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Restorative nursing: It takes a facility

May 15, 2012
by Joe Graham
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In 2010, my administrator was staring at our most recent three-month FQIP (Facility Quality Measure/Indicator Report) report, when he turned to me (the rehab manager) and the director of nursing and asked: “Are we or are we not a Medicare Five-Star facility?” I replied that we are.

His response: “Then why do we continue to accept failure month after month in our physical functioning quality measures? Our three-month FQIPreport ranked us in the 95th percentile for the state in the domain ‘Residents whose ability to move in and around their room’ got worse.”

That ranking meant that 95% of facilities in the state were outperforming us. To make matters worse we were in the 97th percentile in the domain “Residents whose need for help with daily activities has increased.” It was time for a “gut check.”

I had been the rehab manager for more than four years and I prided myself on not only providing excellent rehab care to our short-term residents, but also to the residents who called our facility home.


However, this was not just a rehab issue; this was not just a nursing issue. It was a Renaissance Gardens at Riderwood issue. We succeed or we fail as a team. So after much discussion with the team, an interdisciplinary approach was established.

Were we successful? Six months later, our FQIP report scored us in the 13th percentile in “Residents whose ability to move in and around their room got worse” and in the 17thpercentile in “Residents whose need for help with daily activities has increased.” 

Our plan called for all LTC residents to have an appropriate five-day restorative nursing program each week. Rehab staff evaluated all LTC residents with two goals in mind. First, the therapist would determine if the resident experienced a decline in function and, if so, a treatment plan would be developed. The second goal focused on evaluating the resident’s current restorative nursing program to determine if it was still appropriate. 

If the plan was not appropriate or if the resident currently did not have a plan, one was developed and reviewed with our restorative nursing assistants (RNAs) and the resident. Specific communication pathways for our RNAs were established so they could communicate with the therapists in real time. As a result, the therapist was aware that a resident was beginning to decline, which enabled him or her to intervene before the decline became significantly detrimental to the resident.


Restorative nursing often doesn’t happen the way it should. Perhaps the facility has a number of staff call-outs and needs to pulls its RNAs to work as nursing assistants on the floor. The RNA gets bogged down with nonrestorative duties (stocking supplies, etc). This can happen even in the most committed facilities, but I believe it often occurs because the staff has not fully bought into the benefits of restorative nursing.

Remsburg et al found that “a progressive mobility restorative program implemented by a certified nursing assistant specially trained in restorative techniques resulted in most residents maintaining their baseline ADL self-performance abilities and the level of assistance provided by staff.”1 I believe that a restorative nursing program can do much more.

The benefits of exercise for the elderly has been well studied and has been shown to improve cardiovascular functioning and endurance, increase strength, improve balance, decrease joint pain and even to improve mood.2 To realize these benefits, the intensity of the restorative program needs to be high enough as to challenge the residents. This is where most programs fall short and why I advocate that an “appropriate” physical or occupational therapist develop the program.

The reason I use the word “appropriate” because the therapist designing the program needs to have both experience and knowledge in working with LTC residents. He or she also must understand recent research that shows that elderly residents can benefit from an “aggressive” exercise program. If the program challenges the resident, then he or she likely will require less physical staff assistance, will be more likely to be able fight off disease such as pneumonia, will have a lower risk of skin breakdown and a lower risk of falls. Basically, you get a healthier, happier resident who has a better quality of life and, perhaps, requires less assistance.

Restorative care also allows a facility to comply with the Code of Federal Regulations 42 Subpart B, Section 483.25 Quality of Care, which states: “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”

In addition Section 483.25(a)(1) states: “A resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to (i) bathe, dress and groom; (ii) transfer and ambulate; (iii) toilet; (iv) eat; and (v) use speech, language, or other functional communication systems.