you may stop. Your participation is completely voluntary.
There are no right or wrong answers to our questions. Nothing that you tell me in the discussion
will be identified as coming from you personally. Everything we learn from you and use in the
study will be kept confidential and notes and recordings will be stored in a locked file cabinet
and on a secure computer.
With your permission, we would like to tape record the interview. This will ensure that we
capture your words, not our interpretation of them. We will destroy the tapes once our analysis
is completed. Is it OK if we tape?
This consent form also explains in more detail what I just told you. It has phone numbers for
people you can call if you have any questions. You should keep one of the forms for your
records, and I will keep the other one for mine.
Please take a few minutes to review the consent form and sign one copy.

Do you have any questions before we get started?
Operational questions
1. Please describe the medication review process, and your role in it.
2. Please describe the medication review process that was in place prior to this project.
How does it differ from the medication review process used in this project?

3. What is your role in quality monitoring and improvement at this facility? Did that change
as a result of this project?
4. Who trained you to do the medication review and follow-up task? What training did you
require for this task? What experience did you have in this area, before beginning the
project? Did you receive any ongoing support from the consulting pharmacist in conducting
this task? What type of support?
5. How long does it take to complete the medication review? About how many medication
reviews did you do in the course of the project? About what proportion of these were
rescreenings due to a change in medication regimen.
6. How did you know if a resident needed a medication review? (new residents and
changes in medication regimen)
7. How often did you find medication risk factors for falls? Were there certain medications
or combinations of medications or dosages that came up frequently? Certain types of
residents that were most likely to have falls risk factors related to their medications?
1. How often did you need to contact a physician about potential falls risk factors? About
how many different physicians did you have to contact? Were they physicians you had
contact with before this project? How did they react when you contacted them about
potential falls risk factors associated with their prescribed medication regime? Did this
change over time- i.e., as you called a physician about a second, third or additional
resident changes?
2. About what percent of the time did physicians respond at all to the information that you
sent them?
3. About what percent of the time did physicians make a change in resident medications in
response to the information that you sent?
4. About what percent of the time did physicians let you know they had received the report
but did not plan on making any changes?
5. Who explained any changes to residents? Did you communicate these changes to anyone
else in the facility? Who? How?

Evaluative questions
1. Overall, do you consider the medication review system successful? Why or why not?
What contributed to the success of the project? What obstacles were there to success?
2. What benefits to residents, staff or the facility have you seen from this aspect of the
project? How important do you feel this task is to resident well-being?

3. What challenges were there to
a. implementing the medication review process?
b. Communicating with physicians about falls risks associated with medications
c. Were there other aspects that were challenging?
4. Did you overcome some of these challenges? How?
5. How well were you trained in conducting this aspect of the project? Did you have
adequate support from the consulting pharmacist in conducting this aspect of the project?
What additional support needs did you have, if any?
6. How well did the PC-based medication review program work? What are its strengths?
What problems did you encounter in using it? Do you have any recommendations for
improving it?

7. What impact did doing this task have on your overall workload? How much of that was
related to training and start-up vs ongoing implementation? What were the most time
consuming components of these tasks? Do you have any suggestions for how to
streamline the process or make it more efficient?
8. How well did the approach to informing physicians work? What recommendations do
you have to improve this process? What support or training did you need to conduct this
component?
Future
1. Do you expect to continue using this medication review program and alerting physicians
to any possible falls risk factors?
2. What training or ongoing support would your facility need to maintain this program?
3. Could you train staff at another facility in your chain in the medication review and
follow-up tasks?
4. Do you have any other recommendations to improve this program?

Preventing Falls in Assisted Living Facilities
Resident Interview
Protocol for identifying residents to interview: RTI International staff will ask the
exercise leader and / or the facility intervention team to nominate residents for interview
based on their levels of participation in the exercise program. A total of 6 residents in
each facility will be interviewed. Will we attempt to vary the resident interviews by their
risk for falls.

This interview will start with introductions and informed consent. Residents will
complete a written consent form, and will receive a copy.
Hello, my name is _____________, from the Research Triangle Institute in North
Carolina. This is ______________ who will be taking notes and helping me with other
activities. I would like to talk to about the “Preventing Falls in Assisted Living” project.
Once we get started, the discussion will last about 30 minutes.
I’ll ask you for your thoughts about the Preventing Falls in Assisted Living Project,
including the exercise program; what you liked and disliked about it; the impact the
program had on you; your reasons for participating or not participating, your interest in
continuing in any other programs like this one if it’s offered here; and your
recommendations for improvements.
We do not expect that any harm will come to you by participating in this interview.
However, you can choose not to answer any question and you can choose not to
participate in the interview. Also, if at any time during the interview you decide that you
do not want to continue, you may stop. Your participation is completely voluntary.
There are no right or wrong answers to our questions. Nothing that you tell me in the
discussion will be identified as coming from you personally. Everything we learn from
you and use in the study will be kept confidential and notes and recordings will be stored
in a locked file cabinet and on a secure computer.
With your permission, we would like to tape record the interview. This will ensure that
we capture your words, not our interpretation of them. We will destroy the tapes once
our analysis is completed. Is it OK if we tape record the interview?
This consent form also explains in more detail what I just told you. It has phone numbers
for people you can call if you have any questions. You should keep one of the forms for
your records, and I will keep the other one for mine.
Please take a few minutes to review the consent form and sign one copy.

Do you have any questions before we get started?

Introduction
1. Do you participate in the {Falls Intervention Project or name of project}? What
aspects of the project did you participate? Probes: medication review, exercise,
PT, new special equipment or equipment checked, changes to how room was set
up.
2. Why did you decide to participate?

3. Were any of your medications changed because they created a risk for falling? If
so, how did the change affect you?
Probes;
Less sleepy
Less dizzy
More alert
4. Did anyone come into your room and evaluate it for safety? What
recommendations for changes did they make?
5. What changes did you allow them to make? What benefits did you notice from
the changes?
The Exercise Intervention
6. Are you involved in the group exercise program?
7. How often do you participate?
Probes:
Frequency – every time it’s scheduled
Once a week
Only went a few times and quit
8.

What effects whether or how often how you participate?
Probes: Feeling bad, not as interested as time goes on, not dressed in time,
conflicted with other plans, didn’t like it.

9. What would make it easier or more likely that you would participate more often?

10. What do you like or not like about the exercise program?
Probes: like the exercises
find it helpful / enjoyable
look forward to it
socialization
Gives confidence
The exercises themselves
Education – how to use assistive devices??
time of day
Length of time required
Location
Types of exercises
Afraid you’ll lose your balance or fall while exercising

Before this project did you do participate in any kind of regular exercise? If so, what
types? On your own or in a class? Have you continued with that exercise routine in
addition to the exercise program?
11. If participated in an organized exercise program before: How is this one [the
project’s] different from the one you in which you participated before?
Probes:
Types of exercises / level of intensity
Times of day / frequency
Note: we need a clear way of distinguishing the intervention exercise program from
any other exercise program that may have existed before.

12. Were you referred to a physical therapist? If so, why were referred to the physical
therapist? Did you go? If not, what kept you from going to see the physical
therapist?
13. How many visits did you have? Where did you see the physical therapist? How
did seeing the physical therapist help you?
14. Did you have any problems going to physical therapy? What kinds of problems
did you have?
Probes: paying for it
getting an appointment
transportation to PT

15. What effect has the exercise program or physical therapy had on you?
Probes:
improved balance
improved confidence
increased strength or stamina
socialization
has helped improve your health
16. What are you doing differently as a result of participating in the project?
Probes;
involved in more activities
fall less

17. If the facility continued to offer the exercise program would you continue to
participate? Why or why not?
18. This project involved reviewing medications, evaluating your room for safety and
exercise classes and physical therapy. Do you have any suggestions for
improving any of these activities?
.
Wrap up
19. Anything else?

Person Implementing the Exercise Program – NICE !
Draft 2/12/07
Introduction
Consent process
45 minutes to one hour for interview
Introduction
1.

What is your role in the exercise and falls prevention program?

What is your background? Volunteer or staff member?

How did you get involved in the program?

Who else in the facility did you interact with in conducting this program?
What was the nature of the interaction?

Program Participants
8.

What types of residents participated in the exercise program?
Probes: Frail
Mobility Problems
Fairly Healthy or active
Etc.

Describe the frequency of attendance.
Same people come on regular basis
each time
A few new people attend each time

10.

Were there people who attended the exercise program that you felt were
inappropriate for the program? How did you handle those situations?

11.

What kind of difficulties did participants experience?

Probes:
getting to the location
some exercises easier to do than others
stamina issues
anxiety about participating

12.

What changes were observed in the participants?
Probes:

stamina increased
balance improved
people seemed to enjoy
level of interest in exercise increased / seemed to enjoy it
flexibility improved
effect on socialization
increased level of independence

The program
13.

Did you have an exercise program at the facility prior to this project? If so,
how did it differ from this one? THIS IS MORE FOR THE
ADMINISTRATOR TO ANSWER, NOT THIS PERSON.
Probes: attendance
types of residents
frequency / number of days or times offered

14.

How often do you have the exercise program? How long does session last?

15.

Who trained you in doing the program? Does it require a lot of training to be
able to oversee this program? What type of experience and training is
necessary?

16.

Did you receive any ongoing support from the consulting physical therapist in
conducting the exercise program? What type of support?

17.

What things worked particularly well during the program?

Probes: did any one exercise work better than another
Schedule / location
Getting people to the location
Participation level
Education component (will there be one)
18.

What things did not work well?
Probes: did any one exercise work better than another
Schedule / location
Getting people to the location
Participation level
Education component (will there be one)

19.

What types of barriers were there to residents’ participation?

20.

What support would other facilities need to implement the exercise program?

21.

Do you feel you could train someone else here at the facility to do the exercise
program?

22.

Any recommendations for change.

23.

Did you enjoy doing the exercise program?

Wrap up
24.

Anything else

File Type	application/pdf
File Title	Microsoft Word - Appendix_A.doc
Author	thall
File Modified	2007-03-19
File Created	2007-03-16