Nursing Home Survey on Patient Safety

Survey

Nursing homes can use this survey as indicators in establishing a culture of safety.
Select to download print version PDF file (PDF File, 240 KB).
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 resident 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
___ b. 2 to 11 months
___ c. 1 to 2 years
___ d. 3 to 5 years
___ e. 6 to 10 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.
Page last reviewed November 2014
Internet Citation: Nursing Home Survey on Patient Safety: Survey. November 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/nhsurvey.html