HI510 Unit 5 Resident Assessment Exercise Example

Her First Scheduled Assessment After a Hip Repair: A Unit 5 Resident Assessment Exercise Working Section by Section and Tracing Where Each Group of Answers Travels

[Student Name]

Purdue University Global

HI510: Health Information Applications and Systems

Unit 5 Resident Assessment Exercise

[Instructor Name]

[Date]

The resident and every answer are composite; the regulation, instrument guidance and studies cited are real.

Case Summary

Mrs. R., a composite 84-year-old, was admitted to Ostervale's skilled nursing facility on a Monday after four days in the hospital for a left hip fracture repaired with a hemiarthroplasty. Her diagnoses include atrial fibrillation, hypertension, osteoarthritis and mild chronic kidney disease. Her medications include apixaban, an anticoagulant; oxycodone as needed for pain; acetaminophen on a schedule; metoprolol and a stool softener. Nursing notes from the first three days describe her as alert, oriented, cooperative and anxious about walking. Physical therapy notes record that she stands from the bed with substantial help and walks five feet with a walker and two staff.

Setting the Assessment Reference Date

Federal rules require a comprehensive admission assessment completed by day 14 of the stay (42 C.F.R. § 483.20), and Medicare Part A payment requires a five-day assessment whose reference date falls on days 1 through 8. Because both windows overlap, the facility sets one reference date, day 5, and completes a single assessment that serves both purposes, as the instrument's manual permits (Centers for Medicare & Medicaid Services [CMS], 2024). The reference date matters because most sections look back over a fixed period ending on it, usually seven days, while admission functional performance uses the first three days of the stay. Choosing the reference date is not paperwork: it fixes the window for nearly every answer that follows, and a date set one day too late can push pain, falls or mood answers out of view.

Worksheet: Selected Sections

1. Identification and entry: admission date, admitted from an acute hospital, payer Medicare Part A, entry type admission.

2. Cognitive patterns, resident interview: the Brief Interview for Mental Status asks the resident to repeat three words, state the year, month and day, and recall the three words later. Mrs. R. repeats all three words, gives the correct year and month and is one day off on the day of the week, and recalls two words without cues and one with a category cue. Her score is 13 of 15, in the cognitively intact range. The interview was designed and tested for the federal assessment so that cognition could be scored from the resident's own answers (Saliba et al., 2012).

3. Mood, resident interview: the nine-item patient health questionnaire asks about the past two weeks. She reports feeling down on several days and trouble sleeping on several days, for a total of 6, in the mild range.

4. Pain, resident interview: she reports pain almost constantly over the past five days, at worst 7 of 10, limiting her sleep and therapy.

5. Functional abilities, admission performance over days 1 to 3, from nursing and therapy observation: eating, setup or cleanup assistance; oral hygiene, setup; toileting hygiene, substantial or maximal assistance; sit to stand, substantial or maximal assistance; walk ten feet, not attempted because of medical condition and safety on the first two days and substantial assistance on day 3, so the usual performance is coded at the substantial level with a note.

6. Discharge goals for function: set by therapy for each item, such as partial assistance for sit to stand.

7. Falls: fall in the month before admission, yes, the fall that caused the fracture; fall with major injury, yes.

8. Active diagnoses: hip fracture aftercare as the primary reason for the stay, with atrial fibrillation, hypertension and arthritis.

9. Medications: anticoagulant received on all 7 days, opioid received on 5 days.

Where the Answers Travel

1. To payment: the primary diagnosis category, the functional items and the cognitive score feed the Part A payment classification, setting the physical, occupational and speech therapy components, while diagnoses and medications contribute to the nursing and other components.

2. To quality reporting: the functional items, falls and pain answers feed measures that are publicly reported for the facility, including functional improvement between admission and discharge.

3. To the care plan: answers in pain, falls, function and mood trigger care areas that the interdisciplinary team must assess and address in the care plan within seven days of completing the assessment.

4. To the facility's own operations: the anticoagulant and opioid answers, with the fall history, drive the fall prevention plan and pharmacy review.

5. To federal submission: the completed assessment is transmitted electronically to the national system, where it becomes part of the resident's assessment history and the facility's quality data.

What the Exercise Shows

A single assessment serves five destinations at once. The same functional score that sets therapy payment also shapes a quality measure and a care plan, so an inflated or deflated answer distorts all three. That is why the instrument insists on observed usual performance and resident interview wherever possible, and why the record that produces this assessment must be built around its schedule and look-back windows rather than around the clinical events of the stay.

References

Centers for Medicare & Medicaid Services. (2024). Long-term care facility resident assessment instrument 3.0 user's manual. U.S. Department of Health and Human Services.

42 C.F.R. § 483.20 (2024). https://www.ecfr.gov/current/title-42/section-483.20

Saliba, D., Buchanan, J., Edelen, M. O., Streim, J., Ouslander, J., Berlowitz, D., & Chodosh, J. (2012). MDS 3.0: Brief interview for mental status. Journal of the American Medical Directors Association, 13(7), 611-617. https://doi.org/10.1016/j.jamda.2012.06.004