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CAHPS Nursing Home Survey
Version: Family Member Survey
Language: English
File name: FILENAME \* MERGEFORMAT nhfamily-eng-1652a.doc
Last updated: September 1, 2011Response Scale: 4 points
For assistance with this survey, please contact the CAHPS Help Line at 800-492-9261 or HYPERLINK "mailto:cahps1@westat.com" cahps1@westat.com.
Instructions for Front Cover
Replace the cover of this document with your own front cover. Include a user-friendly title and your own logo.
Include this text regarding the confidentiality of survey responses:
Your Privacy is Protected. All information that would let someone identify you or your family will be kept private. {VENDOR NAME} will not share your personal information with anyone without your OK. Your responses to this survey are also completely confidential. You may notice a number on the cover of the survey. This number is used only to let us know if you returned your survey so we dont have to send you reminders.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the care your family member gets.
What To Do When Youre Done. Once you complete the survey, place it in the envelope that was provided, seal the envelope, and return the envelope to [INSERT VENDOR ADDRESS].
If you want to know more about this study, please call XXX-XXX-XXXX.
Instructions for Format of Questionnaire
Proper formatting of a questionnaire improves response rates, the ease of completion, and the accuracy of responses. The CAHPS teams recommendations include the following:
If feasible, insert blank pages as needed so that the survey instructions (see next page) and the first page of questions start on the right-hand side of the questionnaire booklet.
Maximize readability by using two columns, serif fonts for the questions, and ample white space.
Number the pages of your document, but remove the headers and footers inserted to help sponsors and vendors distinguish among questionnaire versions.
Survey Instructions
Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
FORMCHECKBOX Yes ( I f Y e s , g o t o # 1 o n p a g e 1
F O R M C H E C K B O X N o
T h e R e s i d e n t
1 . W h o i s t h e p e r s o n l i s t e d i n t h e c o v e r l e t t e r ?
1 F O R M C H E C K B O X M y S p o u s e / P a r t n e r
2 F O R M C H E C K B O X M y P a r e n t
3 F O R M C H E C K B O X M y M o t h e r - i n - L a w / F a t h e r - i n - L a w
4 F O R M C H E C K B O X M y G r a n dparent
5 FORMCHECKBOX My Aunt or Uncle
6 FORMCHECKBOX My Sister or Brother
7 FORMCHECKBOX My Child
8 FORMCHECKBOX My Friend
9 FORMCHECKBOX Other
Please print:
2. For this survey, the phrase family member refers to the person listed in the cover letter. Is your family member now living in the nursing home listed in the cover letter?
1 FORMCHECKBOX Yes ( I f Y e s , g o t o # 4
2 F O R M C H E C K B O X N o
3 . W a s y o u r f a m i l y m e m b e r d i s c h a r g e d f r o m t h i s f a c i l i t y o r d i d h e o r s h e d i e ?
1 F O R M C H E C K B O X D i s c h a r g e d ( I f D i s c h a r g e d , S t o p H e r e . P l e a s e r e t u r n t h i s s u r v e y i n t h e p o s t a g e - p a i d e n v e l o p e .
2 F O R M C H E C K B O X D e c e a s e d ( I f y o u r f a m i l y m e m b e r i s d e c e a s e d , w e u n d e r s t a n d t h a t y o u m a y n o t w a n t t o f i l l o u t a s u r v e y a t t h i s t i m e .
I f y o u w o u l d l i k e t o f i l l o u t t h e r e s t o f t h e s u r v e y , w e w o u l d b e v e r y g r a t e f u l f o r y o u r f e e d b a c k . P l e a s e g o t o # 5 a n d a n s w e r t h e q u e s t i o n s about your family members last 6 months at the nursing home. Thank you for your help.
4. Do you expect your family member to live in this or any other nursing home permanently?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Dont know
5. In total, about how long has your family member lived in this nursing home?
1 FORMCHECKBOX Less than 1 month ( I f l e s s t h a n 1 m o n t h , S t o p H e r e . P l e a s e r e t u r n t h i s s u r v e y i n t h e p o s t a g e - p a i d e n v e l o p e .
2 F O R M C H E C K B O X 1 m o n t h t o a l m o s t 3 m o n t h s
3 F O R M C H E C K B O X 3 m o n t h s t o a l m o s t 6 m o n t h s
4 F O R M C H E C K B O X 6 m o n t h s t o a l m o s t 1 2 m o n t h s
5 F O R M C H E C K B O X 1 2 m o n ths or longer
6. In the last 6 months, has your family member ever shared a room with another person at this nursing home?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
7. Does your family member have serious memory problems because of Alzheimers disease, dementia, a stroke, an accident, or something else?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
8. In the last 6 months, how often was your family member capable of making decisions about his or her own daily life, such as when to get up, what clothes to wear, and which activities to do?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
Your Visits
Please answer the following questions only for yourself. Do not include the experiences of other family members.
9. In the last 6 months, about how many times did you visit your family member in the nursing home?
1 FORMCHECKBOX 0 to 1 time ( If 0 to 1, go to #43 on page6
2 FORMCHECKBOX 2 to 5 times
3 FORMCHECKBOX 6 to 10 times
4 FORMCHEC K B O X 1 1 t o 2 0 t i m e s
5 F O R M C H E C K B O X M o r e t h a n 2 0 t i m e s
1 0 . I n t h e l a s t 6 m o n t h s , d u r i n g a n y o f y o u r v i s i t s , d i d y o u t r y t o f i n d a n u r s e o r a i d e f o r a n y r e a s o n ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o ( I f N o , g o t o # 1 2
1 1 . I n t h e l a s t 6 m o n ths, how often were you able to find a nurse or aide when you wanted one?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
12. In the last 6 months, how often did you see the nurses and aides treat your family member with courtesy and respect?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
13. In the last 6 months, how often did you see the nurses and aides treat your family member with kindness?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
14. In the last 6 months, how often did you feel that the nurses and aides really cared about your family member?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
15. In the last 6 months, did you ever see any nurses or aides be rude to your family member or any other resident?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
16. In th e l a s t 6 m o n t h s , d u r i n g a n y o f y o u r v i s i t s , d i d y o u h e l p y o u r f a m i l y m e m b e r w i t h e a t i n g ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o ( I f N o , g o t o # 1 8
1 7 . W a s i t b e c a u s e t h e n u r s e s o r a i d e s e i t h e r d i d n t h e l p o r m a d e h i m o r h e r w a i t t o o l o n g ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o
1 8 . I n t h e l a s t 6 m o n t h s , d u r i n g a n y o f y o u r v i s i t s , d i d y o u h e l p y o u r f a m i l y m e m b e r w i t h d r i n k i n g ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o ( I f N o , g o t o # 2 0
1 9 . W a s i t b e c a u s e t h e n u r s e s o r a i d e s e i t h e r d i d n t h elp or made him or her wait too long?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
20. Help toileting includes helping someone get on and off the toilet or helping change disposable briefs or pads. In the last 6 months, during any of your visits, did you help your family member with toileting?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( I f N o , g o t o # 2 2
2 1 . W a s i t b e c a u s e t h e n u r s e s o r a i d e s e i t h e r d i d n t h e l p o r m a d e h i m o r h e r w a i t t o o l o n g ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o
2 2 . I n t h e l a s t 6 m o n t h s , h o w o f t e n d i d y o u r f a m i l y m e m b e r l o o k a n d s m e l l c l e a n ?
1 F O R M C H E C K B O X Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
23. Sometimes residents make it hard for nurses and aides to provide care by doing things like yelling, pushing, or hitting. In the last 6 months, did you see any resident, including your family member, behave in a way that made it hard for nurses or aides to provide care?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( I f N o , g o t o # 2 5
2 4 . I n t h e l a s t 6 m o n t h s , h o w o f t e n d i d t h e n u r s e s a n d a i d e s h a n d l e t h e s i t u a t i o n i n a w a y t h a t y o u f e l t w a s a p p r o p r i a t e ?
1 F O R M C H E C K B O X N e v e r
2 F O R M C H E C K B O X S o m e t i m e s
3 F O R M C H E C K B O X U s u a l l y
4 F O R M C H E C K B O X A l w a y s
Y o u r E x p e r i e n c e W i t h N u r s e s & A i d e s
2 5 . I n t h e l a s t 6 m o n t h s , d i d y o u w a n t t o g e t i n f o r m a t i o n a b o u t y o u r f a m i l y m e m b e r f r o m a n u r s e o r a n a i d e ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o ( I f N o , g o t o # 2 7
2 6 . I n t h e l a s t 6 m o n t h s , h o w o f t e n d i d y o u g e t t h i s information as soon as you wanted?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
27. In the last 6 months, how often did the nurses and aides explain things in a way that was easy for you to understand?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
28. In the last 6 months, did the nurses and aides ever try to discourage you from asking questions about your family member?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
The Nursing Home
29. In the last 6 months, how often did your family members room look and smell clean?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
30. In the last 6 months, how often did the public areas of the nursing home look and smell clean?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Usually
4 FORMCHECKBOX Always
31. Personal medical belongings are things like hearing aids, glasses, and dentures. In the last 6 months, how often were your family members personal medical belongings damaged or lost?
1 FORMCHECKBOX Never
2 FORMCHECKBOX Once
3 FORMCHECKBOX Two or more times
32. In the last 6 months, did your family member use the nursing homes laundry service for his or her clothes?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( I f N o , g o t o # 3 4
3 3 . I n t h e l a s t 6 m o n t h s , w h e n y o u r f a m i l y m e m b e r u s e d t h e l a u n d r y s e r v i c e , h o w o f t e n w e r e c l o t h e s d a m a g e d o r l o s t ?
1 F O R M C H E C K B O X N e v e r
2 F O R M C H E C K B O X O n c e o r t w i c e
3 F O R M C H E C K B O X T h r e e o r m o r e t i m e s
3 4 . I n t h e l a s t 6 m o n t h s , w e r e y o u e v e r u n h a p p y w i t h t h e c a r e y o u r f a m i l y m e m b e r r e c e i v e d a t t h e n u r s i n g h o m e ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o ( I f N o , g o t o # 3 6
3 5 . I n t h e l a s t 6 m o n t h s , d i d y o u e v e r s t o p y o u r s e l f f r o m t a l k i n g t o a n y n u r s i n g h o m e s t a f f a b o u t y o u r concerns because you thought they would take it out on your family member?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
Care Of Your Family Member
36. In the last 6 months, have you been involved in decisions about your family members care?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No (
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2 Z Ҏ " r t $ f $$ I f N o , g o t o # 3 8
3 7 . I n t h e l a s t 6 m o n t h s , h o w o f t e n w e r e y o u i n v o l v e d a s m u c h a s y o u w a n t e d t o b e i n t h e d e c i s i o n s a b o u t y o u r f a m i l y m e m b e r s c a r e ?
1 F O R M C H E C K B O X N e v e r
2 F O R M C H E C K B O X S o m e t i m e s
3 F O R M C H E C K B O X U s u a l l y
4 F O R M C H E C K B O X A l w a y s
O v e r a l l
3 8 . U s i n g a n y n u m b e r f r o m 0 t o 1 0 , w h e r e 0 i s t h e w o r s t c a r e p o s s i b l e a n d 1 0 i s t h e b e s t c a r e p o s s i b l e , w h a t n u m b e r w o u l d y o u u s e t o r a t e t h e c a r e a t t h i s n u r s i n g h o m e ?
F O R M C H E C K B O X 0 W o r s t c a r e p o s s i b l e
F O R M C H E C K B O X 1
F O R M C H E C K B O X 2
F O R M C H E C K B O X 3
F O R M C H E C K B O X 4
F O R M C H E C K B O X 5
F O R M C H E C K B O X 6
F O R M C H E C K B O X 7
F O R M C H E C K B O X 8
F O R M C H E C K B O X 9
F O R M C H E C K B O X 1 0 B e s t c a r e p o s s i b l e
3 9 . I f s o m e o n e n e e d e d n u r s i n g h o m e c a r e , w o u l d y o u r e c o m m e n d t h i s n u r s i n g h o m e t o t h e m ?
1 F O R M C H E C K B O X D e f i n i t e l y n o
2 F O R M C H E C K B O X P r o b a b l y n o
3 F O R M C H E C K B O X P r o b a b l y y e s
4 F O R M C H E C K B O X D e f i n i t e l y y e s
4 0 . I n t h e l a s t 6 m o n t h s , h o w o f t e n d i d y o u f e e l t h e r e w e r e e n o u g h n u r s e s a n d a i d e s i n t h i s n u r s i n g h o m e ?
1 F O R M C H E C K B O X N e v e r
2 F O R M C H E C K B O X S o m e t i m e s
3 F O R M C H E C K B O X U s u a l l y
4 F O R M C H E C K B O X A l w a y s
Y o u A n d Y o u r R o l e
P l e a s e r e m e m b e r t h a t t h e q u e s t i o n s i n t h i s s u r v e y a r e a b o u t y o u r e x p e r i e n c e s . D o n o t i n c l u d e t h e e x p e r i e n c e s o f o t h e r f a m i l y m e m b e r s .
4 1 . I n t h e l a s t 6 m o n t h s , d i d y o u a s k t h e n u r s i n g h o m e f o r i n f o r m a t i o n a b o u t p a y m e n t s o r e x p e n s e s ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o ( I f N o , g o t o # 4 3
4 2 . I n t h e l a s t 6 m o n t h s , h o w o f t e n d i d y o u g e t a l l t h e i n f o r m a t i o n y o u w a n t e d f r o m t h e n u r s i n g h o m e a b o u t p a y m e n t s o r e x p e n s e s ?
1 F O R M C H E C K B O X N e v e r
2 F O R M C H E C K B O X S o m e t i m e s
3 F O R M C H E C K B O X U s u a l l y
4 F O R M C H E C K B O X A l w a y s
A b o u t Y o u
4 3 . W h a t i s y o u r a g e ?
1 F O R M C H E C K B O X 1 8 t o 2 4
2 F O R M C H E C K B O X 2 5 t o 3 4
3 F O R M C H E C K B O X 3 5 t o 4 4
4 F O R M C H E C K B O X 4 5 t o 5 4
5 F O R M C H E C K B O X 5 5 t o 6 4
6 F O R M C H E C K B O X 6 5 t o 7 4
7 F O R M C H E C K B O X 7 5 o r o l d e r
4 4 . A r e y o u m a l e o r f e m a l e ?
1 F O R M C H E C K B O X M a l e
2 F O R M C H E C K B O X F e m a l e
4 5 . W h a t i s t h e h i g h e s t g r a d e o r l e v e l o f s c h o o l t h a t y o u h a v e c o m p l e t e d ?
1 F O R M C H E C K B O X 8 t h g r a d e o r l e s s
2 F O R M C H E C K B O X S o m e h i g h s c h o o l b u t d i d n o t g r a d u a t e
3 F O R M C H E C K B O X H i g h s c h o o l g r a d u a t e o r G E D
4 F O R M C H E C K B O X S o m e c o l l e g e o r 2 - y e a r d e g r e e
5 F O R M C H E C K B O X 4 - y e a r c o l l e g e g r a d u a t e
6 F O R M C H E C K B O X M o r e t h a n 4 - y e a r c o l l e g e d e g r e e
4 6 . A r e y o u o f H i s p a n i c o r L a t i n o o r i g i n o r d e s c e n t ?
1 F O R M C H E C K B O X Y e s , H i s p a n i c o r L a t i n o
2 F O R M C H E C K B O X N o , n o t H i s p a n i c o r L a t i n o
4 7 . W h a t i s y o u r r a c e ? M a r k o n e o r m o r e .
1 F O R M C H E C K B O X W h i t e
2 F O R M C H E C K B O X B l a c k o r A f r i c a n - A m e r i c a n
3 F O R M C H E C K B O X A s i a n
4 F O R M C H E C K B O X N a t i v e H a w a i i a n o r o t h e r P a c i f i c I s l a n d e r
5 F O R M C H E C K B O X A m e r i c a n I n d i a n o r A l a s k a N a t i v e
6 F O R M C H E C K B O X O t h e r
4 8 . W h a t l a n g u a g e d o y o u m a i n l y s p e a k a t h o m e ?
1 F O R M C H E C K B O X E n g l i s h
2 F O R M C H E C K B O X S p a n i s h
3 F O R M C H E C K B O X E n g l i s h a n d S p a n i s h e q u a l l y
4 F O R M C H E C K B O X S o m e o t h e r l a n g u a g e
4 9 . D i d s o m e o n e h e l p y o u c o m p l e t e t h i s s u r v e y ?
1 F O R M C H E C K B O X Y e s
2 F O R M C H E C K B O X N o ( I f N o , g o t o # 5 1
5 0 . H o w d i d t h a t p e r s o n h e l p y o u ? M a r k o n e o r m o r e .
1 F O R M C H E C K B O X R e a d t h e q u e s t i o n s t o m e
2 F O R M C H E C K B O X W r o t e d o w n t h e a n s w e r s I g a v e
3 F O R M C H E C K B O X A n s w e r e d t h e q u e s t i o n s f o r m e
4 F O R M C H E C K B O X T r a n s l a t e d t h e q u e s t i o n s i n t o m y l a n g u a g e
5 F O R M C H E C K B O X H e l p e d i n s o m e o t h e r w a y
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