Community RAI-HC

Annual Compulsory Education for Supportive Living RN/LPNs and HCAs

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Learning Objectives
 To increase your awareness of the purpose behind the RAI-HC Assessment.

 To understand your role in the completion of the RAI-HC assessment by proper

utilization of the RAI Tracking Tool.

 To understand the components of the RAI Tracking Tool and how to properly code
your observations.
What is RAI – HC (Home Care)?
 Resident Assessment Instrument.
 A system that informs and guides comprehensive planning of care & services in community
settings.
 Focuses on the individual’s functioning and quality of life by assessing needs, strengths, and
preferences.
 Facilitates referrals when appropriate.
 Gives an outcome based assessment of the person’s response to care and/or services provided.
What is RAI – HC (Home Care)?
 The professional nurse has the responsibility to set-up the RAI tracking tool initiated at 2400 hours
on the day of admission. This may be completed for up to 14 days.
 Within 21 days of admission the AHS RN Case Manager will complete the RAI Assessment. From
this point on the RAI will be completed annually and with a significant change in the residents
status.

 All resident’s will have a current car plan that reflects the CAPS triggered in the RAI assessment.

 The purpose is to identify physical,

mental and functional needs from
which a resident’s specific
comprehensive care plan can be
developed.

What is the RAI

Tracking Tool?
Records relevant information about a
client for eight (8) days prior to a Case
Manager’s RAI – HC assessment.
Communicates valuable information to the Case Manager of the care that is
provided to the resident.

Assists in care plan development.

Notifies the Case Manage of the client’s status.

Is a consistent tool in all supportive living sites.

Who completes the RAI Tracking

Tool?
 LPNs/HCAs who work in Supportive Living (SL3, SL4, &
SL4D) facilities and assist/observe residents in their daily
routines.
 Must be accurately completed as this tool forms the
resident’s care plan.
 It is to be completed honestly to reflect your work with the
resident.
 May be audited at any time by BSF management and Alberta Health Services for accuracy.

Note: LPN time includes Medication Passes, wound care, etc.

When will you use the RAI Tracking Tool?

 The Case Manager will set a date and time to start tracking (communicated to the RN/LPN who will then
initiate the tool).

 You record your observations, assistance, and care provided for

eight (8) days on day, evening and night shifts. The assessment can not
have missing spaces.

 No guessing on assessments. Ask the RN/LPN for assistance.

If there is a change in the resident’s status let the Case

Manager know in addition to the Program Manager.
 Moods & Behaviours
 Physical Functioning
  Nutrition & Hydration
What is tracked?  Bathing
 Locomotion (Indoor & Outdoor)
 Continence (Bladder & Bowel Control)
 Problem Conditions/Symptoms
 Skin Condition/Problems
 Pain

Describe pain & skin conditions

section

Mood
 Moods may be expressed
verbally or non-verbally.

 Indicate if the resident has

feelings of sadness, anger,
anxiety, or depression in
accordance to the tracking
tool.
 Examples:
Behaviours  VERBAL – resident may say “Life is not worth living.”  NON-

VERBAL – resident is frowning or teary.

 All moods must be recorded regardless of why and/or when it is

being shown.

DO NOT confuse personality traits with actual moods.

 All behaviours have meaning and must be recorded
regardless of when, why, and/or where it is shown.

 Pacing is not wandering.

 Wandering can be done in a wheelchair.

 Resident may move without any obvious purpose .

 Verbally abusive – resident has screamed at or threatened

others.
 Physically abusive – can include swinging out with intent to hit others or care givers.

 Socially inappropriate behaviours such as disruptive sounds, disrobing, hoarding or pacing.

 Resisting care verbally or physically and includes resisting medication.

Behaviors Continued…
Questions to ask:
 Were these behaviours easily altered?
 Was the resident easily removed or re-directed from the situation?

Basically, ask if you were successful in re-directing the resident and/or preventing
one resident from hitting or pushing another person.

Very important to code as this could be the cause of other problems.

 Note: Pacing is not included in wandering. If the pacing is disruptive to others
include this as “Resident was socially inappropriate or disruptive.” The same
statement may be used with hoarding.

Activities of Daily Living (ADL) Self-performance

Record what the resident actually does on their own or what help is needed with activities
of daily living

This category includes:

 Transfers
 Mobility in bed
 Locomotion (how the resident moves around)
 Dressing the upper & lower body
 Eating
 Toileting
 Personal Hygiene
  Bathing
Activities of Daily Living (ADL) Self-performance
What to record/code (Choose one of the following): a) Did not
need help
b) Set-up help only. Example: article placed within reach, or cut up food.
c) Needed supervision, includes cueing, encouragement, or stand-by assistance
d) Hands on guiding. Example: guiding arm into shirt, but no lifting or supporting of arm.
e) Hands on help with less than half of task, including lifting of arms/legs. Example: physically
supporting arms when putting through shirt sleeve
f) Hands on help with more than half of task, including lifting of arms/legs etc. Example: applying
compression stockings while physically supporting the legs.
g) Hands on help for everything, Resident NOT helping. Example: use of a mechanical lift for
transfer.
h) Activity did not occur.

In the same box document the number of minutes you spent assisting the resident with the
particular ADL.
 Some days or on different shifts a resident can do more for themselves than at other times. Record what
actually occurs during your shift.

Primary Modes of Locomotion

The aid or device the resident most often uses to get around
both indoors & outdoors

What to record/code (Choose one of the following):

a) No assistive device
b) Cane
c) Walker/Crutch(es)
d) Scooter
e) Wheelchair (includes
electric wheelchair)
f) Activity did not occur
(indoor section or the
outdoor section of the
tool).

If not too sure what to code, think about what the resident uses more than
50% of the time
 Bladder Continence (Control)
 Incontinence includes any level of dribbling or wetting of urine.
 Leaking indwelling catheter = incontinence.
 R All that apply

Bladder Devices
 Incontinent Product.
 Do not include panty liners and/or pad placed on the bed/chair routinely if the resident is never or
rarely incontinent.
 R All that apply

Note: Leaking or bypassing of catheter should be reported right away to nursing supervisor as per
policy
 Bladder Continence (Control)
 Does not include the resident’s ability to toilet themselves
 Leaking ostomy = incontinence
 Record each time a client has a bowel movement (BM)

Note: Leaking ostomies should be reported to the Nursing Supervisor as per policy
 Problem Conditions
 Diarrhea – frequent watery stools
 Difficulty urinating or urinating 3 or more times at night
 Vomiting
 Chest Pain
 Dizziness or light-headedness
 Hallucinations – Seeing/hearing/touching/smelling things that are not really there

Note: New, sudden, or continued symptoms should be reported right away

Pain
Complains of pain – may be verbal and/or non-verbal.
• wincing or favoring the affected site
Complains of pain in more than one area.

Change in behaviour • residents with dementia.

R All that apply

Very important to assess and record as it could be a

sign of other issues

Describe pain and location in the comment

section
Nutrition/hydration
Percentage of food eaten at meal and/or snack time
 75-100
 50-75  25-50
 0-25
 Enteral Tube Feeding
 Place yes or no in
areas that apply or the
percentage.

Weigh client once over the eight (8) day period (bath day)
 Skin Conditions

 Itchiness
 Rash
 Bruises
 Skin tears/cuts
 Scrapes
 Open sores
 Burns
R All that apply and describe in comment section
Reminders

 Accurately record observations, assistance, and care provided.

 Report any sudden changes and/or concerns.  Record your time spent with the resident.
  Round time off to the nearest increment of 10 minutes.

 Add up minutes at the end of your shift before rounding off.

 Sign your initials at the end of your shift.

Add any comments regarding any unusual event(s) – be sure

to document the date and time it happened.

References
 BSF Resident Care Supportive Living Manual: Admission Protocol.
 BSF Resident Care Supportive Living Manual: Care Process Component.
 BSF Resident Care Supportive Living Manual: Fall Prevention and Management
Program.
 BSF Resident Care Supportive Living Manual: Integrated Client Care Plan
 Continuing Care Health Service Standards, January 2016
 Resident Assessment Instrument (RAI) RAI-HC user manual, September 2010,
Canadian Version.

Thank you.
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