Long-Term Care Survey Alert

Detect these clinical impediments to effective therapy.

Your survey will hit a tailspin if surveyors spot a resident receiving rehab who's gone downhill--or one who could have benefited from rehab therapy but didn't receive it.

Surveyors could cite a care plan tag or the "catch all F309," if a resident didn't meet rehab goals due to the facility's lack of attention or adequate treatment, cautions John Lessner, attorney with Ober/Kaler in Baltimore.

Real-world examples: One nursing facility received an H-level tag for failing to provide speech therapy to help a resident with a feeding tube eat again. Facilities have also been cited when surveyors find a resident didn't participate fully in therapy due to inadequate pain management, reports Donna Senft, a physical therapist and attorney with Ober/Kaler.

Your best bet: Identify residents who aren't progressing or participating in therapy as expected so you can intervene immediately.

If a person isn't meeting therapy goals, make sure the goals aren't the culprit. "Are they reasonable, attainable and measurable?" asks Shehla Rooney, a physical therapist and owner of Premiere Therapy Solutions in Cookeville, TN. Does the resident understand and buy into the goals?

If so, look for common clinical issues that might be interfering with someone's rehab potential. For example, does the person have an "infection or depression? Did he have another small stroke or fall?" asks Rooney.

The top clinical problems that may interfere with a person's therapy include:

• Pain. "Pain affects many aspects of a person, including his psychological health," says Cheryl Boldt, RN, a consultant with Maun-Lemke in Omaha, NE. Pain can lead to depression and behavioral symptoms, loss of appetite and weight loss, she notes. The person in pain may not heal well or have the motivation to participate in therapy and activities of daily living, Boldt adds.

•  Anemia. This condition will not only affect a person's ability to tolerate therapy but he may lose ground in functional status. For example, the person with anemia may show a "decreasing ability to ambulate," says Richard Marasco, a clinical pharmacist in Valdosta, GA. In his view, a hemoglobin of less than 12 in elderly patients warrants further investigation, he says.

• Medication side effects. Some of the common culprits include blood pressure medicines, which "as a class cause dizziness and orthostatic hypotension," says Carla Saxton McSpadden, RPh, CGP, with the American Society of Consultant Pharmacists. "People taking the medications may feel lethargic and lousy--especially until they get used to them. Beta blockers are especially likely to do that," she notes.

But you can time administration of the blood pressure medicine so the person doesn't have "that immediate effect from it before or during therapy," says McSpadden. The prescribing clinician could re-evaluate the dose or try a different medication, although "many factors" play into the decision to change medication, McSpadden says. "If the person has orthostatic hypotension, teach him to get up and change positions slowly."

Diuretics could cause the person to worry about incontinence episodes in therapy--and thus refuse to attend. "Staff tends to give diuretics in the morning so the person won't have to urinate at night," says McSpadden. But "creative timing could help the resident avoid that diuresis effect during therapy."

• Dietary shortfalls. A rehab resident's diet has to keep pace with the increased caloric demands of therapy and illness.  "The injury response or illness often causes appetite loss," says Annette Kobriger, RD, CD, MPH, MPA, a long-term care nutritional expert and president of Kobriger Presents in Chilton, WI. "You'll often see this with new admissions," she adds, noting that the problem often resolves within a week or two.

Residents who haven't been active will require 20 to 40 percent more calories a day to participate in rehab effectively, depending on the program's intensity, adds Kobriger. Those who don't receive adequate calories or fluid will tire more easily in therapy, she says. The registered dietitian should thus ensure the resident's diet includes enough calories, protein and fluid to help him heal an injury or pressure ulcer and participate in therapy.

Boost caloric intake: During the med pass, provide the resident with 60 to 90 cc's of a 2 Kcal/cc supplement, Kobriger suggests. "The person is more likely to accept the small volume."

Editor's note:  Also catch part 2 of this story, "Shore Up Your Rehab Program Before Your Survey Record Needs Rehabbing", in the October 2006 Long-Term Care Survey Alert.