Assignments

Chapter 9

Medical Care, Nursing, and Rehabilitation

What You Will Learn

•  Medical care in a nursing facility is akin to primary care office-based practice. Physician visits are infrequent as treatments are provided by the nursing staff.

•  A licensed physician must be appointed as the medical director, who should help implement best practice standards of care, offer medical advice and training, and represent the facility to the medical community.

•  The director of nursing is responsible for ensuring that there is adequate staff, that the staff’s skills remain current, that any patient care issues are promptly addressed, that patient care policies are updated as necessary, and that the nursing department functions smoothly.

•  Assessment is essential for evaluating the patient’s strengths and needs for care. A plan of care for each resident is developed by a multidisciplinary team to specify goals and interventions.

•  An effective infection control program focuses on prevention. It requires policies, screening of residents and associates, aseptic and antiseptic practices, standard and transmission-based precautions, surveillance for early detection, education, and prompt control when outbreaks occur.

•  Falls can be caused by environmental hazards, physical effects of aging, and certain medical conditions and side effects of drugs. Several steps can be taken to prevent falls.

•  Pressure ulcers can be traced to a number of causes. Preventive measures and early treatment are essential.

•  In most instances, use of restraints does not promote safety. Their use is illegal, except when they are temporarily used according to a physician’s orders.

•  Many causes of urinary incontinence are reversible and transient. Toileting programs and other therapies should begin after the underlying causes have been treated. Catheters are indicated only when other measures have failed.

•  Depression, delirium, and dementia can be difficult to diagnose. These problems are common in nursing homes, and they pose special challenges. Recognition of symptoms and caregiving strategies can help nursing home associates deal with them.

•  Pharmacy services and pharmacy consultation are required by regulations. Facilities must have policies and procedures to safeguard controlled substances and to maintain an emergency kit. Psychotropic drugs present special challenges.

•  Rehabilitation therapies can be restorative, maintenance, and adaptive.

Introduction

The need for medical care, nursing services, and rehabilitation therapies is the main reason patients are admitted to nursing homes, particularly when these services cannot be obtained adequately in community-based settings. Hence, these services form the core of care delivery in a long-term care facility. The other services interface with this clinical core.

Medical care has been traditionally delivered by physicians. Increasingly, however, practitioners with advanced qualifications and training who work closely with physicians are employed to take over some of the responsibilities of physicians, such as making regular rounds to see nursing home patients. Research suggests that services provided by these professionals have resulted in improved quality, such as lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviors. Family members have also expressed greater satisfaction with the care delivered by these nonphysician practitioners (Donald et al., 2013).

Medical Care

Attending Physicians

Each patient’s individual care is under the general direction of an attending physician, who is a general internist or family practitioner having his or her own private practice. Often, the patient has been under the care of a community-based physician for some time and, after being admitted to a nursing facility, may have the same physician follow up with medical care in the facility. Many physicians, however, avoid nursing home practice. In that case, the patient is given the option of selecting a physician from among those who make regular nursing home visits.

Time constraints, rigid regulatory requirements, negative perceptions of nursing homes, and litigation are some of the main reasons many physicians do not participate in nursing home care. Although reimbursement is not viewed as a barrier to nursing home practice, many physicians express some issues with nursing support in the facility and accurate or accessible information when needed (Caprio et al., 2009). Conversely, physicians report that caring for nursing home residents is gratifying and meaningful work. Physicians working in nursing homes report that relationships with residents, families, and staff members; interesting and meaningful patient care; and autonomy are the most positive aspects of their role. Less desirable aspects included staff turnover, difficult expectations, and administrative issues (Bern-Klug et al., 2003). This type of information about what physicians value about their work in nursing facilities can help administrators structure more desirable roles and attract more physicians to meet the growing demand in nursing homes.

Medical services for long-term care patients differ quite substantially from hospital care, which focuses on acute episodes, medical procedures, and surgical interventions. Medical care in a nursing facility is more akin to primary care office-based practice. For treating patients in nursing homes, the physician bills a third-party payer, such as Medicare or Medicaid, not the nursing home. Typically, physician visits are infrequent, generally occurring every 30 days or longer, because most chronic conditions do not require frequent medical evaluation and treatment. Attending physicians diagnose medical problems and prescribe treatment and medications, but the actual treatments are rendered by the facility’s nursing staff in accordance with the attending physician’s orders. Nurses routinely monitor the patient’s condition. Any substantial changes, nonresponse to treatments, or other negative observations are immediately relayed to the attending physician who then decides on the course of action to pursue. If a patient’s condition changes for worse or some complication develops, most physicians require that the patient be transferred to a hospital.

Both physicians and nurses feel the need for shared communication to facilitate treatment decisions. Physicians must typically rely on nurses’ skills. Nurses often express pride in their ability to judge clinical situations, report them to physicians by telephone, and get orders they need to give good care (Hanson et al., 2002).

Good patient care in nursing facilities is the product of teamwork in which a multidisciplinary—also referred to as “interdisciplinary”—team of professionals is responsible for patient assessment, care planning, and delivery of clinical services. The attending physician should be a member of this team. Medical oversight by the physician is critical, but it must incorporate the input from other disciplines such as nursing, rehabilitation, social work, dietetics, recreational therapy, and pharmacy. To the extent possible, the patient and family should also be involved in the plan of treatment.

The attending physician also makes referrals when specialized services are needed. For example, referrals can be made to medical specialists such as cardiologists, nephrologists, and orthopedists. Nursing facilities generally provide the more common types of specialty services through contracts with independent practitioners such as podiatrists, dermatologists, and ophthalmologists who may do routine screenings and evaluations in addition to receiving sporadic referrals.

Medical Director

Nursing home regulations require the appointment of a licensed physician to function as the medical director. In all but a handful of large nursing homes, the administrator contracts with a community physician to fill the position on a part-time basis. In an average-sized facility, the medical director can be expected to spend 2 to 4 hours per week (Krein, 2003).

The medical director reports to the administrator but has an advisory relationship with the rest of the organization. Through regular communications with the medical director, the administrator can keep abreast of major patient care issues in the facility. On the other hand, by regularly communicating with the administrator, the medical director can remain in touch with administrative policies and management issues that may have a bearing on patient care delivery.

Personal Traits and Qualifications

The medical director should have good interpersonal and conflict-resolution skills that will enable him or her to work effectively with the multidisciplinary team. He or she should have a flexible nature and be a good listener, with tolerance for addressing regulatory issues (Krein, 2003). He or she should also have the patience to work with and teach mostly licensed practical (vocational) nurses (LPN/LVN) and nursing assistants who predominate in the nursing department.

The medical director may have either the MD or the DO degree. Ideally, the medical director should be a geriatrician, but physicians who have this kind of specialization are rare. The next best choice is to have someone who has substantial experience in geriatric medicine or someone who has an interest in the field and is committed to acquiring the necessary knowledge and skills through continuing education.  Geriatrics  is a specialized area of medicine that deals with the special health problems faced by the elderly. Knowledge of geriatrics is essential for effectively treating a wide array of medical conditions in a diverse elderly population residing in nursing homes.

The American Medical Directors Association (AMDA) has developed the Curriculum on Geriatric Clinical Practice in Long-Term Care to train attending physicians in both administrative and clinical management. AMDA also offers certification as a Certified Medical Director based on demonstrated competence in clinical medicine and medical direction/administrative medicine in long-term care. A number of residency programs in internal medicine and family practice also provide additional training in geriatric medicine. The American Board of Internal Medicine and the American Board of Family Practice confer a Certificate of Added Qualification in Geriatric Medicine on physicians who complete this training and pass the examination. However, only a few physicians hold such certification.

Functions

The medical director functions as a key consultant to the nursing facility on almost all aspects of patient care. Not uncommonly, the medical director is also the attending physician for most patients in a facility. As an attending physician, the medical director is in a position to obtain first-hand knowledge of the adequacy and appropriateness of clinical care provided to the patients and to become involved in consultations to improve quality of care for all residents. The medical director’s involvement as an attending physician must be a completely separate practice as far as reimbursement and compensation are concerned.

The main functions of the medical director can be classified into four essential roles:

•  Oversight

•  Advisory

•  Teaching

•  Representative

Oversight Role    As the chief medical officer for the facility, the medical director helps ensure that clinical services meet or exceed established standards. Standards of care are defined in written policies and procedures, which should incorporate evidence-based practices when they are available. Some examples of clinical practices in which policies and procedures are necessary include catheterization procedures, obtaining urine and stool specimens, isolation practices, handling contaminated linen, and preventing and treating pressure ulcers. A medical director who has drive and perseverance can truly be a transformative influence in the facility, for example, by reducing the use of restraints and unnecessary medications, improving the care of patients with dementia, and reducing falls (Ferrini, 2011).

Regular rounds, observations, and attentiveness to any patient care concerns expressed by patients, associates, and family members are generally the means of monitoring the adequacy of clinical care. Any breakdowns in the facility’s skill capacity must be addressed with the administrator. Such breakdowns generally occur when the facility experiences turnover of key staff or when it adds a new service.

Advisory Role    The medical director’s advisory role directly stems from his or her effectiveness in carrying out the oversight role. Admission policies should be periodically reviewed to ensure that the facility has adequate skill capacity to deliver services to the types of patients being admitted. Similarly, other policies and procedures should be periodically reviewed to ensure that they remain current. The medical director also functions as an advisor to the various committees such as the infection control committee, quality improvement committee, utilization review committee, medical records committee, pharmaceutical review committee, safety committee, and ethics committee. Most of these committees meet once a quarter, and, for the sake of efficiency, meetings of the various committees are often combined.

Teaching Role    The medical director plays an active role in staff training and can promote a professional and caring culture in the organization (Krein, 2003). This role is mostly carried out informally during routine interactions with caregivers or while making bedside rounds with nurses. Occasionally, the medical director may also be invited to make presentations in formal training sessions. Communicating with families and educating them about issues that are commonly misunderstood and the medical director’s participation in family seminars can help establish better relationships among the patients, families, and associates.

Representative Role    The medical director is the facility’s representative to the medical community. During interactions with colleagues, he or she should function as the facility’s advocate and as an expert on medical care issues in long-term care in general. Nursing facilities often have to address regulatory noncompliance issues related to the required frequency of visits and documentation with attending physicians. A medical director’s collegial influence can go a long way in helping the facility gain compliance from attending physicians. On the other hand, the medical director does have a responsibility to oversee that the delivery of medical care by other physicians is adequate and appropriate. In consultation with the administrator, he or she may have to take steps if attending physicians do not comply with basic standards of medical practice. The medical director can also assist when there are issues with patients admitted from the hospital but timely medical information is not received.

Nursing Services

Nursing is the largest department, employing about 70% of the nursing home associates. Nursing services are also the central hub, and the nursing staff generally has the most interaction with residents and their families. But nursing’s central role should not be interpreted as dominant over other services. The best patient care can be delivered only when each discipline—including nursing—recognizes the interdependency between the various departments and services.

Nursing Administration

The nursing department is headed by a director of nursing (DON). The DON is generally supported by an assistant director of nursing (ADON), who may be responsible for staffing and also function as the inservice director (director of training) in average-size nursing homes. In larger facilities, an alternative to the ADON is to have a nursing supervisor on each shift—three supervisors covering the three shifts—in which case, a separate inservice director’s position would be necessary. Because resident assessment has become a critical driver of the Medicare prospective payment system, most average-size facilities also have a registered nurse (RN) in the position of resident assessment coordinator. This position, as well as the inservice director, may report to either the DON or the administrator.

Director of Nursing

The DON is a key member of the top management team and has a position of substantial responsibility. In most facilities, the position is second only to that of the administrator. The DON is often in charge of the facility during the administrator’s absence. In large nursing homes where an assistant administrator may be employed, there is sometimes a direct chain of command between the administrator and the DON, whereas the assistant administrator may have direct responsibility for the remaining departments. Effectively managed nursing facilities have a triad relationship among the administrator, the medical director, and the DON, and this triad is involved in making many top-level evaluations and decisions regarding the facility’s operation.

Research shows that job tenure of a DON in a nursing facility is associated with higher quality ratings on the five-star system developed by the Centers for Medicare and Medicaid Services (CMS). The DON’s stability also helps retention of other RNs (Hunt et al., 2012). These findings highlight the need for owners and administrators to support DONs in their leadership roles (Krause, 2012).

Skills, Qualifications, and Functions

The DON must be an RN, and the position requires a composite of clinical and management skills. However, DONs who have formal training in both nursing and management are rare. Most acquire management skills through experience, although management skill development through continuing education, seminars, or college-level courses is highly recommended. On the clinical side, some DONs possess a bachelor’s degree in nursing, but many have nursing preparation through a 2-year associate’s degree or an RN diploma. A small number have master’s degrees. Some have completed certification requirements in gerontology, but many have not.

The DON is not a direct caregiver but mainly performs administrative and supervisory functions, which at times can be quite challenging. The main responsibilities of this position can be summarized under five main categories:

•  Staffing

•  Training

•  Patient care

•  Policy

•  Administration

Staffing    The DON is responsible for ensuring that the nursing units are adequately staffed and that the nursing personnel are adequately trained. Staffing can pose some daunting challenges, because depending on labor-market conditions, nurses may be in short supply. Recruiting and retaining qualified staff members is often difficult, and a typical facility experiences high turnover and absenteeism among certified nursing assistants (CNAs). Hence, the DON should have some training in human resource management. Staff shortages coupled with the need to have adequate 24/7 staff coverage present special challenges in staffing and scheduling. Large facilities often designate a full-time person to the tasks of recruiting and scheduling CNAs.

Training    The DON must ensure adequate levels of skill competency among the nursing staff. Needs for individual as well as group training should be evaluated periodically. Many facilities also operate CNA training programs. Regulations require that these programs be under the DON’s general supervision. The DON, however, is not permitted to do the actual training, which should be delegated to a nurse instructor who must be an RN. To provide well-rounded instruction, professionals from other disciplines such as the medical director, physical and occupational therapists, dietitian, pharmacist, social worker, activities director, fire and safety expert, and nursing home administrator should also be included. The law prohibits states from approving nurse aide training programs at facilities found to have substandard quality of care or that have been subject to certain enforcement actions such as civil monetary penalties.

Patient Care    The DON oversees timely execution of patient assessments, development of an individualized plan of care for each patient, and the delivery of nursing care. The nursing staff looks to the DON for leadership and expertise when care-related problems arise. The DON also plays a vital coordinating role with attending physicians by facilitating timely visits and ensuring that they receive the necessary nursing support.

Policy    The DON is an active participant in the various patient care committees mentioned earlier (infection control committee, quality improvement committee, etc.). The DON’s input into the policy and decision-making process is often indispensable. The DON generally provides information and data for evaluation and deliberation by the various committees. The facility’s nursing care policies, procedures, and practice guidelines constitute the standards of patient care delivery. They are compiled into a nursing policies and procedures manual, which is used as a reference and training resource for new associates. This manual becomes a living document that is updated as policies and practices are revised. It is important for the nursing home staff to deliver services in accordance with the policies established by the nursing facility.

Administration    The DON is responsible for the effective management of the nursing department. The DON is also involved in a variety of administrative tasks that free the caregivers so that they can devote their time and energy to delivering patient care. Although, as a matter of routine, the DON is in the facility during regular business hours, some variation from routine is necessary so that the DON has some ongoing contact with the staff, patients, and families during evenings, nights, and weekends. Many families can visit the facility only during evenings or weekends. Therefore, charge nurses on the evening and weekend shifts should be trained to address family concerns. A communication system should be implemented so that family complaints and concerns regarding patient care are related to the DON. On the other hand, periodic availability of the DON during nonroutine hours can lend support to the nursing staff, and contact with families can help resolve issues before they turn into bigger problems. Having a large staff, and a preponderance of LPNs/LVNs in relation to RNs, the DON is frequently involved in ongoing training and consultation and in handling staff-related issues that include disciplinary action for nonperformance of duties.

Nursing Organization

Nursing home regulations require a charge nurse, who can be an RN or an LPN/LVN, on each tour of duty. Regulations also require the facility to employ an RN for 8 consecutive hours per day, 7 days per week. The DON is prohibited from serving as a charge nurse unless the facility has an average daily occupancy of 60 or fewer residents (Gittler, 2008).

Charge nurses report to the nursing supervisors, the ADON, or the DON, depending on how the nursing department is organized. In most facilities of moderate size, charge nurses report directly to the DON. Charge nurses are responsible for assessing patient needs and planning care, supervising associates on the unit, communicating with physicians and family members regarding patient care issues, and supervising patient care delivery.

The number of nurses on each nursing unit, skill mix of nurses (ratio of RNs to LPNs/LVNs), and the ratio of CNAs to patients on each shift are dictated by the number of patients and the level of clinical care required by the patients. Most RNs working in long-term care are graduates of hospital-based diploma programs or 2-year associate’s degree (ADN) programs. RNs are generally responsible for patient assessment, care planning, and quality assessment. LPNs render treatments and administer medications. Several states allow the routine administration of medications by specially trained medication aides (or medication technicians) under the general supervision of licensed nurses. Use of qualified medication aides/technicians can relieve nurses, enabling them to devote their time to other nursing care and monitoring functions.

CNAs provide most of the hands-on nursing care to residents. To deliver effective care, CNAs must possess basic nursing skills in four main areas:

  1.  Clinical skills, such as taking vital signs (temperature, pulse rate, and blood pressure), measuring height and weight, recognizing abnormal changes in body functions such as urine output and bowel function, reporting changes in patient’s condition to the charge nurse. For example, CNAs’ frequent contact with patients enables them to observe changes in a patient’s skin that may result in pressure ulcers (Sparks, 2011).

  2.  Personal care skills to assist patients with bathing, dressing, grooming, oral hygiene, eating, hydration, transferring, positioning, turning, toileting, and cleaning up and drying after incontinence.

  3.  Rehabilitation skills to do range of motion exercises, bowel and bladder training, and use of assistive devices to promote independence.

  4.  Documentation skills to record what they do and what they observe.

CNAs should also receive appropriate training in how to communicate with residents and visiting family members. In addition, CNAs must be trained in infection control practices; they must be prepared to use fire and safety procedures in case of an emergency; and they must understand how to preserve and promote the patients’ rights to privacy, confidentiality, autonomy, dignity, and freedom from abuse and neglect.

Patient Assessment and Care Planning

The primary tool used in patient assessment is the Minimum Data Set (MDS). Assessment can be regarded as the first step in patient care planning and the delivery of patient care.  Assessment  is defined as the process through which health care professionals attempt to reliably characterize the patient’s physical health, functional abilities, cognitive functioning, psychological state, social well-being, and past and current use of formal services (Kane, 1995). Patient assessment serves two major purposes:

  1.  The process helps the facility staff to learn about the resident’s strengths, problems, and needs. These strengths and needs are subsequently addressed in the individualized plan of care for the resident.

  2.  It enables the staff to track important changes in the patient’s overall status and to revise care plans accordingly.

A skilled nursing facility (SNF) must complete an initial assessment on a patient within the first 8 days of SNF stay. The facility must reexamine each patient at least once every 3 months and revise the assessment as necessary. A new assessment must be done when there is a significant change in a patient’s condition. MDS information is electronically transmitted to the state, and the state transmits it to the CMS.

Although the nursing department often coordinates and oversees the process, input from other disciplines such as social services, activities, dietary, and rehabilitation is also necessary. Included in the formal assessment is history and physical information obtained from the admitting physician. The patient’s and family’s involvement in the assessment and care planning process have become increasingly more important because they can furnish nonmedical information vital to holistic care. Perhaps the most significant advance in MDS 3.0 is the use of direct interview items to consistently elicit the resident’s input. This is because often the most accurate way to assess many topics is to ask the resident directly. Studies have shown that for areas such as cognition, mood, preferences, and pain, staff or family impressions often fail to capture the resident’s real condition or preferences (Saliba & Buchanan, 2008).

Plan of Care

Nursing facilities are mandated by regulations to prepare a comprehensive plan of care (or care plan) for each resident within 7 days of completing the assessment. A  plan of care  is a written plan developed through team participation of various disciplines to clearly outline how each assessed need of a given patient will be addressed and what specific goals will be accomplished. It is like a blueprint that guides the staff in providing routine interventions necessary for accomplishing clinical goals for a specific patient. Examples of intervention include nursing treatments, medications, special diets, rehabilitation therapies, social interventions, and participation in recreational activities. A professional staff member such as an RN or social worker is assigned the responsibility of scheduling care plan meetings and inviting representatives from the various disciplines to participate and share their input.

As the plan of care is carried out, each member of the multidisciplinary team adds progress notes to the patient’s medical record. Progress made, or lack thereof, in achieving the established goals is evaluated over time and is carefully documented. The progress evaluations provide further guidance in establishing new goals and in deciding which interventions should be discontinued, modified, or added. Care plans are generally reviewed and revised every 60 to 90 days, or when a major change has occurred in the patient’s condition.

Infection Control

Infections are a common problem in health care settings. The elderly in particular are predisposed to various types of infections because of weakened immune systems. In addition, cognitive impairments among many nursing home residents may compromise their basic sanitary habits such as hand washing and personal hygiene, passing disease-causing bacteria to other people. Also, residents live in close proximity to others, come in contact with staff and visitors, and are served food and beverages from a common source. Such an environment facilitates both the introduction and subsequent transmission of certain infectious agents in a vulnerable population (Strausbaugh et al., 2003).

In nursing homes, most infections affect the urinary tract, respiratory tract, skin and soft tissues, or gastrointestinal tract (Ouslander et al., 1997). Complications resulting from infections constitute the main reason for transferring patients from a long-term care facility to an acute care hospital. Hence, preventing and containing infections should be a primary concern. Because overuse of antibiotics in recent years has rendered certain bacterial and viral strains resistant to drugs, treating some infections is presenting major medical challenges. Multidrug resistant organisms (MDROs) are becoming common in health care facilities. These microbes include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), as well as strains of Streptococcus pneumoniae, Pseudomonas spp., Neisseria gonorrhoeae, Salmonella spp., and others (Sharbaugh, 2003). Of these, MRSA and VRE are the most common. MRSA causes “staph” infections that are resistant to treatment with common antibiotics such as methicillin, penicillin, oxacillin, and amoxicillin. MRSA can cause serious and potentially life-threatening infections, such as bloodstream infections and pneumonia. VRE are bacteria that live in the intestines and in the female genital tract and become resistant to the antibiotic vancomycin. These bacteria can cause infections of the urinary tract, the bloodstream, or wounds. The main mode of transmission to other patients for both MRSA and VRE is through unwashed hands. Hence, hand hygiene is the primary preventive vehicle.

State and federal regulations require nursing facilities to implement infection control programs.  Infection control  is a comprehensive program to prevent the transmission of infections protecting the residents, the staff, and visitors from contracting infections while in the facility. An effective infection control program focuses on prevention.

Generally, the task of surveillance and monitoring of infections is assigned to a registered nurse, such as the ADON. This individual is often called the  infection control practitioner (ICP) . But infection control is not merely a nursing responsibility. An effective program requires the involvement of all departments. In the following sections, the main features of an effective infection control program are described:

•  Policies and procedures

•  Screening

•  Infection control practices

•  Surveillance

•  Education

•  Control of infectious outbreaks

Policies and Procedures

The facility should develop and update infection control policies and procedures in consultation with the infection control committee. The policies should cover areas such as admission and transfer of residents, employee health, immunizations, guidelines for visitors, housekeeping practices, laundry procedures, food preparation, food poisoning, procedures for cleaning and sterilizing equipment, isolation procedures, waste disposal, removal of biohazardous waste, pest control, detection and control of infection outbreaks, and staff education. Nursing practices such as caring for wounds, inserting catheters, and collecting urine specimens require sterile techniques, which should be outlined in the facility’s written policies and procedures.

Screening

The patient’s history and physical at the time of admission should be carefully reviewed for the presence of any infections or contagious disease. Associates who show symptoms of transmissible infections, such as influenza or staphylococcus infection, should not come to work until they are declared safe to return.

New tuberculosis (TB) cases, caused by bacteria called mycobacterium tuberculosis, occur more frequently among the elderly than among younger age groups. Although TB cases in the United States have declined, almost 10,000 cases were reported in 2012, and reported cases are much higher among those who have HIV infection (Centers for Disease Control and Prevention [CDC] 2013). Also, the rate of TB in older adults remains 30% higher than in younger adults (Pratt et al., 2011).

All patients admitted to nursing homes must be screened for TB in accordance with state health department guidelines. All associates must have an initial physical examination at the time of employment and subsequent annual physicals to screen for any infectious diseases.

Infection Control Practices

Asepsis , the absence of harmful microorganisms called  pathogens , requires practicing clean procedures. The primary goal of asepsis is to prevent cross-contamination, that is, transferring pathogens from soiled surfaces to clean ones. Frequent hand washing with soap and clean water is among the most important aseptic practices that is often neglected. Examples of other aseptic practices include washing food and utensils in the kitchen before cooking, cleaning food preparation surfaces, separating and properly handling clean and soiled linens, and using specific techniques for trash removal.

Hand hygiene should also incorporate hand  antisepsis : removing or destroying microorganisms. Hand antisepsis can be achieved by using an alcohol-based hand rub, which is waterless and therefore does not require a sink and paper towels. The microbe-killing action of an alcohol-based hand rub is twice as fast as that of traditional hand washing. Alcohol rubs have also been proven to be gentler on the hands than soap and water because they contain emollients or moisturizers to help the skin retain more of its natural water content, which soap and water often strip away.

Infection control training and practices are particularly important for nursing staff members, who are frequently exposed to soil and body wastes. They also provide patient care and then touch clean surfaces. Without frequent hand washing and sanitizing in between clean and soiled contact, they can spread disease-causing pathogens. The environment should also be protected while transporting trash or soiled linens. All trash must be properly bagged and placed in sealed containers. Similarly, soiled linens should be placed in sealed containers when they are transported through the facility.

Isolation precautions constitute another important aspect of infection control. Two types of isolation precautions are used (Grubbs & Blasband, 2000):

•  Standard precautions

•  Transmission-based precautions

Standard precautions (SPs)  are used when caring for all residents, regardless of whether or not they have an infectious disease. SPs are designed to protect caregivers from infection through exposure to blood, body fluids, and body substances. It is assumed that all body fluids are potentially infectious. The precautions include wearing gloves during patient care, wearing gowns when the caregiver’s clothing may come in contact with body fluids, and wearing masks and protective eye wear when body fluids may splash. SPs also include preventing injuries and infections from sharps, such as needles and blades, which must be disposed of in appropriately marked sharps containers.

Transmission-based precautions  are required during care for residents who may have a communicable disease. Transmission-based precautions are used in addition to standard precautions. Example includes patients diagnosed with TB or influenza. The facility must establish procedures for visitors to report to the nursing station before visiting patients for whom transmission-based precautions are indicated.

Surveillance

Surveillance for  nosocomial  infections—infections caused by the process of health care delivery—has been clearly established as a key element of all infection control programs (Stevenson, 1999).  Surveillance  refers to identifying and reporting all cases of infection in the facility and identifying all infected residents and staff (CDC, 1990). The purpose is early detection that would allow for timely interventions to check the spread of infections. Surveillance may give early warning about the outbreak of an epidemic. A strong surveillance program requires all nursing staff members to be vigilant and report all cases of infection.

Education

Ongoing education of all staff about infection control is a critical preventive measure. These educational programs should be repeated often, particularly given the high staff turnover common in nursing homes.

Control of Infectious Outbreaks

An  epidemic  is defined as the excessive prevalence of a negative health condition in the facility. Epidemic outbreaks are noted by clustered cases of symptoms such as diarrhea, urinary tract infections, influenza, or scabies (Garibaldi et al., 1981). Influenza outbreaks can be prevented by annual flu shots for residents and associates. Many health care organizations have made an annual flu shot mandatory for their associates.

Prompt control of any outbreaks is essential. The medical director should work closely with the nursing staff in identifying the pathogen, preventing its spread, treating the affected patients and staff members, and, if necessary, reporting and coordinating recommended measures with the appropriate public health agency.

Access to a laboratory must be available to perform rapid antigen testing, and influenza antiviral medication must be available to control outbreaks. The DON-administrator-medical director triad should work together to isolate and address any outbreaks as swiftly as possible. The local health department is also typically involved in assisting the facility with a systematic approach to controlling infectious outbreaks.

Special Areas of Nursing Care Management

Nursing care deals with numerous health conditions found in a diverse elderly population. Some of these conditions require special attention from caregivers and nursing managers. The topics discussed in this section also have a great deal of relevance for improving the quality of patient care.

Falls and Fall Prevention

Falls are the most common cause of both fatal and nonfatal injuries in older adults (Crogan & Dupler, 2014). In nursing homes, approximately 50% of the residents fall each year (Yarme & Yarme, 2001), and an estimated 10% of falls result in serious injury (Tinetti, 2003). Fall-related injuries result in substantial legal liability for the nursing facility, as well as pain, suffering, loss of function, and death among residents. Recovery from fall-related injuries is slow in older persons, which in turn increases the risk of subsequent falls (Rubenstein, 2006). Psychological factors such as anxiety and depression may follow.

Prevention of falls begins with the understanding that causes of falls are multifactorial; hence, fall prevention interventions must also be multifactorial. A person with a history of falls is likely to fall again. History of falls is one of the strongest predictors of future falls, along with use of walking aids and disability (Deandrea et al., 2013). Rubenstein (2006) concluded that roughly one-third of the falls can be attributed to environmental factors such as poor lighting, wet floors, loose objects, incorrect bed height, and improperly fitted or maintained wheelchairs. The second most common cause was related to gait problems, balance disorders, and weakness. This was followed by dizziness, which is a common symptom among the elderly. Other specific causes of falls include disorders of the central nervous system, cognitive deficits, poor vision, drug side effects, anemia, unstable joints, and severe osteoporosis. The risk of falls in nursing homes has also increased because of the growing use of antidepressants (Messinger-Rapport et al., 2007) and the use of psychotropic medications (Li-MacDonald et al., 2014).

Working with new residents until they become properly oriented to where the bed is in relation to the chair and the bathroom, teaching residents how to safely navigate from the bed to the bathroom and back, engaging residents in strength training to improve gait and balance, and monitoring and supervising of residents by the nursing staff can all play a role in preventing falls. Toileting schedules are appropriate for some patients so they are assisted to use the bathroom at established time intervals. The physical therapist can evaluate whether assistive devices are needed for safe ambulation. Staff members should train the patient on the safe use of devices for ambulation and transfer. In some cases, it may be necessary to reduce or withdraw certain drugs that are potentially related to falls through their sedating, hypotensive, or cognitive effects (Lipsitz et al., 1997).

In patient rooms, a clearly visible passage should be maintained from the bed and chair to the bathroom. Bed height should be adjusted or protective floor pads used for those who may roll over and fall during sleep. For high-risk patients, it may be necessary to put the mattress on the floor. High-risk patients may also be fitted with hip pads to prevent hip fractures from falls. An alarm system can also be installed to alert staff when a high-risk patient tries to get out of bed. For example, weight-sensitive floor mats are now available that can be placed next to the bed; an alert sounds when someone steps on the mat.

One study reported that almost half of the falls in nursing homes occur on the 3 p.m. to 11 p.m. shift. Adding one staff member on this shift, repositioning room furniture, and adding a physical activity program on that shift curtailed the total number of falls by 38% and the total number of fractures by 50% (Hofmann et al., 2003).

Safety of the environment is one of the key elements in fall prevention. Nursing facilities, as a rule, already have railings in hallways, grab bars in bathrooms, and other required safety adaptations. However, a program should be in place to routinely check these devices for proper maintenance and repairs. Janitorial procedures should be evaluated for resident safety during cleaning and mopping floors and during carpet vacuuming or floor buffing, when long electric cords running through hallways can become a tripping hazard. Patient incontinence can leave urine puddles, which may not be easy for other patients to see. The nursing staff should be trained to observe such hazardous conditions and promptly clean up the affected areas.

Pressure Ulcers

A  pressure ulcer , also called a pressure sore or decubitus ulcer, is a localized area of soft-tissue injury resulting from compression between a bony prominence and an external surface (Smith, 1996). Pressure on the skin is normal when a person is sitting or lying down. With aging, however, the skin tissue develops reduced tolerance for pressure. Limited ability to change position while in bed or wheelchair that causes prolonged pressure against bony prominences, friction against wrinkled bed sheets or objects such as casts and braces, exposure to moisture from urine or feces, and poor nutrition (especially low calorie and protein intake) can all play a part in forming pressure ulcers. Neurological and cardiovascular disease can predispose the elderly to sores (Bennett, 1992).

Once formed, pressure ulcers are slow to heal. They are also susceptible to infections, a vulnerability that can lead to further complications such as permanent disability and even death (Bliss, 1992). Therefore, prevention and early treatment are essential features of pressure ulcer management. Pressure ulcer prevention begins with proper nutrition and hydration. Basic care routines such as proper bedmaking, positioning the patient properly while sitting or lying down, use of pads and pillows to relieve pressure, repositioning at least once every 2 hours, keeping the patient clean and dry, and skin care are important in preventing pressure ulcers. At least once a day, skin should be systematically inspected in patients at risk. The skin should be cleansed at regular intervals and whenever it is soiled. Hot water and drying soaps should be avoided for skin care. Areas of redness over bony prominences should not be massaged or rubbed. To treat dry, flaky, scaly skin, optimum environmental humidity should be maintained and moisturizers used. Mobility through rehabilitation should be encouraged (Bergstrom, 1997). Various types of pressure-relieving devices are also available and should be used as necessary.

Pressure ulcers are categorized into four stages according to the depth of tissue destruction (Exhibit 9–1). Once developed, there can be rapid deterioration. Stage I is the beginning stage with a notable discoloration of the skin. This stage is actually not a true ulcer, because the skin is intact. However, a stage I pressure area increases the risk of additional ulcers tenfold (Allman, 1999), and stage I can be difficult to recognize in persons with dark skin (Dharmarajan & Ahmed, 2003). At stage IV, the most advanced stage, muscle or bone become exposed. Treatment is to be directed by the attending physician. Depending on their stage, treatment may include bed rest in a special pressure-relieving bed, use of anti-inflammatory drugs, antibiotics, special dressings called occlusive dressings that keep tissue hydrated, whirlpool treatment, removal of dead tissue by surgical debridement, and skin grafting.

Exhibit 9–1  Pressure Ulcer Stages

	Stage 1	A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved.
	Stage 2	A partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater.
	Stage 3	A full thickness of skin is lost, exposing the subcutaneous tissues—presents as a deep crater with or without undermining adjacent tissue.
	Stage 4	A full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone.

Courtesy of Centers for Medicare and Medicaid Services.

In skilled nursing facilities, complete elimination of pressure ulcers is often an unrealistic goal because patients are often admitted with preexisting pressure ulcers. Hence, the facility must undertake a two-pronged approach that focuses in treatment of existing pressure ulcers and prevention of skin breakdown, as discussed previously. Treatment protocols should incorporate best practices in nursing care.

Use and Misuse of Physical Restraints

A  restraint  can be any device that is used to restrict a person’s freedom of movement (Grubbs & Blasband, 2000). Examples of physical restraints include waist belts or chest jackets to prevent people from getting out of a chair or bed, geri-chairs with secured tray tables, bed siderails, roller bars for wheelchairs, mitts, and wrist ties. In the past, these restraints were in common use because of a widespread assumption that restraining was necessary to keep patients from falling or otherwise hurting themselves. Restraints were also widely used to control behavioral disorders such as agitation and aggression.  Agitation  is defined as verbal, vocal, and motor activities that are repetitive and outside of socially acceptable norms (Cohen-Mansfield & Billig, 1986).

Later, studies found that the value of using restraints in promoting patient safety was, at best, marginal. Contrary to what was earlier believed, restraint use often caused injuries and promoted a number of negative physical outcomes—such as falls, decline in ADLs, pressure ulcers, and asphyxiation—as well as psychological problems, such as anger and increased agitation (Chaves et al., 2007). Actually, there is no evidence that supports the use of physical restraints to prevent injuries (Goethals et al., 2012). For example, a recent study showed that residents who were physically restrained had almost 70% greater likelihood of falling than individuals who were not restrained (Thomas et al., 2012).

Bedrails and siderails may or may not be regarded as restraints. Yet, between 1985 and 2004, at least 358 people died and 111 were injured from entrapment in bedrails in various health care settings (Braun & Capezuti, 2004). For some patients, on the other hand, bedrails can be regarded as enablers that facilitate movement and may reduce the risk of pressure ulcer development (Mullette & Zulkowski, 2004). Hence, the use of certain restraints can depend on an individual’s clinical needs.

When considered medically necessary, restraints should only be used temporarily and under physician’s orders and in close supervision by the nursing staff. Otherwise, their use is illegal. Use of restraints should be considered only when alternative means to ensure safety have failed because patients have the right to receive care in an environment that is the least restrictive. When patients manifest agitation or aggression, nursing professionals must first evaluate the underlying causes. For example, agitation may stem from depression or some other psychiatric disorder, in which case therapy should be directed toward the underlying disorder (Ouslander et al., 1997).

Urinary Incontinence and Catheters

There is a high prevalence of urinary incontinence in nursing homes. The starting point for addressing this problem is to maintain a bladder record over a period of 5 to 7 days to determine the type and frequency of incontinence. A clinical evaluation and treatment of reversible causes is the next step. Reversible or transient causes include urinary tract infection, urinary retention, delirium, restricted mobility, atrophic vaginitis, urethritis, fecal impaction, and pharmaceuticals. Other serious conditions—such as bladder cancer, prostate cancer in men, stones or other types of blockage—may also lead to incontinence. Once the underlying reversible causes have been treated, therapeutic programs should be instituted as the next step. Developing toileting schedules has been a common approach. Some residents may require staff assistance for toileting every 2 hours; others can do quite well on a schedule of every 3 or 4 hours (“Helping residents stay dry,” 2003). The schedule is based on the voiding patterns observed. Staff support with transfer and ambulation should be provided as necessary, and the resident should have easy access to the toilet or a portable commode. Low-intensity exercise programs to strengthen the pelvic muscles can be combined with the toileting program.

Use of a catheter would be indicated only when other measures have failed to control incontinence. Condom catheters are used for men who have difficulty retaining urine. An  indwelling catheter , that is, a catheter that remains in the bladder to drain urine into a bag, is used in both men and women when medically indicated and approved by the attending physician. Some of the highest infection rates among nursing home residents are attributed to indwelling catheters. Hence, their use should be minimized.

Mental and Cognitive Disorders

Depression

Traditional nursing home environments tend to promote dependency and negative affect, which increase the risk of depression (Meeks et al., 2006). However, biological, psychological, and social factors also contribute to the cause of depression. Among patients with dementia, 25 to 35% may experience depression (Aalten et al., 2005). Depression is associated with higher morbidity, greater mortality, and poor quality of life. Although nurses and CNAs do not formally diagnose depression, they play a key role in observing the mental, emotional, and behavioral state of patients. Nurses and CNAs may be able to recognize between 56 and 78% of patients with depression (Brühl et al., 2007). Common depressive symptoms include the following:

•  Loss of interest in things that otherwise bring enjoyment

•  Feelings of worthlessness

•  Diminished ability to make decisions

•  Fatigue

•  Underactivity (psychomotor retardation) and, sometimes, overactivity (psychomotor agitation)

•  Loss of appetite

•  Sleeping too much

•  Insomnia

•  Recurrent thoughts of death or suicide

Depending on the number of symptoms and their duration, depression can be mild or severe. Both biological (such as drugs, light therapy, and exercise) and psychotherapeutic treatments are available to treat depression (Thakur & Blazer, 2007).

Delirium

Delirium  is an acute organic brain disorder. It is a state of acute mental confusion that often manifests itself in the form of disorientation, incoherent speech, and physical agitation due to distress. Memory impairment and hallucinations may also be present. Delirium is often caused by acute illness or toxicity. It may be precipitated by immobility, use of physical restraints, use of bladder catheters, psychotropic medications (discussed later), malnutrition, or dehydration. A good sensory environment, appropriate lighting levels, mobility and activities, reality orientation, and one-on-one care can help alleviate or prevent delirium (George et al., 2006). The condition is treatable, but a quick medical diagnosis is critical because the underlying causes can lead to a fatal outcome. Without proper diagnosis, delirium can be mistaken for dementia or depression. For example, delirium is thought to occur four to five times more often in a person with dementia (Fick & Mion, 2007). Such comorbid conditions can leave delirium unrecognized. A delirious patient must show all of the following signs (American Psychiatric Association, 1994):

•  A lack of awareness of one’s environment and a reduced ability to focus, sustain, or shift attention

•  A change in cognition such as memory deficit, disorientation, or language disturbance

•  Development of the disturbance over a few hours or days and tendency of the disturbance to fluctuate during the course of the day

•  Existence of evidence that the disturbance is caused by a direct physiological consequence of a general medical condition, substance intoxication, or substance withdrawal

Management of delirium requires treatment of the underlying cause. Low doses of a psychotropic medication may be prescribed.

Dementia

Dementia  is a generic term for progressive, irreversible cognitive decline.  Alzheimer’s disease  is the most common type of dementia. Alzheimer’s is a progressive degenerative disease of the brain, producing memory loss, confusion, irritability, and severe functional decline. The disease becomes progressively worse and eventually results in death.

Dementia is common among residents in nursing homes and assisted living facilities. Diagnosing dementia is challenging, particularly in its early stage. Depression and delirium must first be ruled out. Dementia can be classified into mild, moderate, severe, and very severe stages (Sloane et al., 2001):

•  Mild dementia. Unreliable memory for recent events. Difficulty managing various instrumental activities of daily living (IADLs). May need supervision for dressing and bathing. Difficulty in carrying out a conversation.

•  Moderate dementia. Very poor memory for recent events. Easily confused or upset by changes in routine, new places, or unfamiliar people. Needs 24-hour supervision and assistance with bathing, dressing, and grooming. Displays confusion, repetitive questioning, disorientation, mood swings, delusions, and wandering.

•  Severe dementia. Poor memory for both recent and past events. Recognizes only persons seen very regularly. Difficulty following daily schedules. May develop gait instability and sustain falls. Resists caregiving, may have delusions, and may display physical abusiveness, such as hitting and biting, and other socially inappropriate behaviors, such as saying inappropriate things and disrobing in public.

•  Very severe dementia. Little awareness of surroundings. Speaks in a few words or unintelligible sounds. Rarely recognizes individuals, even close family members. Needs almost total assistance with ADLs. May be able to shuffle short distances with assistance or is nonambulatory. Incontinence of bowel and bladder. Resists caregiving and has screaming episodes.

Unlike depression and delirium, dementia is irreversible. Because of the issues mentioned, caregiving becomes challenging, and the burden of caregiving increases as the disease progresses. Patients with Alzheimer’s disease may live for 8 to 10 years after the disease is first diagnosed and often progress to the very severe stage.

Emotional behavior of caregivers can be sensed by even patients suffering from severe dementia. For example, negative behaviors by CNAs may contribute to increased behavioral problems and agitation in dementia patients. Person-centered communication strategies can help calm down the patient. Hobson (2008) recommended the following:

•  Communication with body language becomes more common in patients with advanced dementia. Hence, watch for body language.

•  The caregiver should introduce him- or herself. Communicate in short and simple sentences. Complex information can lead to frustration. Allow plenty of time for the person to respond.

•  Try to ask questions that require a “yes” or “no” answer.

•  During caregiving, try to explain what will be done. Explain each step of a process.

•  What works with one patient may not work with another because people with dementia are not all alike. Getting to know the person is important.

•  When offering things, try to limit the choice to two items.

Planning and delivering care to patients with early dementia is likely to be quite different from those in the final stages of dementia. For example, patients with advanced dementia are prescribed a larger number of medications from numerous medication classes, and prescribing patterns change over time (Blass et al., 2008). It is suggested that for the management of advanced dementia in its terminal stage, palliative care may be the most appropriate strategy and should include appropriate emphasis on quality of life, dignity, and comfort (Volicer, 2007).

Pharmacy Services

A nursing facility is required by regulations to provide pharmaceutical services and to have consultation from a licensed pharmacist. Long-term care pharmacies specialize in meeting the special needs of nursing homes.

The facility should have a written agreement with the consulting pharmacist, who should also be an active member of the multidisciplinary team. The pharmacist assists the facility in developing policies and procedures for the dispensing, storage, administration, review, discontinuation, and disposal of drugs. Pharmacy standards require a monthly review of the drug regimen for each resident and appropriate labeling and storage of drugs. Drug interactions and unexpected response to a given medication are special concerns in the medical care of the elderly. State laws govern how medications are dispensed and labeled. Drugs should be stored in locked cabinets to which only authorized personnel have access. Certain medications require proper refrigeration.

A system that allows separate storage of medications for each patient should be used. The unit-dose medication dispensing system has become the industry standard. In a  unit-dose system , medications are prepackaged and labeled in unit-of-use form and are ready to be given to the patient. This eliminates the need for a nurse to take out the medication from a bottle and prepare medicine cups for each patient. Internet-based drug ordering systems have become common. These systems save time, reduce medication errors, and minimize drug waste.

Controlled Substances

Controlled substances  include various narcotics, stimulants, depressants, hallucinogens, anabolic steroids, and chemicals; their prescription, dispensing, use, and safeguarding are governed by federal and state laws. A nursing facility must have specific policies and procedures in compliance with the law and standards of medical practice. Controlled substances are governed by the Controlled Substances Act (CSA), Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970. Except as provided under the law, possession or use of controlled substances is illegal. Controlled substances are listed in Schedules I through V of the CSA:

Schedule I. These substances are illegal because they have no currently accepted medical use in the United States. Examples include heroin and LSD.

Schedule II. These substances have a currently accepted medical use in the United States and generally have severe restrictions, and they may be illegal in certain jurisdictions. Examples include morphine, cocaine, and methamphetamine.

Schedule III. These substances have a medical use and also have less potential for abuse than substances in Schedules I and II. Examples include anabolic steroids and painkillers containing codeine or hydrocodone.

Schedule IV. These substances have less potential for abuse than substances in Schedule III. Examples include Darvon (also called Darvocet) used for pain, and Valium prescribed for anxiety disorders.

Schedule V. These substances have the least potential for abuse. Examples include cough medicines containing codeine.

Schedule II through V substances must be appropriately prescribed by a physician, but their abuse generally has a substantial and detrimental effect on health and general welfare—hence the need for strict control. A facility must store controlled substances in a double-locked cabinet and implement proper recordkeeping and verification systems to prevent unauthorized use. A system must be in place to adequately account for all used and unused medications for each patient. When an order for a controlled substance is discontinued for any reason, federal regulations require the controlled substance to be destroyed and its destruction to be duly witnessed and documented. Individual states may issue their own regulations for safeguarding controlled substances.

Emergency Kit

Nursing facilities must maintain an emergency medication kit. The pharmaceutical review committee should determine its contents. In general, the emergency kit contains drugs needed during life-threatening emergencies such as cardiac arrest, severe allergic reaction, or seizures. The drugs in the emergency kit are the responsibility of the pharmacist. They are often limited to a 72-hour supply. The kit is kept sealed (not locked), and records are kept whenever anything is used from the kit.

Psychotropic Drugs

Psychotropic (or psychoactive) drugs include antipsychotics, antidepressants, anxiolytics (antianxiety), sedatives, and hypnotics. In the past, these drugs were overprescribed for nursing home residents. Some of these drugs were prescribed as “chemical restraints” to sedate patients who were considered overly aggressive, disruptive, or assaultive. As a result of nursing home reform efforts, OBRA-87 contains specific rules for the use of psychotropic drugs in nursing facilities with the objective of reducing their use. For example, the legislation prescribes that antipsychotics can be used only when certain specified conditions have been documented. Less severe conditions for which these drugs should not be prescribed are also specified. Other requirements of the law include gradual dose reductions unless such action is clinically contraindicated. Whenever appropriate, behavioral interventions should be tried first, such as modifying the environment and implementing approaches to care delivery that would accommodate the resident’s behavior to the largest degree possible. This is a broad requirement, which needs to be carefully evaluated when mental or behavioral problems are observed. For example, depression may be attributed to certain medications the patient may be on, in which case the nursing staff should work with the physician and the pharmacist to review the patient’s drug regimen. If the depression is not severe enough, the patient may come out of it in a few days. Instead of rushing to seek pharmacological therapy, the nursing staff should carefully observe the resident’s behavior and maintain appropriate documentation. Nonpharmacologic approaches should also be tried in cases of anxiety, which is another common problem in nursing home residents. Interventions such as biofeedback, relaxation techniques, and participation in recreational programs may be useful for some residents (Ouslander et al., 1997). Decrease in the use of antipsychotic drugs has also been noticed in facilities that have a person-centered culture (Svarstad et al., 2001). Pain management has been found to reduce agitation in patients with moderate to severe dementia (Husebo et al., 2011). A review of research literature also suggests that a combination of pharmaceutical drug regimen review and educational interventions for physicians and nursing staff may be effective in reducing psychotropic drug use (Nishtala et al., 2008).

Rehabilitation

In the geriatric context,  rehabilitation  can be defined as the process of delivering the minimal services that maintain the present or highest possible level of function (Osterweil, 1990). Rehabilitation has three main objectives: (1) to restore functional status lost through disease, injury, or surgical intervention; (2) to maintain residual function and prevent further decline; and (3) to help disabled individuals adapt to their functional deficits. Hence, rehabilitation therapies can be restorative, maintenance, and adaptive in design. In many instances, restoring an individual to his or her former functional status may not be possible. In that case, maintaining or maximizing remaining function would be the goal.

Restorative Rehabilitation

Restorative rehabilitation  is designed to help regain or improve function. It requires intensive short-term treatments. Restorative therapy is generally provided immediately after the onset of a disability. Examples of cases requiring short-term restorative therapy include orthopedic surgery, stroke, limb amputation, and prolonged illness. Frequently, the goal of intensive short-term rehabilitation is to enable the patient to return to independent living. In other cases, especially when a patient must continue receiving long-term care because of other chronic needs, longer term maintenance rehabilitation is necessary after short-term restorative care has ceased.

The attending physician must authorize all short-term rehabilitation treatments. Short-term treatments are carried out by professionally trained therapists—mainly, registered physical therapists (PTs), physical therapy assistants (PTAs), registered occupational therapists (OTs), certified occupational therapy assistants (COTAs), and speech/language pathologists (SLPs).

Physical therapy  treatments are geared toward improving ambulation, range of motion, physical strength, flexibility, coordination, balance, and endurance. PTs also specialize in fitting and training patients to use artificial limbs, canes, and walkers. PTs are also trained to give treatment modalities such as hot packs, cold packs, massage, ultrasound, paraffin bath, electrical stimulation, compression therapy, and hydrotherapy. PTs can assist and train the nursing staff in techniques for preventing falls.

Occupational therapy  is tailored for the adaptive use of the upper extremities for performing various tasks. OTs can help patients with fine motor skills, adaptive equipment, splints, and other support mechanisms that are tailor made to facilitate the performance of daily tasks (Ramsdell, 1990). OTs also play a vital role in evaluating the independent living environment when the patient is scheduled for discharge to home.

Speech/language pathology  encompasses evaluation and treatment of speech, language, and communication disorders. Speech/language pathologists treat several kinds of disorders such as  aphasia , in which a person’s ability to communicate is impaired;  dysarthria , in which speech is slurred or unintelligible because of muscle weakness; or motor speech disorders such as  apraxia , in which the tongue, lips, and vocal cords are unable to work together (Reynolds & Slott, 1999). As a result, the person is unable to say what he or she wants to say.  Dysphagia , or the inability to swallow, is another common problem SLPs are called upon to treat in nursing facilities.

Maintenance Rehabilitation

Maintenance rehabilitation  has the goal of preserving the present level of function and preventing secondary complications. Certain capabilities cannot be recovered, but patients should be assisted to adapt to their deficits so that they can do for themselves as much as they possibly can in their daily activities. Maintenance rehabilitation is based on maximizing the use of a person’s remaining capacities. Without maintenance therapy, complications such as pressure ulcers, contractures, muscle atrophy, constipation, fecal impaction, and edema can result. Ambulation and range of motion are two common types of exercise programs. These programs often continue restorative treatments initiated by PTs and OTs. The treatment is generally less intense and of longer duration than restorative therapy. Long-term maintenance therapy is carried out by paraprofessionals such as specially trained rehabilitation aides or CNAs.

Adaptive Rehabilitation

Despite efforts to restore function, deficits often remain. When these deficits interfere with a person’s ability to do certain things for himself or herself, adaptive rehabilitation becomes necessary.  Adaptive rehabilitation  deals with an evaluation by a licensed therapist to prescribe adaptive equipment and devices, and training the patient on their proper use. For example, an OT can prescribe commercial devices that can enable a person to independently dress, eat, or brush teeth. OTs can also make splints so that a person can use his or her hands and arms to perform ADLs, or adapt a person’s living environment to improve safety. A PT can prescribe braces or orthotics to support the knee or foot so a person can ambulate safely.

Terminology for Review

adaptive rehabilitation

agitation

Alzheimer’s disease

antisepsis

aphasia

apraxia

asepsis

assessment

controlled substances

delirium

dementia

dysarthria

dysphagia

epidemic

geriatrics

indwelling catheter

infection control

infection control practitioner

maintenance rehabilitation

nosocomial

occupational therapy

pathogens

physical therapy

plan of care

pressure ulcer

rehabilitation

restorative rehabilitation

restraint

speech/language pathology

standard precautions

surveillance

transmission-based precautions

unit-dose system

For Further Thought

  1.  Discuss the ways in which nursing plays a central role in a nursing facility. How can the centrality of nursing sometime result in conflict with other departments? As an administrator, how would you prevent such conflicts?

  2.  As a nursing home administrator, you are recruiting a new medical director. What are some of the main elements you should discuss during the interview?

Cases

Case 1: Fallen Out of Bed

Both cases were contributed by Laura M. Wagner, PhD, RN, GNP, FAAN; and Katerina Melino, RN, BA, MS, University of California, San Francisco, School of Nursing.

Mary Branscombe is an 83-year-old woman who was admitted a week ago to a skilled nursing facility. She was transferred from an acute care hospital, where she was treated for 2 weeks following her first stroke. Before her recent hospitalization, Mrs. Branscombe lived at home with her adult daughter, son-in-law, and their four children. She required little to no help with ADLs. Now, with the change in her condition, the family does not think that she can return home to live with them. Mrs. Branscombe’s gait remains unsteady. The physical therapist at the hospital tried to have her use a wheelchair, which she refused and insisted on ambulating independently.

Mrs. Branscombe’s other medical conditions include glaucoma (diagnosed 3 years ago), osteoporosis (diagnosed 22 years ago), and depression (diagnosed 14 years ago, after death of her husband). Her prescriptions include alendronate (for osteoporosis), fluoxetine (an antidepressant), warfarin (a blood thinner), and timolol eye drops (prescribed for glaucoma).

During the 7:30 a.m. nursing rounds, Mrs. Branscombe is found on the floor beside her bed. She is confused, disoriented, and in a lot of pain. She tells the nurse that she attempted to get out of bed to use the bathroom and fell as she was climbing out of bed. It is unknown if she hit her head. Mrs. Branscombe is transferred to the emergency room where it is determined that she has sustained a hairline hip fracture.

Questions

1.  What nonmodifiable and modifiable risk factors does Mrs. Branscombe have for falls?

2.  What steps would you recommend to reduce the likelihood of this type of falls?

3.  Which staff members should be involved in the planning process, and what should their roles be?

Case 2: Oh, Please Authorize Restraint Use!

You are the administrator of a 75-bed nursing home. Two CNAs approach you regarding their concerns about a resident, Mr. Valdez, who is an 86-year-old long-stay resident with Alzheimer’s. Having been diagnosed and treated early in the disease process, his dementia has followed a fairly slow course, but has worsened more recently. Over the last few weeks, Mr. Valdez’s behavior has become aggressive, particularly in the late afternoon and early evening. He has struck several caregivers when they attempted to serve his dinner tray. He has also started wandering into other residents’ rooms, creating disturbances. Last week, he attempted to escape from the facility and was combative when brought back to his room. The associates have expressed concerns about their safety around him, and other residents have complained that Mr. Valdez is intrusive and dangerous. The two staff members have learned about restraint use for aggressive clients. They have just walked into your office, and asked you to authorize the use of restraints for Mr. Valdez so that the safety of staff and residents could be ensured.

Questions

1.  As the administrator, how would you address the situation?

2.  Name some interventions other than restraint use that may help to decrease Mr. Valdez’s agitation.

3.  Would using restraints with Mr. Valdez be appropriate?

4.  In situations where restraints must be used, what is the role of each health care professional in ensuring that they are used as safely as possible?

FOR FURTHER LEARNING

The American Geriatrics Society is the premier professional organization of health care providers dedicated to improving the health and well-being of older adults.

http://www.americangeriatrics.org

American Medical Directors Association is the professional association of medical directors and physicians practicing in long-term care, dedicated to excellence in patient care by providing education, advocacy, information, and professional development.

http://www.amda.com

National Association of Directors of Nursing Administration in Long Term Care (NADONA-LTC) is a professional organization of directors and assistant directors of nursing in long-term care. It has established standards of practice for directors of nursing and also has a certification program for directors of nursing.

http://www.nadona.org

National Gerontological Nursing Association (NGNA), an organization of nurses specializing in care of older adults, informs the public on health issues affecting older people, supports education for nurses and other health care practitioners, and provides a forum to discuss topics such as nutrition in long-term care facilities and elder law for nurses. NGNA offers information on gerontological nursing and conducts nursing research related to older people.

http://www.ngna.org

National Mental Health Association is the country’s oldest and largest nonprofit organization addressing all aspects of mental health and mental illness. It allows a search feature.

http://www.nmha.org

National Rehabilitation Information Center (NARIC), funded by the U.S. Department of Education, provides information on rehabilitation of people with physical or mental disabilities. Contact NARIC for database searches on all types of physical and mental disabilities, as well as referrals to local and national facilities and organizations.

http://www.naric.com

REFERENCES

Aalten, P. et al. (2005). The course of neuropsychiatric symptoms in dementia. Part I: Findings from the two-year longitudinal Maasbed study. Psychiatry, 20(6) 523–530.

Allman, R. M. (1999). Pressure ulcer. In W.R. Hazzard et al. (Eds.), Principles of geriatric medicine and gerontology (4th ed., pp. 1577–1583). New York: McGraw-Hill.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.

Bennett, G. C. J. (1992). Pressure sores—Aetiology and prevalence. In J. C. Brocklehurst, R. C. Tallis, and H. M. Fillit (Eds.), Textbook of geriatric medicine and gerontology (4th ed.). Edinburgh, U.K.: Churchill Livingstone.

Bergstrom, N. I. (1997). Strategies for preventing pressure ulcers. Clinical Geriatric Medicine, 13(3) 437–454.

Bern-Klug, M. et al. (2003). “I get to spend time with my patients”: Nursing home physicians discuss their role. Journal of the American Medical Directors Association, 4(3) 145–151.

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