Free Resident Evacuation Assessment-F-62373 - Wisconsin


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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62373 (Rev. 04/09)

STATE OF WISCONSIN Page 1 of 5

RESIDENT EVACUATION ASSESSMENT
Completion of this form is required per DHS 83.35(5) and 88.05(4)(d)2a and b, Wisconsin Administrative Code, within 3 days of admission and must be retained in the resident's record. Failure to complete this form could result in Department sanctions.
Name Facility Date Form Completed

Address

Name Resident

Apartment or Room Number

Name Evaluators

The ability of residents to successfully use a means of egress depends on how they will perform in an actual emergency. This sample checklist has been adapted from the Fire Safety Evaluation System, Appendix F of Chapter 51, which appears in the 1985 Life Safety Code. To successfully rate each resident, the evaluator should not speculate on a resident's behavior during an emergency, but instead, should consult with someone who has observed the resident in a crisis situation. A spirit of cooperation must be fostered among all personnel involved, i.e., fire inspectors, building inspectors, owners, operators and staff, to correctly determine the resident risk factors. During a real fire emergency, some residents are not likely to perform as well as they do in drill situations. Therefore, ratings based on commonly observed examples of poor performance provide the best indication of actual behavior due to the unusually stressful conditions of an actual fire.

CBRF ONLY: Refer to DHS 83.04(2)(a)-(f), Wis. Admin. Code, when completing this form. I. RISK OF RESISTANCE
This means there is a reasonable possibility that during an emergency evacuation, the resident may resist leaving the facility. Mere complaining or arguing is not considered resistance. (Check one.) Yes No N/A 1. 2. The resident can be classified as MINIMAL RISK (no specific evidence to suggest that the resident may resist evacuation. The resident has exhibited MILD RESISTANCE (the resident may mildly resist leaving the facility, such as mildly resisting instructions from the staff, or hiding from the staff during a situation similar to a fire emergency). The resident has exhibited STRONG RESISTANCE. Resident may offer resistance that requires the full attention of one or more staff members. EXAMPLES INCLUDE: Struggling in a situation similar enough to a fire emergency to react that the behavior could recur during a fire emergency. Totally refusing to cooperate in a situation similar enough to a fire emergency. Hiding in a similar situation and once found, continuing to offer resistance.

3.

II. IMPAIRED MOBILITY
This means that the resident is physically limited in his/her ability to leave the home unassisted. The ratings should reflect and/or be based on: Present physical environment in the building. The resident lying awake on his/her bed. How easily the resident can leave, given: o the presence of physical barriers that hinder movement (such as stairs) o the resident's ability to get out of bed or chair which he/she normally uses. o the resident's ability to use devices that aid movement (such as wheelchairs, walkers, crutches and/or leg braces). Credit is given only if such devices are always available for emergency evacuation. o the resident's ability to use the most accessible route out of the facility o the influence of any routine medication that slows his/her movement.

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(Check one.) Yes No N/A 1. 2. 3. SELF STARTING means the resident is physically able to start and complete an evacuation without physical assistance. SLOW means the resident prepares to leave and travels to the exit, for an area of refuge, at a speed significantly slower than norms. (Specifically, not within a period of 90 seconds.) NEEDS LIMITED ASSISTANCE means that the resident may require some initial or brief intermittent assistance, but can accomplish most of the evacuation without assistance. Total time required for staff to assist the resident, and for the resident to evacuate the facility, should not exceed the required evacuation time for the facility. EXAMPLES INCLUDE: The resident needs help to get into a wheelchair. The resident needs help to descent stairs. The resident needs help to get out of bed. The resident needs help to open a door. 4. NEEDS FULL ASSISTANCE OR VERY SLOW a. NEEDS FULL ASSISTANCE means the resident may require physical assistance from a staff member during most of the evacuation or the total time required for staff assistance and for the resident to evacuate the facility, is greater than the required evacuation time for the facility. EXAMPLES INCLUDE: The resident may need to be carried from the building. The resident needs help to get into a wheelchair and must be wheeled out of the building. The resident needs help to get into leg braces and needs help to descend steps. b. VERY SLOW means the time necessary for the resident to prepare to leave and travel from his/her bedroom to the exit is so long that the staff cannot permit the resident to evacuate unassisted. Specifically, if the resident cannot leave and exit within 150 seconds.

III. IMPAIRED CONSCIOUSNESS
This means the resident could experience a partial or total loss of consciousness in a fire emergency. (Check one.) Yes No N/A 1. NO SIGNIFICANT RISK means the resident is not subject to loss of consciousness or has had fewer than six (6) episodes of consciousness loss (partial and/or total) during the three months preceding the ratings. PARTIALLY IMPAIRED means the resident has had at least six episodes of consciousness loss in the last three months, and the most severe of these episodes was only a partial loss of consciousness, and the resident would still be able to participate somewhat in his/her own evacuation. EXAMPLES INCLUDE: mild seizures (partial or petite mall) dizzy spells intoxication any other partially incapacitating impairment of consciousness 3. TOTALLY IMPAIRED means the resident has had at least six episodes of consciousness loss in the last three months, with the most severe being a total or severely incapacitating loss of consciousness, and requiring full assistance of at least one staff member to get out of the building. EXAMPLES INCLUDE: severe seizures (generalized or grand mal) fainting spells intoxication any other total or severely incapacitating loss of consciousness

2.

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IV. NEED FOR EXTRA STAFF
There is specific evidence that more than one staff member may be needed to evacuate the resident. "Specific evidence" means two or more persons have been previously required to assist the resident and could be required during a real fire emergency. When rating the resident on this category, disregard the presence of staff members who appear unusually strong or weak. (Check one.) Yes No N/A 1. NEEDS ONLY ONE STAFF means there is no specific evidence that the resident needs help from two or more persons in a fire emergency. 2. NEEDS LIMITED ASSISTANCE from TWO STAFF means the resident requires some initial or brief assistance from two persons but will otherwise need help from no more that one person. EXAMPLES INCLUDE: resident needs two persons to get into a wheelchair resident needs two persons to descend stairs in the building. 3. NEEDS FULL ASSISTANCE FROM TWO STAFF means the resident requires assistance from two persons during most of the evacuation. EXAMPLES INCLUDE: resident may need to be carried from the building requiring two persons resident needs two persons to get into a wheelchair and to get the wheelchair down a flight of stairs resident may vigorously resist an evacuation and two persons would be required to get him/her out.

V. RESPONSE TO INSTRUCTIONS (STAFF DIRECTED EVACUATION)
This means the resident's ability to receive, comprehend, and follow-through with simple instructions. Since residents do not respond equally well to all staff members, the resident should be rated on his/her response to a staff member whose directions he/she is least likely to follow. (Check one.) Yes No N/A 1. FOLLOWS INSTRUCTIONS means the resident can usually be depended upon to receive, comprehend, remember and follow simple instructions. 2. REQUIRES SUPERVISION means the resident is generally dependable and needs to be guided, reminded, reassured or otherwise accompanied during his/her evacuation, but will not require the exclusive attention of a staff member. EXAMPLES COULD INCLUDE A RESIDENT WHO: is deaf or hearing impaired and sometimes misinterprets communication from staff using sign language. sometimes forgets instructions after a brief period of time is sometimes distracted or confused and fails to follow-through with instructions is sometimes groggy and may fail to listen carefully or follow-through with instructions is sometimes uncooperative without apparent cause is confused and sometimes becomes "lost" in a familiar place. 3. REQUIRES CONSIDERABLE ATTENTION OR MAY NOT RESPOND means the resident may fail to receive, understand or follow through with instructions and may require most of the attention of a staff member during the resident's evacuation. EXAMPLES INCLUDE A RESIDENT WHO: sometimes does not understand simple instructions. may not respond to instructions from a particular staff member. is sometimes emotionally upset and is, therefore, unable to follow instructions is deaf or hearing impaired and the staff cannot communicate reliably with the resident is easily forgetful, easily confused or easily distracted.

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VI. WAKING RESPONSE TO ALARM
This means the fire alarm may fail to awaken the resident. (Check one.) Yes No N/A 1. RESPONSE PROBABLE means the resident has demonstrated his/her ability to respond to the fire alarm during periods of sleep. This demonstration should be conducted under conditions simulating sleeping patterns, i.e., without hearing aide, after taking night-time medications. Also the resident should be alert enough to follow simple instructions. A device such as an alarm clock that makes a sound similar to, but not louder than the fire alarm, may be used. 2. RESPONSE NOT PROBABLE means that the resident has not been tested for his/her ability to wake up to the fire alarm, that the resident failed to demonstrate his/her ability to respond to the alarm or that one or more of the following conditions are true: The building does not have an alarm system meeting the requirements of Chapter 21, or the alarm is not very loud where the resident sleeps (doors should be closed and barriers kept in place when testing the loudness of the fire alarm). Medication taken by the resident before retiring differs in type or the amount is increased from the medication taken in waking hours. The resident has a readily apparent hearing impairment or removed his/her hearing aid when sleeping. There is some specific evidence that the resident is an exceptionally sound sleeper, i.e., did not awaken during some particularly loud clamor or racket; staff members have had to vigorously shake resident to wake him/her, etc.

VII. RESPONSE TO FIRE DRILLS (SELF-DIRECTED EVACUATION)
This is the ability of the resident to make a decision to leave the building as demonstrated by his/her performance during fire drills. There are three basic tasks under this category that a resident must perform reliably and without instructions or supervision. (Check one.) Yes No N/A 1. INITIATES AND COMPLETES EVACUATION PROMPTLY. A "YES" score is given if the resident has demonstrated response to an alarm or warning of a fire by starting and completing the evacuation without delay. A "NO" score is given when: The resident does not react to the alarm until alerted by a staff member. The resident spends an excessive amount of time preparing to leave , i.e., getting dressed, seeing what everyone else is doing. The resident has a hearing impairment and must be alerted by a staff member. The resident is sometimes upset or confused and may seek out a staff member before evacuating. The resident will reliably start an evacuation but is easily distracted and requires some supervision. 2. CHOOSES AND COMPLETES BACK-UP STRATEGY. A "YES" score is given if the resident has demonstrated the ability to select an alternative means of escape or to take any other appropriate action if the primary escape route is blocked. A "NO" score is given to those residents who are unlikely to select a good course of action if the primary escape route cannot be used. This is, if they have not been trained to find an alternative escape route, to find an area of refuge, or to perform other appropriate actions. An example is a resident who lacks the conceptual ability to understand about fire hazards and blocked escape routes and, therefore, needs supervision.

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Yes

No

N/A 3. STAYS AT DESIGNATED LOCATION IN A SAFE AREA. A "YES" score is given if the resident has demonstrated that he/she will stay at a designated safe location during fire drills. EXAMPLES INCLUDE: The resident has been specifically trained to remain at the designated location in a safe area and has done so without the presence of staff members in three of the last four fire drills. The facility uses a tree, telephone pole, or a detached and remote building as the designated location and the resident has demonstrated that he/she will remain there without staff presence in three of the last four fire drills. The resident is physically immobile and, therefore, cannot leave the designated location. The resident may tend to wander, but a reliable resident has been assigned to keep him/her at the designated location without using any force or coercion in three of the last four fire drills. A "NO" score is given to: A resident who has not been trained to stay at a designated location without staff supervision. A resident who has been trained but has failed to demonstrate this capability in three of the last four fire drills.

In all three basic tasks mentioned, the resident shall be credited only if specifically trained or instructed in the task and only if he/she has demonstrated the desired response at three of the last four fire drills. When the task has not been tested in four fire drills, then the performance can be evaluated on the last two testing opportunities. Ratings must be based on demonstrated performance. Anyone not trained must be given the higher score. A resident must be rated assuming that a fire might find him/her in a common situation where he/she is least likely to respond well to an emergency, i.e., after being awakened at night.

Evaluator's Remarks: