Make restorative nursing a focus and a priority this year!

By Kimberly D. Green, M.Ed. CCC-SLP, Chief Operating Officer, Diakonos Group, LLC

I am throwing down the gauntlet, hoping to inspire you to make restorative nursing a focus and a priority this year . . .

Yes, you too, Assisted Living!

At the end of the day restorative nursing is simply excellent resident care. It is not rehab driven; it is purely care driven. It is mandated for SNFs, but can be very successful in keeping residents in assisted living longer.

One of Those Boxes

Mostly we tend to put it in a box and label it as our problem. It is shameful that restorative nursing has a bad reputation in our industry, yet it does. I train it all over the country and continue to see the same issues in restorative nursing I was seeing 15 years ago.

We continue to fail in keeping up with a successful program or even worse, we continue to fail in recognizing the absolute necessity of a successful program.

With Quality Assurance and Performance Improvement (QAPI) and re-hospitalization rates being an immediate focus we must take restorative nursing out of the closet, dust it off and wake it back up. It has been typically done because “we HAVE to do it” but now we must own it. You think I am wrong? This is what I see:

We tend to pull our restorative aides to the floor constantly or we use restorative services for just physical needs. Restorative by regulation and definition (OBRA 1987) must cover psychosocial, mental AND physical. There isn’t any way that a resident can achieve their highest functioning level without all three of those areas being addressed.

Bad Behavior

We can see this best when we look at residents with dementia . . . and there are a lot of them. We may have numerous physical programs, such as walk-to-dine and morning exercise with these residents, and yet we still see wandering, yelling or acting out.

These behaviors continue because we have not addressed all aspects of the resident. Too often psychosocial and mental needs are not addressed. I also frequently see pain that is not addressed or that residents do not feel safe in their current situation.

Until all those areas are addressed we will continue to struggle at keeping our residents at their highest functional level. Pulling our restorative aides to the floor is perfectly fine as long as those CNAs and nurses working the floor cover those treatments and meet the needs that go along with those treatments.

The floor staff must then divide the restorative treatments and document to get those treatments covered to meet those needs.


Another area of struggle is that facilities fail to provide restorative services for the prevention of complications. They focus on the higher levels of functioning and don’t see that the complications of avoidable issues of lower level residents often eat up the majority of nursing time.  

If we identify residents at risk for falls, contractures, swallowing disorders, wounds, behaviors, etc. and train our floor staff on WHY these residents are at risk, WHEN to monitor and HOW to avoid the issue then we will prevent the complication from ever occurring.  

We cannot wait to put someone on the restorative program AFTER the fall. We must prevent the fall from ever occurring. Identify the diagnoses that put residents at risk for complications. Start the prevention PRIOR to anything ever occurring.

An Example

One example of the level of prevention of complication is that you may have a resident who is in end-stage cancer and is on hospice but at risk to have skin breakdown and swallowing difficulties. The first response is often that the resident is on hospice and that is the normal course of disease progression.  

Here our goal is not to FIX the resident but to prevent complications for the resident and allow a more peaceful death. It can be as simple as a different positioning schedule is put into place that will decrease how quickly wounds develop, if at all.

A speech-language pathologist (SLP) could come in for one visit to evaluate and to train staff on positioning, swallowing strategies, or texture and consistency to decrease the choking of the resident. Yes this is absolutely possible while a resident is on hospice.

This makes the resident and the resident’s family feel safe and decreases the great fear that comes with swallowing disorders and death itself. There isn’t any need for this type of struggle if it is avoidable. We may not be able to prevent or stop all declines or complications but we can absolutely make a drastic impact.

There are many, many, many examples of this type of restorative nursing. It is the most underutilized area of restorative nursing that could make the biggest impact on resident care, staffing, staff satisfaction.  It also has the added benefit of decreasing worker’s compensation cases and the overall burden on the facility.

The Dollars

Restorative nursing can have a positive financial impact on your bottom line. There are direct lines to resource utilization groups (RUGs) under Medicare A and direct lines to increasing the case mix index (CMI) under Medicaid and in upper payment limit (UPL) states. There is a dotted line for financials in decreasing staff burden, decreasing worker’s compensation cases related to injuries involving heavy care and decreasing staff turnover from dissatisfaction at workload.


There is also a positive marketing effect when all your residents are at their highest level of function in all areas. I challenge you to tackle your restorative program in 2016. Create or recreate it and grow a passion for it within your team. Inspire others to learn and discover an entirely different side to the care we provide.

Keeping every resident at his or her highest level, regardless of age, regardless of diagnosis and regardless of prognosis should not just be a mandate it should be our mission.