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Is a return to mobility possible?

December 12, 2011
by Mary M. Harroun, MS, LNHA
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Mary m. harroun, ms, lnha, demonstrates a leg lift
Mary M. Harroun, MS, LNHA, demonstrates a leg lift


The answer is yes. It might not be possible for all of your residents but a significant number of them will benefit. As a facility administrator, owner and manager, you may walk through your facility to observe your staff and residents firsthand. What are you really seeing? Are many of your residents in wheelchairs outfitted with chair alarms to keep them seated and safe from falls? Is wheelchair use a “best practice” or is there another way to design their care? Is your facility actively engaged in real culture change?

As you continue your walk-through, are you observing your restorative CNAs walking residents? Do you see two CNAs walking one resident? Is one CNA holding up the resident with a gait belt while the resident walks behind a walker and another restorative CNA walks behind the resident with a wheelchair? Have you studied and talked with your restorative nurse about the outcomes of this type of walking program? Can the outcomes be improved?

Lots of questions and lots of answers, but are the current outcomes as beneficial to your resident as you would like? Start making some changes to the assessment process. Some improvements might be made to your restorative nursing process. Each resident undergoes the normal MDS 3.0 assessment process. However, is this assessment process complete enough to set goals and objectives for restorative care? Does the present process help the resident regain more independent ambulation?

INTERDISCIPLINARY APPROACH

Each professional department, under your guidance and the guidance of your medical director, should work together to assess residents thoroughly by asking the basic question: “Why is this resident not walking and what can we do to get him or her to walk safely once again?” A thorough assessment might be the key and all of your professional staff is trained to complete this process. The dietary department will look at bone density, calcium and vitamin D levels and recommend changes in prescriptions, if necessary. Nursing will look at medications to see if any can be recommended to be decreased such as psychoactive medications or other medications that might interfere with the independent ambulation process. The social worker will look at social history and complete assessments such as cognitive levels and mental status tests, which include the SLUMS [Saint Louis University Mental Status] assessment and depression scales.

The physical therapy department, under a doctor's order, will employ assessments such as the Jacobsen's Handicap Inventory, ABC Scale, DGI Gait Assessment, Static and Dynamic Balance and test for muscle mass. The occupational therapy department, again under doctor's order, will perform assessments such as the Functional Independence Measure, Tinetti Balance Scale, Get Up and Go Test, FAST Assessment Scale, Allen Cognitive Levels and Barthels Index of ADLs. The recreation therapy department will use the standard recreation therapy assessment and share its evaluations.

MOBILITY ASSESSMENT CLINIC

After all the assessments are completed, everyone involved, including the resident, family members and the resident's assigned CNA, will meet at the care plan meeting. I suggest changing the name from care plan meeting to Mobility Assessment Clinic. This changes the focus of the meeting to why the resident is not walking and what can be done to assist the resident to walk once again. All staff members share information so each department has a more complete profile on each resident under its care.

After the Mobility Assessment Clinic's findings have been documented and objectives and goals written for the resident in his or her care plan, the next step in the process commences.

RESTORING MOBILITY

Remember watching the CNAs just walking residents down the hallway? Under the restorative program, CNAs exercise the residents more extensively than just by walking them. They are able to work with up to four residents at a time, which allows them to work with all of the assessed residents every day, seven days a week to realize outcomes. After retraining on new methods, the CNA will start off slowly and cautiously with each resident. Seat the resident in a chair with regular arms, play music that he or she enjoys and help them do leg lifts, eventually adding ankle weights and increasing lower leg strength with exercises designed to increase muscle mass.

The big day comes when the resident is able to reach an independent level of advancing from a sitting position to a standing position. The next exercise phase is to have the resident stand at the handrail in your hallway and be directed in more strengthening exercises while also working on balance.

OPTIMUM OUTCOMES

First, residents will experience less injurious falls, thereby decreasing unnecessary trips to the hospital. By increasing calcium and vitamin D intake, bones will be stronger. The restorative CNA and all other staff members and families will watch the residents return to independent ambulation and the term “fall prevention” will become a phrase of the past.

The surrounding community will learn that your facility is a place for the elderly to live their lives to the fullest. State surveyors will smile when they see an active restorative program that is changing your facility to one that is assisting every resident to reach their fullest ambulation potential.

The cost? Retraining your restorative CNA staff. The RUG category, under Rehab, RLB, RLA, low intensity, is reimbursable.

Mary M. Harroun, MS, LNHA, is President of the GROW Corporation and author of

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