This survey maintains respondent confidentiality. Once submitted, the survey can not be directly tied by the organization to the individual responding.

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

Survey Instructions

This survey asks for your opinions about resident safety issues in your nursing home. 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	Strongly Agree		Does Not Apply or Don't Know
1. Staff in this nursing home treat each other with respect
2. Staff support one another in this nursing home
3. We have enough staff to handle the workload
4. Staff follow standard procedures to care for residents
5. Staff feel like they are part of a team
6. Staff use shortcuts to get their work done faster
7. Staff get the training they need in this nursing home
8. Staff have to hurry because they have too much work to do
9. When someone gets really busy in this nursing home, other staff help out
10. Staff are blamed when a resident is harmed
11. Staff have enough training on how to handle difficult residents
12. Staff are afraid to report their mistakes
13. Staff understand the training they get in this nursing home
14. To make work easier, staff often ignore procedures
15. Staff are treated fairly when they make mistakes
16. Residents needs are met during shift changes
17. It is hard to keep residents safe here because so many staff quit their jobs
18. Staff feel safe reporting their mistakes

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
2. Staff are told right away when there is a change in a residents care plan
3. We have all the information we need when residents are transferred from the hospital
4. When staff report something that could harm a resident, someone takes care of it
5. In this nursing home, we talk about ways to keep incidents from happening again
6. Staff tell someone if they see something that might harm a resident
7. Staff ideas and suggestions are valued in this nursing home
8. In this nursing home, we discuss ways to keep residents safe from harm
9. Staff opinions are ignored in this nursing home
10. Staff are given all the information they need to care for residents
11. It is easy for staff to speak up about problems in this nursing home

Section C: Your Supervisor

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree		Does Not Apply or Don't Know
1. My supervisor listens to staff ideas and suggestions about resident safety
2. My supervisor says a good word to staff who follow the right procedures
3. My supervisor pays attention to resident safety problems in this nursing home

Section D: Your Nursing Home

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree		Does Not Apply or Don't Know
1. Residents are well cared for in this nursing home
2. Management asks staff how the nursing home can improve resident safety
3. This nursing home lets the same mistakes happen again and again
4. It is easy to make changes to improve resident safety in this nursing home
5. This nursing home is always doing things to improve resident safety
6. This nursing home does a good job keeping residents safe
7. Management listens to staff ideas and suggestions to improve resident safety
8. This nursing home is a safe place for residents
9. Management often walks around the nursing home to check on resident care
10. When this nursing home makes changes to improve resident safety, it checks to see if the changes worked

Section E: Overall Ratings
1. I would tell friends that this is a safe nursing home for their family.
Yes
Maybe
No

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

Poor	Fair	Good	Very Good	Excellent

Section F: Background Information
1. What is your job in this nursing home? Check the category that best applies to your job. If more than one category applies, check the highest level job.
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))
Physician (MD, DO)
Other Provider (Nurse Practitioner, Clinical Nurse Specialist, Physician Assistant)
Licensed Nurse (Registered Nurse (RN), Licensed Practical Nurse (LPN), Wound Care Nurse)
Nursing Assistant/Aide (Certified Nursing Assistant (CNA), Geriatric Nursing Assistant (GNA), Nursing Aide/Nursing Assistant)
Direct Care Staff (Activities Staff Member, Dietitian/Nutritionist, Medication Technician, Pastoral Care/Chaplain, Pharmacist, Physical/Occupational/Speech, Respiratory Therapist, Podiatrist, Social Worker)
Administrative Support Staff (Administrative Assistant, Admissions, Billing/Insurance, Secretary, Human Resources , Medical Records)
Support Staff (Drivers, Food Service/Dietary, Housekeeping, Laundry Service, Maintenance, Security)
Other

2. How long have you worked in this nursing home?
Less than 2 months
2 to 11 months
1 to 2 years
3 to 5 years
6 to 10 years
11 years or more

3. How many hours per week do you usually work in this nursing home?
15 or fewer hours per week
16 to 24 hours per week
25 to 40 hours per week
More than 40 hours per week

4. When do you work most often?
Days
Evenings
Nights

5. Are you paid by a staffing agency when you work for this nursing home?
Yes
No

6. In your job in this nursing home, do you work directly with residents most of the time?
YES, I work directly with residents most of the time
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?
Many different areas or units in this nursing home/No specific area or unit
Alzheimers/Dementia unit
Rehab unit
Skilled nursing unit
Other area or unit

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.

This Survey is unavailable for submission.