Sunnyslope Wildlife Program Engages Residents, Families, and Community
By James Barnhart III, LNHA, Quality Improvement Project Leader, and Robert A. Feigenbaum, MS, Editor. Photos by Kevin Jordan.
A wildlife program that brings nursing home residents in touch with nature is going a long way to enhance patient-centered care at Sunnyslope Retirement Center. Sunnyslope is a 50-bed facility on a 40-acre campus in rural Bowerston, Ohio.
“The Sunnyslope Wildlife Program began as an effort to improve the quality of life for our residents,” explained Linda Jordan, Occupational Therapist. The program has its origins in traditional occupational therapy, which uses culturally relevant and meaningful activities to correct functional deficits in residents. The program also addresses residents’ symptoms of depression including feelings of loneliness in a crowd and of worthlessness, loss of meaning, and self-imposed isolation. Other goals include the ability to identify cognitive and fine motor skill declines more effectively and to begin treatment prior to irreversible loss.
The 40-acre campus includes a spring-fed lake, meadows, forests, and a nearby beaver dam. The staff quickly realized that this “natural healing environment” was underutilized and consequently a committee was formed to identify program goals. Many staff members and volunteers worked to get the program started.
“A key to the program’s success was the efforts of staff and volunteers to obtain National Wildlife Federation certification for the campus as a wildlife habitat,” said Jordan.
Cognitive stimulation
Following initial baseline assessments in occupational therapy, residents will be assigned to different activity modules. These include building and maintaining bird feeders, mixing nectars and seeds for birds, and using a field guide to identify birds and butterflies. The program features a “bird of the month” activity that helps residents with memory.
“These activities provide cognitive stimulation as well as motor skill development and graded opportunities for socialization based on the resident’s skill level,” said Jordan. “Staff report any social, cognitive, or motor skill declines that prevent participation in the program to the treatment team for timely interventions.”
The Wildlife program also features scheduled wildlife education speakers. Each month a speaker lectures on a topic such as hummingbirds or bees. The sessions are advertised and open to the public. The educational program also helps residents identify both native and invasive species of birds.
Sunnyslope welcomes family participation in the program. “Many family members have volunteered for habitat improvement projects and assist their loved ones with monitoring or filling feeders,” said Jordan. Additionally, children enjoy visiting their grandparents to feed the geese or to go fishing. These interactions help to form more positive feelings about visits than those that might be fostered in traditional medical model facilities.
“The program wants to make the experience of visiting Sunnyslope seem more like a visit to Grandma’s house,” said Jordan.
Since the program began many residents who were reluctant to get dressed and leave their rooms are now doing so. Residents have also stated that they “feel good” about helping to preserve the environment, birds, and wildlife for their grandchildren. These feelings dovetail nicely with the Appalachian-area residents’ love for nature and the outdoors.
“The preservation aspects of the program encourage seniors to contribute to society in real and meaningful ways, create dignified, positive, final memories of the senior for family members to cherish, and enable residents to leave a legacy of hope,” said Jordan.
Possibilities are unlimited
A nursing home does not have to have a 40-acre campus to implement a person-centered care program in the same vein as that of Sunnyslope’s. The first step is listening to your residents. Discover who they are, and identify common interests or cultural traits. Then build your programs on that. The possibilities are unlimited. “For example, setting up programs that make use of greenhouse or horticultural themes, or any common resident hobby, can be effective in improving the quality of life for residents, their families, and staff,” said Jordan.
Mercy Siena Retirement Community’s Interventions Significantly Reduce Need for Restraints
By Kori Magallanez, BS, Quality Improvement Project Leader
Mercy Siena Retirement Community is a 99-bed nursing facility located in Dayton, Ohio. Mercy Siena made a decision to move toward a restraint-free environment in December 2005 when the facility had a score of nearly 26 percent on the physical restraint quality measure. This score included residents who had a trunk or limb restraint or chair that prevented rising in daily use. In addition, the facility had several full side rails in the building. The Director of Nursing, Cheryl Bombok, made a policy change to eliminate the use of roll belts beginning in December. The restorative nurse, who championed the project, set a goal to eliminate or reduce two restraints per month, which would allow the facility to be restraint-free by October 2006.
In January 2006, the restorative nurse, Kim Alston, began a systematic review of residents who had full side rails, and either removed the bed rails completely or switched the full rail to a partial rail that residents could use as an assistive device. In addition, for residents at risk of falls, Mercy Siena installed several low beds with floor mats. Bed bolsters were used for positioning and to prevent accidental falling from bed. In April 2006, the restorative nurse began a systematic review of residents restrained with lap belts. One by one, each restraint was eliminated and alternative methods such as positioning cushions and self-releasing belts were implemented for a five-day trial period. Floor nurses monitored the effectiveness of the new intervention.
Buy-in from families and staff
Alston reports that effective restraint elimination requires multiple attempts at interventions, as well as buy-in from family members and staff. For example, one resident with a mild cognitive impairment and frequents falls was restrained with a seatbelt to prevent him from rising without assistance. However, the restorative nurse noticed that his ability to perform activities of daily living had diminished since the restraint was applied, and both the resident and his power of attorney were unhappy with the use of the restraint. The first intervention for that resident was to remove the lap belt and use a positioning cushion in his wheelchair, but the resident fell while trying to get up, so the trial was stopped and the lap belt was replaced. The second intervention reintroduced the positioning cushion with the addition of a chair alarm, but the resident continued to get up alone and staff were unable to respond to the alarm in time to assist. The third intervention has been effective in allowing staff to respond in time to assist the resident with transfers: he now has a Velcro self-releasing chair alarm belt with a positioning cushion. The resident is able to release the belt on his own, but the alarm sounds as soon as he begins to undo the Velcro strap This is an effective reminder for him to wait for assistance.
Fall risk and prevention
Alston also noted that the many misconceptions about the use of restraints to prevent falls could be a significant barrier in attempts to eliminate restraint use. Families of residents whose restraints were reduced or eliminated were educated on an individual basis to address concerns about resident safety. Alston used Ohio KePRO’s Alternatives to Physical Restraints video to in-service staff on the risks involved with the use of restraints and possible alternatives to consider. At the same time, the facility implemented a Falling Leaf program. Staff from all departments were educated on fall risk and fall prevention. Now residents at high risk for falls are identified with a leaf on their name plates, the head of the bed, and any mobility equipment. Coordinating the fall prevention program with the restraint elimination process has helped to keep rates of falls low, and there have been no injuries related to the restraint elimination process at Mercy Siena.
Mercy Siena’s current score on the physical restraint quality measure is less than 6 percent. Now that the facility has met the goal of eliminating physical restraints, the next step is to eliminate the use of bed and chair alarms.
To learn more about Mercy Siena’s success with reducing and eliminating restraints, contact Kim Alston at 937-278-8211. For assistance with your own restraint reduction program, contact Ohio KePRO’s Nursing Home Team at 1-800-385-5080; e-mail: ltc@ohqio.sdps.org.
Nursing Home Achieves Success With Pressure Ulcer Protocols
From the Gables Care Center
Gables Care Center’s pressure ulcer protocols follow the Clinical Practice Guidelines of the Agency for Health Care Policy and Research including assessment on admission using the Braden Scale.
Based on the Braden Scale score, preventive interventions are put in place. The prevention and healing process is individualized and includes nutritional support, management of tissue loads (i.e., specialty mattresses, heel protectors, etc.), ulcer care, managing bacterial colonization, and preventing infection. In conjunction with the medical director, Gables Care Center, which is located in Hopedale, Ohio, developed standing wound care orders that address all skin conditions. All skin is assessed weekly for all residents. We monitor the healing process and interventions are changed as needed. Gables has healed eight “out of house” pressure ulcers since January of this year. The healing process took an average of one to four weeks.
Gables believes the most important part of a pressure ulcer program is not a dressing or a mattress or an ointment—it is communication and education! Pressure ulcers are not just a nursing issue. We recognize that we need the nutrition support and expertise from our dietary department, and we need therapies and restorative nursing to keep our residents mobile. We need central supply to provide use with the appropriate wound healing and preventive equipment, and we need the activities department to assist with hydration and monitoring positioning. How would we heal and prevent infection without a clean environment and linens? Families can literally make or break skin issues based on whether they encourage residents to resist the plan of care or to follow it.
Unique forms of communication
Our facility has established unique forms of communication. Our written 24-Hour Report lists all residents with decreased hydration, decreased nutritional intake, elevated temperatures, and those with pressure ulcers. This report is not limited to the nursing department. It is distributed daily to P.T., O.T., S.T., dietary, activities and central supply. In addition, a Weekly Pressure Ulcer Report notes those residents with pressure ulcers, the progress of healing and those residents at high risk. Nursing assistants also use what we jokingly call a “cheat sheet” to jot down meal percentage intakes and outakes, and any changes in the resident’s skin or mobility. This sheet is turned into the nurse each day. We also make use of an Appliance Check List, which is a list of every appliance (intervention) used to prevent skin break down for every resident in the building. It is maintained in the computer and updated by the Assistant Director of Nursing (ADON) on a weekly basis.
Pressure Ulcer Prevention Video
Gables Care Center has used the Ohio KePRO Pressure Ulcer Prevention Video to educate staff. Following the Ohio KePRO pressure ulcer prevention meeting, we decided to establish a continuous quality improvement pressure ulcer team. Some examples of the issues the team has identified include a change in the brand of incontinence pads used (we felt the old ones were rough and caused shearing) and redirected storage of dressings in the med-room rather than central supply to make them more accessible.
We feel that our team has been a great success, and we’re not done yet. We highly recommend the CQI process. Do make sure that the team consists of everyone involved in the process.
Healthy Heart Program Takes the Lead in Post-Hospital Cardiac Care
By Robert A. Feigenbaum, MS, Editor
Four nursing homes in Ohio are leading the way in providing post-hospital care to cardiac patients through their Healthy Heart Program. The nursing homes, which are part of the Levering Management Group, are Country Court Nursing Center in Mount Vernon; Morrow Manor in Chesterville; Delaware Court in Delaware; and Winchester Terrace in Mansfield.
The Health Heart Program, designed and implemented by Cindi Levering, RN, MS, CNS, Project Coordinator for Levering Management, was started in January 2004. “This model of care delivery has received support from area cardiologists, Dr. Barry George of Mid-Ohio Cardiology and Dr. J. Pala of Knox Cardiology,” said Levering.
The goals of the Healthy Heart Program are to provide post-hospital care for patients as they recover from medical or surgical cardiac events, educate their families, and to improve the overall health, wellness, and fitness levels of the residents. Nurses use clinical pathways to guide the day-to-day care and have received extensive education regarding the assessment, treatment, and evaluation of residents experiencing a cardiac event.
Care that was once given in an acute care setting can now be given at the nursing facility. Nurses throughout the system are certified in Advanced Cardiac Life Support (ACLS). Residents are monitored on a 24-hour basis and activities are coordinated around a cardiac rehabilitation focus with the goal being to maximize residents’ time and efforts. Physical and occupational therapy determine the energy units needed for the residents to return to their maximum level of independence. They are then able to structure the residents’ therapies to safely build their tolerance to that degree of activity. The activities are incorporated throughout a typical 19- to 20-day stay.
Strong education component
One of the most critical most critical components of the Healthy Heart Program involves education regarding cardiac care. “We create opportunities for residents and their families to learn something about their heart every day,” said Levering.
Education includes information about diet, medications, what symptoms to report to their doctors and nurses, and how to incorporate beneficial activities into their lives. Families are extremely positive about the program and initial concerns about having their loved ones’ post-hospital cardiac care being offered in long-term care nursing facilities is quickly dispelled. The Healthy Heart Program participants stay in private rooms and sometimes family members choose to stay as well. The overall focus of the Healthy Heart Program remains to have participants gain as much independence as they possibly can. It also seeks to eliminate the post-surgical readmissions to the hospital. Typically, those needing to return to the hospital do so in the first 48 hours post-hospital discharge.
“In 2005, we did not send any of our cardiac residents back to the hospital,” said Levering.
Get the most out of their lives
Today’s patients now more than ever want to get the most out of their times and lives. The Healthy Heart Program has had participants ranging from 35- to 90-years-old. One was a 66-year-old cyclist who went through rehabilitation and successfully returned to long distance cycling. Another was a World War II veteran who enthusiastically returned home to watch his grandchildren grow up. Perhaps an 83-year-old participant of the Healthy Heart Program best described the experience. “My doctor said that after surgery my heart could last another 10 to 12 years, and I plan on using every one of them.”
The Quality of Health Care Explored in Four-Part PBS Series: Remaking American Medicine™…Health Care for the 21st Century
Remaking American Medicine™…Health Care for the 21st Century explores the quality crisis and the innovative solutions being undertaken by providers, patients and their families to transform the care provided by the institutions on which we depend. The four one-hour programs are scheduled to air on PBS on consecutive Thursdays on October 5, 12, 19 and 26 at 10 p.m.
Each program examines critical health care issues facing Americans today including patient safety, medical and medication errors, hospital-acquired infections, family-centered care and effective management of chronic disease. 
But rather than assign blame for the failings in health care, series producer Crosskeys Media® offers solutions by showcasing the stories of individuals and institutions who are working to ensure better health care for everyone.
“We wanted to present detailed and emotionally engaging profiles of people like Dr. Donald Berwick, founder of the Institute for Healthcare Improvement, who are struggling to fix our broken health care system,” said Frank Christopher, executive producer, Crosskeys Media. “Remaking American Medicine is their story, told through the eyes of doctors, nurses, administrators and patients, showing their struggles, their setbacks and their victories. We call these people and their institutions Champions of Change.”
“Patient safety is at the vanguard of Remaking American Medicine and transformational change,” said Alice Stollenwerk Petrulis, MD, FACP, Chief Medical Officer for Ohio KePRO and its parent organization, KePRO, Inc. “The compelling nature of this unprecedented series will help advance a patient-centered culture of ensuring care that is safe, effective, efficient, timely, and equitable.”
Additional information is available by visiting www.RAMcampaign.org.
Order Free Materials
Ohio KePRO offers a variety of free CD-ROMs, brochures, booklets, and note cards to help your nursing home manage pressure ulcers, become restraint free, recognize depression, treat pain, retain staff, and more. View Shopping Bag >>
Just Available!!!
- Staff Education DVD
This DVD contains the following: Pain: Everyone’s Responsibility; Pressure Ulcer Prevention; and Alternatives to Physical Restraints. To order this free DVD, please call the Nursing Home Team at 1-800-385-5080. - Depression Manual CD
This CD contains the following: - Fast Facts: Depression—A 3-page overview of depression, barriers and further reading.
- Depression Change Package—Use this 4-page document to choose improvement strategies and implement related changes to improve recognition and treatment of depression.
- The Depression Quality Measure—This 9-page document contains Chapter 6 of the Quality Measures Resource Manual, which outlines how the depression quality measure is calculated.
- Depression Quality Measure Calculation and Mood Score—A brief 2-page overview of how the depression quality measure is calculated including a copy of the mood scale.
- Snapshot Definitions of Quality Measures—Review a snapshot of all the CMS nursing home quality measures, including depression.
- Key Resources—Access clinical guidelines, national organizations, related Web sites, screening tools, and literature.
- Regulations—FTAG 272 & 273: Guidelines for admission orders and resident assessment; FTAG 279: Guidelines for comprehensive care plans; FTAG 309: Guidelines for quality of care; and FTAG 319 & 320: Guidelines for mental and psychosocial functioning.
To order this free CD, please call the Nursing Home Team at 1-800-385-5080.
Nursing Home Quality Initiative Team
Ronald A. Savrin, MD, MBA
Betty Pilous, RN, MHSA, CPHQ
Leann Schaeffer, MA, RD, LD, LNHA
James Barnhart III, BSH, LNHA
Kori Magallanez, BS
Rosalie McGinnis, RN, MS
Leasa Novak, LPN, BA
Robin Reitzel, BS
Miriam Rose, MEd.
Editor: Robert A. Feigenbaum, MS
