Restorative nursing program - a "recipe" for program success.

How do you design a restorative nursing program that keeps your facility in compliance with Federal law and ensures successful state surveys? Think of it as a recipe, and follow the steps. Then, adapt the "recipe" to your residents' needs and to the "ingredients" you have available (therapy, restorative nursing assistants (RNAs), CNAs, etc.)

A successful restorative nursing program requires the integration of specialty therapy, RNAs and CNAs, all working with clear restorative therapy responsibilities. OBRA guidelines define restorative nursing as the continuation of therapy by nursing following rehabilitation, with nursing responsible for both maintaining the status of the resident after discharge from rehabilitation, and documenting efforts to restore as much functional independence as possible. Each resident's restorative needs must be documented (MDS) and resident-specific care plans that tie into the MDS must be developed. Program objectives should be both realistic and achievable with respect to caseload.

Program implementation begins with the establishment of a starting point that takes full advantage of your existing staff resources post-rehabilitation (therapy). How many nursing staff members (by shift) are trained in restorative care? Is there a need to train additional RNAs? When rehabilitation releases a resident with continuing therapy needs to nursing, that resident should be cared for by the best restorative-trained nursing staff, usually the RNAs. Enough CNAs need to be trained in basic restorative care to free RNAs to focus on meaningful continuation of therapy for those with the greatest needs.

Therapy should be involved in resident assessment, determination of restorative need (including orthotics), training nursing staff, identifying feeding program candidates, etc. The goal is to have as much specialty therapy involvement as possible without limiting resident care.

Each resident with restorative needs should be evaluated by nursing and therapy, and should be classified into one of four categories prior to implementing the program. The appropriate staff is then assigned to provide the specific restorative care.

1) Active Participants

Active participants receive their care from RNAs under the oversight of therapy. Most have just been released from rehabilitation, and require continued ambulation, orthotic daily wear, feeding assistance, etc. All residents needing orthotic devices go to therapy first for determination of a wearing schedule, and are then released back to nursing with a restorative care plan. Other active participants may have returned from a hospital stay needing special care to be brought back to maintenance status (see below).

Some residents may initially need to be active participants to be brought back into compliance with their restorative care plan. The number of active participants should not exceed the RNAs' ability to provide comprehensive care and specialty therapy should closely monitor the caseload and provide assistance as needed.

2) Maintenance Participants

These participants have been following a restorative care plan for several weeks, with good compliance and established progress, or at least maintenance. Care consists of ambulation assistance and range of motion (massage and slow, gentle stretching (MSGS)), proper positioning and functional alignment, and orthotic device application and removal. RNAs are available to assist and work closely with CNAs as a patient is transitioned from active to maintenance status.

Maintenance care plans with a clear delineation of responsibilities, time schedules, etc., are prepared and signed by the CNA(s) responsible for implementing the restorative care. CNAs must immediately report any significant change in condition (the need for modification of an orthotic device, noncompliance, red areas on the skin, etc.) to the RNAs or therapist. These incidents should be documented. When warranted, a change in the care plan should be implemented. The therapists or RNAs should carefully monitor each maintenance participant's status.

3) Residents Awaiting Active Participant Status

Residents with identified restorative nursing needs who are awaiting active participant status receive short-effects restorative therapy (i.e., MSGS-type ROM, ambulation, proper positioning, etc.) from trained CNAs. This therapy, along with the resident's future active participant status, is documented in the care plan. As a "space" becomes available, they are transitioned into active or maintenance participant status, depending on their needs.

Any significant change in condition is immediately brought to the attention of the supervisor and, if warranted, the care plan and the resident's status in the program are modified.

4) Discharged Participants

Participants are discharged from the program for various reasons, such as hospital stays or transfers out of the facility. A resident evaluation is usually indicated upon readmission, as the resident's condition can change significantly when restorative therapy is not provided outside the facility. For this reason, hospitals admitting your residents should always be made aware of the daily restorative schedule needed to maintain their condition.

Active or maintenance participants who progress significantly may qualify for discharge from the restorative program and admission to rehabilitation. For example, if a contracture has been opened or lost range of motion has been reversed, physical or occupational therapy may be indicated to begin ambulation therapy or to teach self-propelling of the wheelchair.

Alert and oriented restorative nursing program participants have the right to refuse treatment. Those refusing treatment should be offered restorative therapy each quarter to assess any change in status warranting inclusion in the program. If participants are combative or uncooperative, maintenance status may be indicated. Repeated attempts to provide therapy for participants with cognitive difficulties must be documented along with the reason for discharge from the program.

Conclusions

An organized restorative nursing program is not as complicated as it may sound. Read this "recipe" several times until you see the "flow" of residents according to their specific needs.

Of course, the easiest and most desirable "recipe" is one that emphasizes prevention - with activity designed to maintain physical and mental health, proper positioning and body alignment, and constant emphasis on a dignified, home-like atmosphere.

Karen L. Bonn, RN, ROF, a former Director of Nursing, is founder and president of Restorative Medical, Inc., Brandenburg, KY.