Nursing, Wound Care & Physical Therapy

By Dustin Rex, PT, DPT, MS, CEEAA, DOR, Cedar Pointe Health and Wellness Center, Cedar Park, TX
Our wound care systems at Cedar Pointe, led by Tiffany Delafosse, RN, DON; Nikki Alvarez, LVN/LPN, ADON; and Elise Mixson, LVN/LPN, are consistently managing our wound care systems successfully and effectively. When he started, Ricardo Cacho, one of our physical therapists, expressed a specific passion for learning about wound care. The combination of clinically talented and motivated team members facilitated our discussion of Nursing and Therapy collaboration within this system.

During the third week of October, we identified a resident with a persistent, complicated wound and began supplementing our standard wound care approach with Closed-Pulse Irrigation (CPI) treatments performed by Ricardo. Through clinical leadership from our Nursing partners, our wound care team, and Dr. Pat Marasco, developer of the CPI system, our resident experienced abrupt differences in wound size and discomfort. By the middle of December, seven-and-a-half weeks, our team had healed their first wound: complete closure from an initial size of over 7 cubic centimeters (7 cm3). We expanded our use of CPI with other residents and have had similarly significant results. The course of healing is always an ongoing, multifactorial process; but, to date, our team has facilitated healing of a combined area of 7.5 cm length x 6.6 cm width x 5.3 cm depth in stage IV wounds in our resident population. All of the success starts with our Nursing partners, who have used their expertise to support and streamline the addition of therapy as a part of the wound care system.

Presently, in addition to CPI, we are participating in a pilot trial with an ultrasound mist wound care program. We have found benefits with both approaches, which allows us to expand our ability to help our residents; expanding our skills means more opportunities to make a difference. It has been a great experience collaborating to maximize the talents of our interdisciplinary team to directly influence our residents’ quality of life.

The Impact of a Student Clinical Internship

By Dustin Rex, PT, DPT, MS, CEEAA, DOR, Cedar Pointe Health and Wellness Center, Cedar Park, TX
We love hosting students across all disciplines for so many reasons — most significantly, students are able to shake up our routine, expose us to the cutting edge of our profession, and bring us back outside the box, where we are able to make the most difference for our residents.

We have recently hosted Chelsea Basilio, SPT, through the University of St. Augustine, Texas. Chelsea will be completing her internship in early April. As a part of the process, most students complete an in-service or project. Chelsea met with Brooke Brown, PT, DPT, and me about her project and what she specifically wanted to accomplish. She identified the need, created from scratch a tool that is comprehensive yet succinct, and composed it in a manner that is visually appealing for patients, families, and staff. It is a great training guide that reflects the essentials of transfer training (safety and function) and reveals the innate talents Chelsea possesses for problem solving and initiative.

Chelsea initially presented to our Rehab team and then also presented to our entire staff during our weekly IDT huddles. She helped create laminated copies for education and training along with hard copies for distribution to patients, families and caregivers.

Chelsea’s work was well-received by everyone and rightfully so. We are grateful for her time and contributions at Cedar Pointe and are similarly grateful for our university partners that continue to excel in training the next generation of clinicians.

Where Am I? – Making Our Building More Dementia Friendly

A Capstone Project by Stephanie Marshall, MOTR/L, PAM, CDP, Glenwood Care Center, Oxnard, CA
When you first enter a skilled nursing facility, it’s likely to look the same as almost any other: neutral flooring and paint colors, limited signage, and identical rooms throughout. This poses significant issues, not just for visitors trying to find their way to family members, but for residents with any type of cognitive disorder looking for their room. It is important to remember that individuals with dementia may experience impaired reasoning and struggle with daily items that we often consider “easy to use” or familiar. Thus, adaptations must be made in order to promote ease of navigation and use throughout the building’s hallways and resident rooms. Our development plan consists of three phases of signage improvement.

What’s The Big Deal About Oral Care?

A Capstone Project by Melissa Alexander, M.A. CCC-SLP, Opus and Millenium Post Acute Care, West Columbia, SC
At Millennium Post-Acute care we wanted to make sure the importance of oral infection control was integrated effectively at our facility. Did you know that tooth brushing prevents more than just cavities and bad breath? Poor oral hygiene has been related to a number of medical conditions including:
• Diabetes mellitus
• Cardiovascular disease
• Strokes
• Atherosclerosis
• Myocardial infarction
• Cancers, including:
• Kidney (risk increased by 49% in men)
• Pancreatic (risk increased by 54% in men)
• Blood (risk increased by 30% in men)
• Pregnancy complications such as low birth weight and prematurity9
• Pneumonia

Oral Health Status can be determined by examining the teeth, tongue, and mouth. The Oral Health Assessment Tool (OHAT) is a recognized, proven screening tool for just that purpose. By implementing a strong oral infection control program we have also been able to have more patients on Free Water Protocols and are helping ensuring adequate hydration. By working together, we are putting attention on quality oral care to prevent infections that lead to adverse medical conditions. Education was key including information on the effects of poor oral hygiene, the pros and cons of toothettes and the basics of good oral care.

Source: American Academy of Periodontology. (n.d.). Gum Disease Information. Retrieved July 1, 2018, from[1]disease.htm

Additional Resources: POSTettes Reducing Risk of Dehydration / Free Water Protocol and Oral Health Assessment Tool for Non-Dental Professionals

Passionate About ACA

By Camrin Nettey, MS, CCC-SLP, DOR, The Healthcare Resort of Leawood, KS
The Occupational Therapy team at The Healthcare Resort of Leawood is passionate about implementing the Abilities Care Approach to improve the quality of life for our residents with dementia. In doing so, they recognize the importance of collaborating with and providing education to other staffing departments within our facility to maximize the ongoing success of this program.

The team recently created a Powerpoint presentation, along with pocket-size strategy reminders to provide at an all-staff in-service. Through collaborating with other staff, we have seen countless success stories for the residents that we serve here at The Healthcare Resort of Leawood.

A recent celebration included a resident, Lee, who was having difficulty participating in bathing/showering tasks. Nursing staff voiced these concerns to the Therapy team, and our OTs identified strategies based on her Allen Cognitive Level that created opportunities to improve Lee’s active participation with showering/bathing. By integrating what they knew about the Allen Cognitive Levels, along with individualized information, the OTs successfully identified strategies to reduce Lee’s level of anxiety, provide dignity, and improve her quality of life.

Using the Abilities Care Approach with Lee has not only helped her ability to participate more in her ADLs, but her overall demeanor has changed. Throughout the day after her therapy sessions, you can see a change in how she holds herself and interacts with others.” — Erin Mallory, COTA

Milestone Retention: Retention Boards and Therapy Involvement

By Gary McGiven, Milestone Therapy Resource, Utah
Milestone’s HR Resource Brandon Lane has rolled out a retention plan with most of our facilities to better live our culture and show our new-hires our Love One Another culture. As a visual for the whole department head team to see and be a part of, this plan includes a retention board. This board has weekly tasks for the department head team to complete, following the employee from new-hire through their first 12 weeks. Some of the weekly tasks include:
● Assign a mentor
● Phone check in
● Non-work connection (i.e., off-site activity with mentor and/or other facility employee)
● Thank-you treats
● Empower them to recognize and reward a peer
● Send a text

With the retention boards being a department head focus, the Therapy leaders and their teams decided they wanted to partner with the department heads to take part in the retention process. To coincide with the facility’s retention plan, the Therapy departments each came up with a plan. Some of those ideas include:
● Therapy involvement in orientation process (transfer, gait belt, and body mechanics training)
● “Therapy Moment” in each all-staff meeting
● Therapy leader identifies new facility hires and relays to the team; each team member is encouraged to introduce themselves and get acquainted with the new-hires
● Discuss facility hires in weekly Therapy meeting and find out what was learned about new-hires
● Therapy “Open Door Friday” new-hires are encouraged to stop by Therapy for a treat and some therapy education

These are just a few of the ideas for the retention boards and the Therapy team retention plans. Our Therapy teams take loss of employees very seriously and want to be part of the solution to making a work environment where we are the facility’s workplace of choice.

Falls Team at Rosewood

By Whitney Wilding, DOR Rosewood Rehabilitation, Reno, NV
We have started a Falls Team at Rosewood that includes two of my PTs and I meeting monthly to discuss issues and trends. We do our meeting following the monthly QA meeting and look at trend data as well as personal experience from those on the floor regarding issues, patterns, etc. I feel it has been very successful at this point! Here are a few of the things we have put together:

We started a screen form specific to falls as we felt the UDA in PCC did not gather the information we really needed to intervene properly after a fall. This screener is filled out by a therapist and includes time-of-day information, fall predictor information such as patient’s history of falls, and qualitative information such as fear of falling to complete our analysis. This also includes what Nursing interventions are currently in place and any referrals to Therapy following the incident. I have attached a copy of that for your perusal. After implementing this form, we began to take note of some patterns that were happening with falls that we could address. After implementing some additional safety measures to address the patterns we noted, our falls declined 18% month over month.

Next, Melinda — who is one of my all star PTs — put together a list of falls predictors that increase someone’s likelihood for falls. These include dementia/cognitive impairment, polypharmacy, DM/neuropathy, incontinence, prior falls, assist with ADLs, ambulation with an assistive device, and fear of falls per self-report. Next, we rolled this out to the entire Therapy team, who are including it and a rating score (i.e., 3/8) on their initial evaluations. This allowed us to prospectively look at those who are at risk for falls prior to the incident for our skilled patients. The idea is to see how we can support them by adding interventions aimed at decreasing fall risk within our treatments to prevent falls. We have just started rolling this part out, but l am very excited about the prospect of having this focus on our initial evaluations for all disciplines. Eventually, all disciplines will be included in a monthly falls meeting, and we are getting them thinking about this now.

We noted that quite a few falls were happening due to the patient’s need to toilet. The PTs again jumped on board and decided to start a day shift toileting program whereby we scheduled time daily for the skilled patients who had the above-mentioned risk factors. One therapist would have those patients scheduled for regular therapy and then follow-up during the second half of their day to work on functional mobility and transfers in a toileting program. They were successfully able to incorporate functional training with toileting to reduce fall risk. . The two weeks we were able to run the program so far evidenced no falls on shift (and high patient satisfaction 😊). Our next step is to include all PTs and OTs on a rotating basis to perform toileting rounds on day shift and see how this impacts our falls. Lastly, this ties in nicely with PIVOT for Nursing and strengthens our Therapy and Nursing partnership.

Discovering the Joy in Collaboration

Submitted by Dominic DeLaquil, Therapy Resource, ID/NV
Like all of the Summit Markets, Meadowview Nursing and Rehabilitation in Nampa, Idaho, is intently focused on building its Therapy-Nursing collaboration into something truly transformative.

Director of Rehab and CTO Kristen Bailey acknowledges that while they have only begun to scratch the surface of the various ways Therapy and Nursing can collaborate to improve quality metrics, increase staff retention throughout the facility, and improve the lives of the residents, she has already seen a significant change in the atmosphere at Meadowview.

“If you’re not in the building every day, you probably won’t see it. Our Nursing and Therapy have always gotten along, but it’s different now. I see the therapists and nurses having a different energy to their conversations in the hallways. I see them laughing with each other much more and in a way that’s different,” Kristen said. “It’s joyful! And it spreads and you can see it in the demeanor of the residents! It’s really fantastic.”

Thank you, Meadowview, for exemplifying two of our core values, Customer Second and Love One Another, as you work on your Nursing-Therapy collaboration. You are demonstrating how these two core values in action improve the day-to-day lives of your residents.

ILF “Outside These Four Walls” Partnership

By Jacqueline Eaton, TPM, The Healthcare Resort of Topeka, KS
HCR of Topeka partnered with the preferred Home Health Agency (HHA) in our community to create better clinical collaboration when patients are finishing their home health services, but continue to have outpatient therapy needs.
Many of the patients seen by the local home health agency reside in an Independent Living Facility (ILF) in our area. In an effort to ensure a smooth transition, the HHA requests outpatient therapy orders once the home health service is ending. Upon receipt of these orders, we schedule the patients for an evaluation at our therapy gym. Some patients will benefit from therapy services provided in their home and community, and we schedule the patient for the service location that will optimize their individualized treatment plan.

We also provide support to the local ILF by providing general education and training to the administration and the Thrive-at-Home representative to ensure optimal wellness programming for ILF residents and to offer our services for PT, OT, and SLP consultation when it is clinically indicated. We collaborate with the HHA, Thrive-at-Home, and the local ILF to offer Health Fairs and balance clinics on a regular basis. When patients are referred for outpatient therapy services, our Rehab Tech works with the patients and/or their caregivers to assist with the outpatient paperwork process, ensure all orders are in place, and assist with information gathering prior to scheduling their evaluations. The Rehab Tech also provides administrative support for ensuring physicians have properly certified the plans of care in accordance with policy. This support from the Rehab Tech allows for a more streamlined and efficient process for the evaluation and therapy services.

Our outpatient program is currently offering PT and OT therapy specializing in cardiac recovery training, pain management, and strengthening, and we are in the process of starting a seating and positioning clinic. Based on the needs of the patients in our community, we plan to hire an SLP to offer outpatient services for communication disorders, swallow dysfunction, as well as cognitive impairment and dementia.

These are just a few of our AMAZing therapists here at the Healthcare Resort of Topeka.

Veranda’s Fun Group Thursday

Submitted by Aaron De La Torre, Therapy Resource, Keystone Borderstone Market, TX
Providing therapy services during the COVID-19 pandemic has been more essential than ever to improve the outcomes of the residents we serve. With all the social distancing mandates that have been implemented to keep our residents safe, our interdisciplinary teams have been hard at work to ensure that therapy is provided in a safe and efficient manner. However, with social distancing also comes more time alone, which can lead to unwanted consequences.

If you were to visit Veranda Rehabilitation & Healthcare in Harlingen, Texas, on Thursday morning at approximately 10 a.m., you would witness the amazing way they encourage safe socialization while improving residents’ functional skills. You would find several groups of residents playing an adapted version of volleyball, where residents are holding pool noodles and working on their dynamic reaching and core strengthening as they hit a balloon over the net. Do not be surprised if you see some friendly competition between residents and therapists! You will likely also see another group of residents with ankle weights kicking balls of different sizes and playing a makeshift version of soccer, all the while strengthening their lower extremities. Music that ranges from oldies to reggaeton will be playing as patients enjoy their group activity.

Fun group Thursday is possible thanks to a collaborative team approach. Vanessa Munoz, DOR, helps identify the patients who would benefit from group therapy and creates a master list on Wednesday. She then emails the master list to Jason Hess, ED, and the rest of the IDT team. Each team member ensures that every patient is up and ready for the fun group activities after they have had a delicious breakfast. The CNAs, nurses, Activities, and of course every therapist who is available plays a crucial role in helping fun group Thursday occur. Pictured are some of the equipment that is used and the amazing Rehab team at Veranda Rehabilitation & Healthcare.