1. Rehab and Restorative Services
In-service Training Guide

2. RESTORATIVE NURSING Restorative Nursing is defined as:
Nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. (RAI, 2011)
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. (OBRA , 1987)
Restorative nursing is person-centered care, whole person nursing care. This kind of nursing is practiced each time a resident is cared for.
Restorative nursing offers instruction, encouragement, guidance, and assistance to residents to perform self-care skills with as much independence as possible .

3. Restorative Nursing The Benefits:
Prevents new / additional complications
Helps resident adjust to new problems and limitations
Prevents functional decline
Promotes Independence
Improves Quality of Care
Improves Quality of Life
OBRA 1987 required SNFs to identify and act on risk factors to prevent functional decline in residents. Facilities are expected to plan care that will delay any decline in function in the residents.
Restorative nursing:
Prevents the negative effects of functional decline such as pressure ulcers, incontinence, social isolation, complications of immobility, depression, withdrawal, and further decline.
Has a positive impact on survey and quality measure outcomes.
Provides reimbursement for good care, which creates resources for more good care.

4. Restorative vs. Rehabilitation
Restoring and maintaining
Long-term, ongoing process
Improves not restores or compensates for skills lost through chronic disease
Retrain and education of new skills
Fast pace, progress must be made
Usually triggered by acute illness or injury

5. Restorative Nursing Keys to Success: RN or LPN must supervise
Nursing assistant must be an aide for at least 6 months and trained in the techniques that promote resident involvement
Nursing staff responsible for overall supervision and coordination
A registered nurse or licensed practical nurse must supervise the activities of a restorative program because restorative is based on the nursing model.
Nursing assistance must be trained in the techniques that promote resident involvement.

6. Restorative Nursing Keys to Success: Nurses order restorative programs
Therapy department work as consultants
Nurses do not have to have a doctors order for a restorative program. Orders can be written as interventions.
Therapy department works as consultants to the restorative program because therapy is based on the medical model.

7. Restorative Nursing Keys to success: Restorative should begin
When a resident is discharged from therapy
Upon admission if the resident is not a candidate for therapy but has a restorative need
At any time a restorative need arises during the residents stay
The RAI Manual states that “Most residents are candidates for nursing-based rehabilitative care that focuses on maintaining and expanding self-involvement in ADLs.”

8. Restorative Nursing Keys to Success:
The resident should have an identified deficit and be at risk for a functional decline.
Resident does not have to show a potential for improvement.
Exercises and treatment are planned, scheduled, and documented.
Assessment is the first step in establishing a successful restorative program.
Restorative nursing requires an assessment of each resident with the MDS, staff input, and other assessments to identify candidates for a restorative program.
Some indicators may be:
Decline in late-loss ADLs ( bed mobility, eating, transfers, toilet use)
Incontinence without a toileting plan
Falls
Decline in Range Of Motion
Resident, Family request, or Concern

9. Restorative Nursing Keys to Success:
All staff must be onboard with restorative nursing approach / Holistic care
Care Plans
Good communication / education for your frontline staff: CNAs & Charge nurses !!!
Look at the individual resident
Consistent staffing assignments
Team work
Regular daily routines mean structure and consistency for the resident and less confusion.
Care plans must be updated on a regular basis to keep progress up to date and to be modified where necessary.
It is important that all staff involved with restorative nursing be kept well informed about the residents involved in the program and all staff follow the same philosophy.
Every resident is a unique individual who has different needs and desires which staff must recognize. Keep attitudes positive – have patience with the resident, encourage them to do their best in all that they can do, recognize their strengths and weaknesses and never undermine their ability.
There might be restorative aides directly dealing with residents but it takes the whole team to make the biggest successes.

10. Restorative Nursing MDS rules are specific for restorative care.
Restorative care must be given 6 days a week. At least 15 minutes of care to qualify for one day of reimbursable care.
Some categories require two restorative nursing programs with a total of 30 minutes a day of restorative care to place residents in the higher RUG groups.
The 15 minute increments must be given to each modality and not figured by adding time from different programs.
Restorative nursing can be offered in groups with similar needs. However, it cannot be larger than four residents per caregiver.
Restorative nursing is planned and scheduled to meet each resident’s individual needs.

11. Restorative Programs:
Range of Motion:
Dressing and Grooming
PROM/ AROM/ AAROM
Amputation/Prosthesis Care
Splint or Brace Assistance
Eating and Swallowing
Transfer
Scheduled toileting / Bladder retraining
Ambulation
Communication
Bed Mobility
Other- any other activity used to improve or maintain the resident’ s highest level of functioning.

12. Restorative Nursing Documentation:
Care plan must include objective, measurable goals
Documentation of assessed need for services
Nurse must periodically evaluate the resident’s progress and change care plan if needed.
License nurse documentation focuses on progress towards objective, measurable goals.
Restorative documentation focuses on the time spent completing activities and how well the resident did or did not tolerate the activity.

13. Restorative Nursing Documentation Includes:
Showing that the restorative nursing care provided was accurate and met nursing standards
Narrative note reflecting progress/lack of progress, refusal, or medical withholding of care
Clearly identify deficit and/or need for maintenance
These are the components to a successful restorative program.

14. Restorative Nursing TRAINING RESOURCES
AHCA Restorative Certification Class
(Highly Recommended)
Long-Term Care Nurse Assistant’s Guide to Advanced Restorative Skills by Barbara Acello
Restorative Nurse: A Training Manual for Nursing Assistants by Linda Pierce
Long-Term Care Restorative Nursing Desk Reference by Barbara Acello
RAI Manual Section O0500
Therapy Department

15. REFERENCES Restorative Nursing
Centers for Medicare and Medicaid services (CMS)2009. “Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual”.
The Centers for Medicare and Medicaid Service
(Accessed January 19, 2013)

16. Thank You! For your efforts to restore movement among our residents.