Every facility must provide the necessary care and services to ensure that a resident’s abilities in activities of daily living do not diminish unless unavoidable due to the resident’s clinical condition. This week on the podcast, we discuss the categories of activities of daily living, how they are assessed, and what it means for quality of life in nursing homes.
Schenk: Hello out there. Welcome back to the podcast. My name is Rob. Today we’re going to be talking all about activities of daily living, assistance needed in them and what role they play in the quality of life in each nursing home resident.
But before we get into that, I have a call to action here for you. If you are enjoying the content of the Nursing Home Abuse Podcast, I would love it if you could like and subscribe wherever you get your podcast from, including going to the YouTube channel for Nursing Home Abuse Podcast. Like and subscribe there. Hit the notification bell. Even better, if you have a suggestion for content, leave a comment, let us know what it is. We’ll be happy to cover that in a future episode. With that being said, let’s get into it
Activities of daily living are categories of actions that people take each day that affect the basic quality of life. Now with regard to activities of daily living in nursing homes, the categories for activities of daily living are bed mobility, transferring, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene and bathing. Those are the categories of activities of daily living. So let’s kind of delve into each of those.
The first one is bed mobility, and bed mobility is how a resident moves to and from a lying position, turn side to side and position the body while in bed or on sleeping furniture. Transferring, which is an extremely important activity of daily living, is how the resident moves between surfaces including to or from the bed and a wheelchair or from a wheelchair to standing position.
Walking in room is how the resident walks between locations in his or her room. Walking in the corridor is how the resident walks in the facility itself in the units or quarters there. Locomotion on unit, which is how a resident moves between locations in his or her room. Location off unit is how a resident moves to and returns from off-unit locations, so for example, if there’s a wheelchair or something like that, or a cane or a walker.
Dressing is just as it sounds – how the resident puts on, fastens or takes off all items of clothing including donning or removing prostheses. Dressing includes putting on and changing pajamas and house dresses. Eating also as it sounds – how a resident eats and drinks regardless of skill, does not take into consideration eating or drinking during medications. Toilet use – toilet use, how a resident uses a toilet room, commode, bed pan or urinal, transfers on or off the toilet, cleanses himself after elimination, manages ostomy or catheter and adjusts clothes. Toileting does not include emptying a bed pan, urinal, bedside commode, catheter bag or ostomy bag. Personal hygiene is how a resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup and so forth.
So these are the areas that we have deemed critical to the quality of life of nursing home residents. So how do we assess these? How do we determine the level of ability that the resident has to carry out these activities of daily living? And how do we determine how much help they need with these? How are they assessed?
So activities of daily living are assessed in the same way everything is assessed. In the very beginning, there’s a comprehensive assessment. So how it’s designed to work is that an interdisciplinary team interacts with the resident. So they will watch the resident perform any one or all of these tasks and determine what’s happening, how much help they need. So by way of eating, the individual resident will be watched, if it’s safe to do so, and they will determine, the staff will determine whether or not that individual needs a special diet, whether or not they have the ability to put the spoon up to their mouth, this type of thing.
This should occur at the very beginning within the first 14 days. There should be a comprehensive assessment that goes through all these activities of daily living, ADLs for short. So typically that’s a nurse in the interdisciplinary team. The interdisciplinary team consists of a physician, the registered nurse and CNAs and a dietitian at minimum, although it can be more people than that. However, the nurse or the CNAs will watch the residents perform these activities and provide obviously the assistance that’s needed. And based on that assessment, and a lot of times this will happen over the course of a few days, so there will be various instances in which the activity will be monitored.
So that’s how the assessment occurs, a team usually consisting of the registered nurse and the CNAs that provide direct care to the resident will monitor and assess the resident through the course of several days and several bouts of that activity and determine the amount of help required and the level of self-care that is applied for each activity of daily living.
And what I mean by self-care, it’s typically not a zero-sum game. Generally the resident can do a little bit, and if the resident can do a little bit, the nursing home should allow the resident to do that little bit. So it’s kind of like two levels of assessment. The first level is how much can the resident do on their own. That’s self-care. Then how much help should be applied to the resident. So for example, does the person need one person to help, another person to help, that kind of thing.
The nursing home will assess in terms of self-care different levels. So the first level is independent. The resident for that particular ADL is completely independent. They are 100 percent capable of doing that ADL on their own without any assistance.
The second level of self-care is supervision. Supervision means the nursing home provides oversight, encouragement or cuing, so, “Okay, it’s time to put on your shirt, Ms. Johnson. Here it is. Can you put it on?” That’s supervision, as opposed to independence, Ms. Johnson at 8 o’clock puts on her clothes.
The next level of self-care is what’s called limited assistance. This is where the resident is “highly involved” in the ADL and receives slight physical help from staff, maybe guiding a limb or guiding the hand, like you need to guide the individual’s hand to the spoon to their mouth. That would be limited assistance.
The next level of self-care is extensive assistance. This is resident performs only part of the activity and the staff is there essentially lifting up body parts, if it’s like, for example, if it’s like mobility, they’re pushing the resident over but the resident can move a little bit. That’s extensive assistance. And the final level of self-care is total dependence, meaning that the resident cannot, he does zero percent of the ADL. The ADL is accomplished 100 percent by the efforts of the nursing home staff.
So those are the levels of self-care – how much can the resident do on their own? And just because a resident is totally dependent in one ADL doesn’t mean they can’t be independent in another, and that again is due to the clinical condition of the resident. Maybe they have paralysis on a side of their body so they can’t dress themselves but perhaps they can eat because they can move the arm on the other side of the body to maneuver the utensils. So just because a resident is categorized for self-care in a particular ADL doesn’t mean that the remaining ADLs will be of the same self-care.
Now once you’ve assessed self-care, then you determine whether or not or how much help the individual resident needs from the staff. And typically that is an amount of staff. So the first level of assistance is essentially what we call setup help. So for example, if the resident needs the nursing home staff to like pull the wheelchair up or if the nursing home staff needs to lay out the clothes, perhaps put the shoes in front of the nursing home resident, that’s setup help and the resident does the rest.
The next level is a one-person assist, meaning one individual is there. The next level of course is a two-person assist, meaning two people need to be on hand to help. Now we see two people assist when an individual resident maybe is obese, morbidly obese, and if it’s transferring, there needs to be two people or a lift or two people and a lift to get that resident from bed to wheelchair or vice versa. So self-care levels and then levels of how much help they actually need, setup help, no setup help, one-person assist, two-person assist.
Why is the assessment of self-care important? The reason why understanding how much self-care is provided or is necessary or is able to be provided by the resident is because that goes to quality of life. That goes to whether or not that resident is baseline or not baseline. So if a resident can eat on their own, that’s preferred because that goes to – ADLs are a basic essential part of life, and when one is not allowed the opportunity to do that, then studies show that quality of life suffers. So allowing the resident to put on their own clothes, pick out their own clothes, where they’re able to do that, we want that. That is something that is appropriate.
The other thing as I mentioned is we want to make sure we understand the amount of self-care that goes into an activity of daily living because that essentially sets forth their baseline. So if you have a resident who can eat on their own and can transfer on their own or only needs limited assistance or setup help with personal hygiene and then you notice they are totally dependent or cannot do anything on their own with regard to those two things, the personal hygiene or transferring, then there is a strong possibility that a medical condition could be causing that and the nursing home needs to investigate that. There could have been a significant change in condition. This could be a side effect of medication. This could be an issue with regard to maybe a cerebral event.
In other words, understanding the level of self-care, understanding the level of assistance needed aside from quality of life is important to understand whether or not a significant change in condition has occurred. And if a significant change in condition has occurred, then there needs to be new interventions, there needs to be new care plans, possibly a new assessment or acute care might be necessary, acute care meaning they need to send that resident out to the hospital for medical care because something has happened that is out of the ordinary.
Why is performance of activities of daily living important to nursing home care? Activities of daily living are important to nursing home care because if a resident is at a certain level with regard to what they can do for activities of daily living, then the federal regulations say that’s where they should remain unless and until their medical conditions say otherwise. So in other words, the nursing home should with its assessment, care plan and monitoring of the care plan should essentially make sure and ensure that that resident maintains that level of ability. That’s the baseline that the care plan should be rewritten and assessment should be conducted if it falls below that or even if the resident gets better. So we see a lot of times that physical therapy allows a resident to overcome certain issues and perhaps their self-care level decreases, meaning they don’t need as much help from the nursing home staff. Either way, their performance in activities of daily living is important because it needs to be maintained again for quality of life, significant change in condition baseline monitoring.
When is a nursing home liable for decreases in activities of daily living if at all? The answer to that is, as it is for any other instance in a nursing home, a nursing home typically will be liable for injuries or liable for decreases in quality of life only if the nursing home failed to do one of three things. One, make an accurate assessment of the resident, an accurate, personalized assessment of that resident. Second, create a care plan with interventions and goals and objectives to essentially reduce or eliminate the possibility that the activities of daily living would decrease. Third, monitor the effectiveness of the care plan.
So is it possible for you to sue the nursing home if your loved one’s abilities and their activities of daily living decrease? Yes, but only if the nursing home has failed to do one of those three things. Then you have the issue of causation, and we’ve talked about that in other episodes, that just because a nursing home has failed one of those three things, it’s possible that the clinical condition caused an unavoidable degradation of activities of daily living. We won’t get into that, but is it possible for you to sue the nursing home for a decrease in activities of daily living? Yes, but you have to meet the obligations that I just set forth, plus overcome any obstacles with causation.
So that is a broad primer of activities of daily living in nursing homes. I hope that has been informative. I hope that you understand better why understanding that is important with regard to the quality of life and the well-being of nursing home residents.
That’s going to conclude this particular episode of the Nursing Home Abuse Podcast. Again, if you are so inclined, mosey on over to our YouTube channel. Like an subscribe there. Leave a comment. New episodes every other week – they come out on Mondays. And with that, we’ll see you next time.