LTC Rehab RN's- Help!!!!

[shal]

Just took a position of Rehab nurse at my CCRC after being out of Rehab for 3 years. The previous Rehab RN has been gone for 1 yr!

In looking in the chart I was unable to locate any type of restroative assessment and the Med rec guru did not find one in thinned records either. Has the MDS now replaced Restorative Assessment that used to be done on admission, quarterly and with change in condition or are both documents required still. The information is often times duplicated. Could a narrative be used to expound on the responses of the MDS. BTW in Illinois a full MDS is done quarterly and with change in condition. (I understand some states still do quarterly assessments. I appreciate any help I can get.

[Talino]

Each facility have their own procedures on how or when to initiate a restorative nursing program on a resident. Some have specific forms solely for this purpose, others simply incorporate notes on a nursing assessment, progress notes, or care plans. And, you're right. These assessments are often duplicated or redundant.

Regardless, the objective is to determine a resident's capacity to improve or be prevented from further loss of function. The MDS assessment is an excellent tool to obtain this information. Simply incorporate your care plan with the applicable triggered RAPs.

Since it's going to be your responsibility now, confer with the DON or the therapist on how this matter was pursued previously. Ask for a policy and procedure and make sure it is within the guidelines. Refer to the criteria for rehabilitation and restorative practice on Section P3: Nursing Rehab/Resto Care (under Definition) in the MDS Manual.

Good luck!