Restorative Nursing Care Plans
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2012 MDS 3.0 Edition
Data Collection tools
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Goal-specific Restorative Nursing Care Plans
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Regulations and definitions
65 Forms and Restorative Nursing Care Plans in the book and on the CD
The goal of a Restorative Nursing Care Plan is to ensure that a resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable.
The Restorative Nurse plays a vital part in improving and maintaining the residents’ quality of life and quality of care in the long term care facility.
The first section gives a full description of the Restorative Nursing position and definitions and criteria of a Restorative Nursing program.
Helpful tools are provided to assure easy and comprehensive data collection, completion of MDS 3.0 information, analysis of data, and recording of vital information.
Sections are included for thirteen different Restorative Nursing programs, and provide evaluations, assessments, and Restorative Nursing care plans.
Restorative care plans and forms have been updated to ensure compliance with the change to MDS version 3.0 and with all of the federal regulations and guidelines updated during the past year.
All of the forms and care plans in the book are included on the CD so they can be saved to a computer whenever needed. By adding or deleting entries, the forms and care plans can be made resident specific.
Forms on the CD are not numbered. Forms in the manual are numbered for the sake of convenience.
Definitions and Criteria of Restorative Nursing Care Plans
From the Revised Long Term Care Resident Assessment Instrument (RAI) User’s Manual, CMS:
Generally, Restorative Nursing care plans are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy.
A resident may also be started on a Restorative nursing care plan when he/she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when a restorative need arises during the course of a custodial stay.
Restorative Nursing care plans:
Do not require a physician’s order.
Do not include procedures or techniques carried out by or under the direction of qualified therapists.
Do not include groups with more than four residents per supervising helper or caregiver.
If a Restorative Nursing care plan is in place when a care plan is being revised, it is appropriate to reassess progress, goals and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this “reassessment” should be documented in the record.
When not contraindicated by State practice act provisions, a progress note written by the Restorative aide and countersigned by a licensed nurse is sufficient to document the Restorative Nursing care plan once the purpose and objectives of treatment have been established.
Restorative Nursing care plans must meet all of the following criteria:
Measurable objectives and interventions must be documented in the care plan and in the clinical record.
Evidence of periodic evaluation by a licensed nurse must be present in the clinical record.
Nurse assistants/aides must be trained in the techniques that promote resident involvement in the activity.
These activities are carried out or supervised by members of the nursing staff. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents.
For Restorative Nursing care plans to qualify for Medicare reimbursement :
There must be 2 or more different Restorative activities at least 6 days per week, each practiced for a total of at least 15 minutes during each 24-hour period.
The 15 minutes of time in a day may be totaled across 24 hours (10 minutes on the day shift plus 5 minutes on the evening shift) however; 15-minute time increments cannot be obtained by combining O0500A through J.