Long-Term Care Survey Alert

Some facilities unintentionally overcode activities of daily living on the MDS when nursing staff does more for residents than is necessary or therapeutic. As a result, the facility's payment might be higher, but so will its staffing requirements, quality indicators and measures flagging decline in the residents' functional status. "The resident won't maintain his range of motion and ADL functioning like he would if he were doing more of his own care and remaining as mobile as possible," cautions restorative nurse B.J.Collard, president of CTS Inc. in Denver, CO.

The potential cure: "CNAs must learn to ask not what they can do for residents but what the resident can do for himself to maintain or improve his ADL functioning," Collard advises.

But busy caregivers often feel pressured to do what it takes to get residents in the dining room for breakfast on time. And CNAs who haven't been trained in restorative care techniques might not know how to use task segmentation (MDS Section G7)to breakdown an activity, such as bathing or grooming, so that the resident can perform part of it on his own.

As a result, the CNAs may end up doing more of the bath for the resident who could do it on his own if he had an hour to complete it. And by receiving too much assistance, the resident misses out on all of the natural range of motion and exercise involved in bathing and grooming himselfnot to mention the self-esteem and dignity that come from being more self-sufficient.

In spite of time crunches, you can teach caregivers to maximize their caregiving and time management to allow residents to become more independent. For example, CNAs can set up a resident who can do his own bath at the same times he is giving a complete bed bath to a totally dependent resident. The CNA can then assist the more independent resident as needed, suggests consultant Jan Stewart, with QUnique Corp. of Carroll, PA.

You can assign CNAs a more equitable work load by calculating residents' ADL scores when making assignments. "That way, the charge nurse won't give one nursing assistant a resident load with an average ADL score of 16, while another staff person gets the same number of residents with an average ADL score of 8," notes Stewart.

Facilities that "think up stream" will realize that a good restorative nursing program reduces the workload for CNAs over time, notes Cheryl Field, director of clinical and reimbursement services for LTCQ Inc. in Lexington, MA. "Then caregiving staff can focus their efforts on the residents who really need the assistance," she says. "For example, staff will have more time to help residents with their toileting programs."

And effective incontinence programs that help residents regain bladder or bowel control save a lot of money,Field notes."That is especially true when you consider the correlation between skin breakdown and incontinencenot to mention the cost of incontinence products and related staffing time," she adds.

Some families may object to the idea of the facility doing less for their loved ones. Indeed, some consumer advocacy groups have lambasted the concept as an underhanded way for facilities to cut corners.

To dispel these fears, explain the restorative plan of care to residents and families at admission and during care conferences. Stewart suggests saying something like: "We know your mother can't brush her hair perfectly and we provide professional services to do that, but we want her to lift her arms and brush for 10 minutes a day because it helps improve the mobility in her shoulder and her circulation."

Tips: Get paid for your restorative nursing efforts. Restorative nursing or nursing rehab counts toward classification in the low rehab RUG under Medicare and also into some of the lower RUGs paid by Medicaid in RUG-based Medicaid states.

To review requirements for what counts as nursing rehab services on the MDS, see chapter 3 (pages 3-191and 3-192) of the Resident Assessment Instrument User's manual at www.cms.hhs.gov/medicaid/mds20/rai1202ch3.pdf.

Use Section G8 of the MDS as a guide to assess whether residents could do more of their own ADLs. This section asks, for example, if the resident believes he could be more independent.