Long-Term Care Survey Alert

If your facility identifies a system-wide problem with the quality of its restorative nursing program, it's time to get the program back on track - fast. Residents go downhill quickly without effective restorative care, and the next thing you know, your facility could be holding an immediate jeopardy citation for avoidable outcomes, such as pressure sores, functional decline, incontinence and hypostatic pneumonia.

Facilities should start by implementing a philosophy of restorative care that involves doing less for residents so they can do more for themselves, suggests Cheryl Field, a rehab nurse specialist and director of clinical and reimbursement systems with LTCQ Inc. in Bedford, MA. "This means giving the resident more opportunity to succeed and achieve or maintain their highest level of functioning - whether in transfer skills or mobility or even social skills - even though it takes more time," she says.

The philosophy starts at the top and has to be integrated throughout the building. "Families have to be sold on this approach, from the time of admission, so that they expect the staff to care for their loved one in a way where they are encouraged to be independent as possible," explains Field. Otherwise, families may complain that staff is neglecting their loved ones.

Field advocates an integrated model where everyone on staff is trained in the principles and philosophiesofrestorativenursingsoitcanbedoneby any certified nursing assistant caring for the resident on any shift. In addition, the activities and volunteer staff can be trained and included in many aspects of various programs. This is important, she says, because "CNAs are taught a dependent model of care, e.g., how to bathe a totally dependent patient, etc. So there has to be a change in mindset that comes from the top down."

Next, teach staff how to identify restorative nursing candidates. Facilities should revisit the ADL resident assessment protocol, which spells out criteria for whether each resident might benefit from restorative services, recommends Debra Ohl, a long-term care consultant in Cleveland.

Field advocates teaching staff to identify people who require restorative care by using the concepts "vulnerable" and "transition." "These two words identify people at risk of losing functional status - physically, emotionally or socially," she says.

A resident newly admitted to the facility is vulnerable and in transition; someone who has been walking to the dining room for a year would be encouraged to walk as part of the care plan, not restorative care. " Yet if that person got the flu and stopped walking - then that's a red flag for restorative services," Field says.

Also, look for small changes in resident decline and intervene promptly. Don't wait until the person is no longer ambulatory, for example, or has developed contractures due to immobility, paving the way for a G-level (actual harm) deficiency.

Facilities should also find ways to ensure residents participate in restorative programs. Staff should assess resident involvement in and satisfaction with the restorative program on a regular basis, suggests Annette Fleishell, vice president of clinical services with JoAnne Wilson's Gerontological Nursing Ventures in Laurel, MD. If residents aren't participating, find out why and address the problem as soon as possible.

"The patient may have arthritis and the pain is keeping them from wanting to participate. Or the person could be depressed," Fleishell says.

Or the restorative programs may be too rote and boring to encourage resident participation. Facilities today are implementing a wide variety of exciting programs, such as a "park and dine" program where residents "park" their wheel chairs and walk in to the dining room."Monday makeovers" that focus on grooming skills are also popular. "Graduations" also motivate residents to achieve a goal, such as walking independently again, so they can receive a diploma during a special ceremony.

To keep staff and administrators invested in restorative programs, it's a good idea to quantify the impactofrestorativecareonthefacility'sbottomline and survey record over time.

Effective restorative care programs affect the facility's bottom line favorably by reducing incontinence, pressure sores, depression and other clinical problems that drain staff time and cost money to manage. "For every five residents you get out of diapers as the result of toileting programs, you can pay for the salary of a CNA," says Fleishell.