Nursing Home Survey on Patient Safety

In this survey, "resident safety" means preventing resident injuries, incidents, and harm to residents in the nursing home.

This survey asks for your opinions about resident safety issues in your nursing home.
It will take about 15 minutes to complete.

To mark your answer, just put an X or a check in the box.

If a question does not apply to your job or you do not know the answer, please mark the box in the last column. If you do not wish to answer a question, you may leave your answer blank.

Section A: Working in This Nursing Home

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don't Know
1. Staff in this nursing home treat each other with respect	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. Staff support one another in this nursing home	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. We have enough staff to handle the workload	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
4. Staff follow standard procedures to care for residents	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
5. Staff feel like they are part of a team	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
6. Staff use shortcuts to get their work done faster	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
7. Staff get the training they need in this nursing home	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
8. Staff have to hurry because they have too much work to do	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
9. When someone gets really busy in this nursing home, other staff help out	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
10. Staff are blamed when a resident is harmed	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
11. Staff have enough training on how to handle difficult residents	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
12. Staff are afraid to report their mistakes	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
13. Staff understand the training they get in this nursing home	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
14. To make work easier, staff often ignore procedures	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
15. Staff are treated fairly when they make mistakes	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
16. Residents' needs are met during shift changes	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
17. It is hard to keep residents safe here because so many staff quit their jobs	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
18. Staff feel safe reporting their mistakes	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section B: Communications

How often do the following things happen in your nursing home?	Never	Rarely	Sometimes	Most of the time	Always	Does Not Apply or Don't Know
1. Staff are told what they need to know before taking care of a resident for the first time	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. Staff are told right away when there is a change in a resident's care plan.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. We have all the information we need when residents are transferred from the hospital.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
4. When staff report something that could harm a resident, someone takes care of it.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
5. In this nursing home, we talk about ways to keep incidents from happening again	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
6. Staff tell someone if they see something that might harm a resident	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
7. Staff ideas and suggestions are valued in this nursing home	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
8. In this nursing home, we discuss ways to keep residents safe from harm.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
9. Staff opinions are ignored in this nursing home.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
10. Staff are given all the information they need to care for residents.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
11. It is easy for staff to speak up about problems in this nursing home.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section C: Your Supervisor

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don't Know
1. My supervisor listens to staff ideas and suggestions about resident safety.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. My supervisor says a good word to staff who follow the right procedures.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. My supervisor pays attention to safety problems in this nursing home	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section D: Your Nursing Home

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don't Know
1. Residents are well cared for in this nursing home.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. Management asks staff how the nursing home can improve resident safety.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. This nursing home lets the same mistakes happen again and again	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
4. It is easy to make changes to improve resident safety in this nursing home	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
5. This nursing home is always doing things to improve resident safety.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
6. This nursing home does a good job keeping residents safe	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
7. Management listens to staff ideas and suggestions to improve resident safety.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
8. This nursing home is a safe place for residents	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
9. Management often walks around the nursing home to check on resident care.	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
10. When this nursing home makes changes to improve resident safety, it checks to see if the changes worked	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section E: Overall Ratings

1. I would tell friends that this is a safe nursing home for their family.

___ a. Yes
___ b. Maybe
___ c. No

2. Please give this nursing home an overall rating on resident safety.

___ 1. Poor   ___ 2. Fair    ____ 3. Good   ___ 4. Very Good    ___ 5. Excellent

Section F: Background Information

1. What is your job in this nursing home? Check ONE box that best applies to your job. If more than one category applies, check the highest level job.

___ a. Administrator/Manager

Executive Director/Administrator
Medical Director
Director of Nursing/Nursing Supervisor
Department Head
Unit Manager/Charge Nurse
Assistant Director/Assistant Manager
Minimum Data Set (MDS) Coordinator/ Resident Nurse Assessment Coordinator (RNAC)

___ b. Physician (MD, DO)

___ c. Other Provider

Nurse Practitioner
Clinical Nurse Specialist
Physician Assistant

___ d. Licensed Nurse

Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Wound Care Nurse

___ e. Nursing Assistant/Aide

Certified Nursing Assistant (CNA)
Geriatric Nursing Assistant (GNA)
Nursing Aide/Nursing Assistant

___ f. Direct Care Staff

Activities Staff Member
Dietitian/Nutritionist
Medication Technician
Pastoral Care/Chaplain
Pharmacist
Physical/Occupational/Speech/
Respiratory Therapist
Podiatrist
Social Worker

___ g. Administrative Support Staff

Administrative Assistant
Admissions
Billing/Insurance
Secretary
Human Resources
Medical Records

___ h. Support Staff

Drivers
Food Service/Dietary
Housekeeping
Laundry Service
Maintenance
Security

___ i. Other (Please write the title of your job):

________________________________

2. How long have you worked in this nursing home?

___ a. Less than 2 months
___ d. 3 to 5 years
___ b. 2 to 11 months
___ e. 6 to 10 years
___ c. 1 to 2 years
___ f. 11 years or more

3. How many hours per week do you usually work in this nursing home?

___ a.  15 or fewer hours per week
___ b. 16 to 24 hours per week
___ c. 25 to 40 hours per week
___ d. More than 40 hours per week

4. When do you work most often? Check ONE answer.

___ a. Days
___ b. Evenings
___ c. Nights

5. Are you paid by a staffing agency when you work for this nursing home?

___ a. Yes
___ b. No

6. In your job in this nursing home, do you work directly with residents most of the time?
Check ONE answer.

___ a. YES, I work directly with residents most of the time.
___ b. NO, I do NOT work directly with residents most of the time.

7. In this nursing home, where do you spend most of your time working? Check ONE answer.

___ a. Many different areas or units in this nursing home/No specific area or unit
___ b. Alzheimer's/Dementia unit
___ c. Rehab unit
___ d. Skilled nursing unit
___ e. Other area or unit (Please specify): ______________________________

Section G: Your Comments

Please feel free to write any comments about resident care and safety in this nursing home.

Thank You for Completing This Survey.

AHRQ Publication No. 08-0060
Current as of September 2008

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Internet Citation:

Nursing Home Survey on Patient Safety. AHRQ Publication No. 08-0060, September 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nhsurvey08/nhsurvey.htm

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