At a local skilled nursing center, the administrator asks staff for assistance to enhance their restorative program. Fortunately, the center had both a therapy director and restorative nurse who expressed a desire to work together for improved resident outcomes.The center’s current approach to restorative programming focuses on residents being discharged from skilled therapy. As part of the center’s performance improvement efforts, they recognized an opportunity to engage the interdisciplinary team such as the nursing department, social services, or activity staff in identifying residents that could benefit from restorative services.

The center’s efforts in this scenario are all-important in starting or assessing a restorative services program. What follows is a review of factors that will help to ensure success: restoring residents’ function and preventing further decline.

Defining Restorative Services

It is important to consider how a center defines restorative services. The easiest starting point, regardless of the case mix and reimbursement process, is the regulatory definition. The Minimum Data Set/Resident Assessment Instrument (MDS/RAI) manual says restorative services refer to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible.

The goal of restorative nursing is to improve resident outcomes by enhancing their ability to attain, retain, and maintain their highest levels of functional status. Physical well-being impacts all areas of functioning, including mood and affect, and these can be benchmarked with the Quality Measure outcomes demonstrating strong systems directly related to residents’ activities of daily living (ADLs), bowel and bladder continence, falls, pain, weight loss, depression, and behaviors affecting others aligning with the restorative programming implemented.

In order to fulfill restorative requirements, at least 15 minutes throughout the day must be spent, and documented, on specific, directed restorative tasks. When there is not a fully implemented restorative nursing program, only a few residents may actually benefit, and this pulls down the overall CASPER quality measure scores for such areas as “increased ADL help” and “bowel and bladder incontinence.”

Documentation is an important aspect of providing restorative services. Upon review of the overall process
for restorative services in the skilled nursing center mentioned earlier, it was determined that staff were actually providing restorative services. However, the documentation was not comprehensive enough to support it as restorative services, thus there was a need to formalize the center’s program.

Promoting Resident Involvement

If the center’s intent is to improve residents’ overall ability to live as independently as possible, there are a lot of options to reach that goal, and a strong restorative nursing program is one way to go.

The MDS/RAI manual Section O0500 says, “Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity.”

As observed in recent literature on the topic, individuals enjoy group activities, but there is more opportunity to capture the enjoyment of small group exercise, not only for the physical benefits but also for socializing and pain and mood management.

Activity team members, who do not need to be certified nurse assistants (CNAs), can be trained to manage exercise programs and lead small groups (four or less) with the intent of improving or maintaining functional status, according to Lorenz, Gooneratne, et al. Activity team members can also facilitate groups that focus on fine motor coordination. Social workers and activity staff can be trained to facilitate communication and cognitive enhancement activities.

Small groups can give team members opportunities to really know the residents and how they respond to the world through social involvement. Moving from the typical one-on-one visits to more small groups may enrich residents’ lives and provide them with more than just exercises and functional improvement.
The key to using non-CNAs, in conjunction with restorative CNAs and direct care staff is in the training, execution, documentation, and dedicated restorative nurse oversight.

Dropping The Ball

Historically, restorative CNAs have been the first to be “pulled” when direct care staffing hours are low. This often creates several long-lasting problems.

First, it makes the restorative CNA position less desirable because there is no continuity of care. Second, it negatively impacts the residents on restorative case load because there are fewer nurses to provide care. 

Third, it makes restorative nursing programs appear less important by making them seem optional/dispensable. A major misconception with this process is the idea that residents will receive restorative programming from CNAs during dressing, brushing teeth, participating in bathing, and other daily activities.

Unless the facility has specifically determined the CNA hours necessary to provide true restorative services, it is difficult to validate improved restorative nursing outcomes with the CASPER report. This is because the level and intensity of restorative nursing services provided by direct care often do not meet the 15-minute requirements, although such tasks as dressing or using the bathroom certainly require this much time and more.

Starting Successfully

Providing restorative services will enhance resident care and assist in avoiding decline post-discharge from a skilled therapy program. However, it is not an easy process. It requires time, energy, and resources. Most importantly, it requires a commitment to improve resident outcomes.

The restorative program cannot be the “stepchild” in the center. In other words, staff should not be continuously reassigned to other duties. It requires highly trained, motivated staff with a focus on resident-centered care and who understand improved resident independence is priceless.

Remember to select restorative staff based on these criteria, not on their tenure within the center or because they want to work the day shift. Meet with each interested candidate, and discuss expectations and clearly define measurable goals and time frames. Remember, the goal is to restore function or prevent further decline, which are not easy tasks.
Angie Szumlinski, LNHA, RN-BC, RAC-CT, BS, is director, HealthCap Risk Management Services, and can be reached at or 734-929-6411. Erica Holman, BA, LMSW, LNHA, CDP, is senior risk manager at HealthCap and can be reached at or 734-929-6434.