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Fall prevention is a primary concern at Willow Bend Nursing & Rehabilitation, and we work diligently to evaluate patients for fall risks as well as implement preventative measures. With Therapy working closely with our Activities Department, we have helped many patients to avoid falls as well as gain greater independence.

Our Balance Program consists of a screening, an evaluation with a standardized test upon admission, therapeutic intervention, quarterly balance assessments and various balance-related activities. The goal is to progress patients from a medium fall risk to a low fall risk, with modified independence in activities such as ambulating, standing balance in grooming tasks and toileting.

In our program, we had a patient move from a Berg score of 27 and a medium fall risk at evaluation to a score of 47 and a low fall risk at discharge. The patient was able to return to assisted living at PLOF and continue being independent with all basic ADLs, simple meal prep, light housekeeping, leisure activities, walking to the dining room and community outings.

Through a close collaboration between Therapy and Activities, we are able to develop and implement balance-related activities for our patients, such as tai chi, core stability and our walking program. The combination of therapy and balance-focused activities enables us to progress patients safely through the program and reduce their fall risk significantly.

At Oceanview Healthcare and Rehab, our mission is simple: to improve the quality of life for residents with dementia, while secondarily improving employee satisfaction. Through the development of patient-specific programs that target each resident’s best ability to function, we are able to accomplish that goal. Below, we’ve outlined just a few of the many success stories we’ve seen at our facility.

Goal: Fall Prevention

• Nursing concern: A resident was having multiple falls, sometimes more than one per day.
• Solution: Therapy identified that the resident was a wanderer and was not safe to walk. We provided a cushion and WC with the height adjusted to allow the patient to wander. We also instructed caregivers to have shoes on the patient at all times and to avoid locking the WC brakes.
• Results: The resident has had a significant decrease in falls.

Goal: Behavior Modification

• Nursing concern: A resident was non-compliant, often displaying physical aggression during care.
• Solution: Therapy provided caregiver education to identify high-risk situations and prevention strategies.
• Results: Caregivers are now better able to prevent situations where the resident becomes aggressive.

By collaborating across disciplines, we are able to maintain patient independence, integrity and safety. We are committed to facility-wide education to improve awareness of the dementia disease process, so that we can speak a common “language” when communicating about patient care. By staying true to our mission, we set up our patients for success, as well as our entire team.

By Jennifer Yocum M.S. CCC/SLP and Sonny Gonzalez DOR, Oceanview Healthcare and Rehab, Texas City, TX

I have found that the use of sleight-of-hand magic as a therapeutic intervention has yielded great success and positive outcomes throughout my occupational therapy career. It provides a wonderful opportunity to facilitate functional gains with occupational skills, including pincer grasp, hand-eye coordination, in-hand manipulation, sequencing, problem solving, short-term memory, crossing the midline, activity engagement, concentration, decision making, among many others.

The use of sleight-of-hand magic as a therapeutic intervention also enhances the psychosocial aspects of our clients’ lives. Learning a magic trick that incorporates skill and technique, and then sharing it with friends, family, or other patients, encourages a social component that is vital to support a healthy quality of life. A patient’s self-efficacy immediately rises after successfully showing a magic trick to a family member who comes to visit.

Additionally, the use of magic as a therapeutic intervention breaks up the monotony that may come with a skilled nursing facility stay. It allows for a creative outlet to attempt something new or experience something novel. The use of sleight-of-hand magic as a therapeutic intervention is evidenced-based, dynamic and client-centered. I have found it essential to include magic in my therapeutic “bag of tricks”!

I was working with a gentleman who had a CABG x 3, as well as middle-stage dementia-related decreased short-term memory. He loved magic and the idea of magic tricks but doubted his ability to perform one himself. Some barriers to his ability to perform included cognitive declines and decreased short-term memory.

I graded down a simple magic trick to reflect the patient’s skill level and to compensate for his short-term memory decline. The patient successfully learned the magic trick! After successfully performing this trick, my patient was overjoyed, stating, “It actually worked, and I did it!” He looked forward to showing it to his grandson who was coming to visit later that day!

By Max Zweig, Occupational Therapist, Park View Post Acute Care, Sonoma, CA

 

What if there were something besides a medication that could assist with redirecting negative behaviors? What else can we offer, after looking at basic needs — cold, hungry, in pain, needing to use the bathroom — when behaviors persist? What if we could tap into a resident’s past and provide meaningful activities to engage the resident and redirect their behaviors?

For Ron, that is exactly what he needed. At first glance, many said Ron was not able to attend to any task. He wandered around throughout the day, pacing the halls and knocking on the tables — a behavior the other residents and staff found annoying as he invaded personal space, knocking on the tables regardless of what was going on. Staff might be able to redirect him momentarily, but within seconds, he was back knocking away.

When we first picked up Ron for OT, there was skepticism — he won’t be able to do anything, he can’t pay attention, he doesn’t even talk. As an OT, I knew that all was not hopeless. I knew there was a way to tap into his past and engage him in meaningful activities. With a little research to find out his past interests, hobbies and jobs, and an assessment of his current cognitive level, we were able to identify activities he enjoyed and tailor them to his current cognitive level. Before we knew it, Ron was smiling and attending to tasks for over 15 minutes at a time. Who knew he could write and answer questions on paper, read a book, sit and do math worksheets or play a game of cards?

With a little staff education and a few supplies, when Ron starts knocking on the table while another resident is eating, he can be easily redirected to a meaningful activity he enjoys and can engage in — ultimately, improving his quality of life and that of those around him.

By Jeanelle Kintner, OT/R, San Marcos Rehabilitation and Healthcare, San Marcos, TX

Helen is a long-term care resident at Northbrook Healthcare Center. Initially when she was admitted, staff was having difficulty caring for Helen because of her cognition, and she was sometimes combative and anxious. When we started implementing the Abilities Care Approach to Dementia, she was one of the initial six residents enrolled in the program. Occupational Therapy identified her Allen Cognitive Level, and with the support of Social Services, we obtained her Life History Profile during an interview with Helen’s daughter, enabling us to better understand her habits, preferences and long-term memories.

By integrating what we knew from her Allen Cognitive Level and the individualized information we obtained from her life profile, we were able to train staff on how to communicate and support Helen to avoid her becoming agitated during care. Puzzles and flower arrangements were identified during the family interview as areas of past interest and skill. The therapist also identified that due to her cognitive challenges and her personality profile, large group settings were difficult for Helen, and that she had a higher quality of engagement in activities if she was by herself.

One day, Helen’s behavior had escalated, and staff wondered what happened. We thought she might be experiencing a change of condition. Upon further observation, we identified that Helen had a change in her routine related to her roommate discharging from the facility. Helen was finding it difficult to cope with this change. Having identified the situation, staff was able to use information from the Life History Profile to calm Helen and help her feel safe, preventing a potential episode of further agitation.

This situation illustrates how important it is that we not only identify the physical and cognitive functioning of our patients, but also understand them as people — what makes them happy and what makes them sad. Understanding the emotional and social component during our interventions can help us effectively approach an individual, thereby helping us to be effective clinicians. We deal with different emotions every day, whether it is happiness due to a goal being met, or sadness due to temporary loss of function or pain. These emotions are expressed by our patients, ourselves and our coworkers. Being equipped with the understanding of not only our patients’ needs, but also our own needs makes us better clinicians and much better people.

Included with this article are pictures of Helen (wearing the yellow jacket) completing her puzzles at the nurse’s station during her period of agitation. Staff was able to decrease the agitation by providing meaningful activities (adapted to meet her Best Ability to Function) that reminded Helen of the person she has always been. By engaging in a familiar task at which she could be successful, Helen gained the confidence to socialize and even got some other residents and staff to help her with the puzzles.

By JB Chua, DOR, Northbrook Healthcare Center, Willits, CA

The purpose of a modified cooking group is to facilitate participation in a meaningful occupation for individuals with disabilities.

Population

• Individuals with cognitive or physical disabilities and diagnoses such as fractures, ORIF, TKR, THR, laminectomy, CVA, Parkinson’s disease, Alzheimer’s disease and dementia
• A modified cooking group is more appropriate for individuals who want to return to living independently

​Relevance to Therapy

• Occupational therapists specialize in assessing for deficits in occupational performance and facilitating participation in occupations through restoration, compensation or adaptation.
• Cooking and meal preparation is categorized under Instrumental Activities of Daily Living.
• Cooking or meal preparation is a prerequisite for living independently with no assistance from family members, friends or caregivers.

Standardized tests can be used to evaluate cooking performance and skills related to cooking:

• Rabideau Kitchen Evaluation – Revised
• Kitchen Task Assessment
• Executive Function Performance Test
• Performance metrics include: strength, endurance, ambulation distance, gait quality, transfers, static and dynamic sitting and standing balance, gross and fine motor coordination, safety awareness, memory, sequencing skills, problem solving skills, etc.

A modified cooking program will enable therapists to:

• Assess the patient’s ability to participate in cooking
• Educate and train the patient in necessary skills to improve performance
• Modify the environment or task and/or train the patient in utilizing adaptive equipment/devices to facilitate successful participation in cooking
• Design and implement therapy exercises/activities to target specific skills required to participate in cooking
• Recommend programs or assistance as part of discharge planning

Methods

Occupational therapists will train and educate clients in:

• Writing down steps and checklists
• Using energy conservation strategies
• Using compensatory techniques
• Delegating tasks to assistants
• Modifying the environment for ease of access to necessary tools, supplies and working space
• Using adaptive equipment/devices such as built-up eating and cooking utensils, long handled equipment, pan handle holder, tray mounted on a wheelchair, four wheel walker or front wheel walker, and kitchen trolley
• Using technological devices such as analog or digital timers with sound or visual reminders, electronic can openers, digital thermometer with sound indication, cooking equipment with presets that automatically adjust for speed, time and temperature

By Ann Marie Hulse, DOR, Lemon Grove Care and Rehabilitation Center, Lemon Grove, CA

At Veranda Rehabilitation and Healthcare in Harlingen, Texas, there is no greater incentive for our therapists to persevere through difficult cases than to see patients returning home to carry on with their lives. In the example of one client, admitted to Veranda with a gunshot wound to the mouth and presenting with ETOH abuse, B nephrolithiasis, malnutrition, liver cirrhosis and other symptoms, it was clear from the start that this patient would require extensive therapy. However, our therapists were up for the task, and his story is just one of many that demonstrates how our commitment to a positive outcome allows us to create a partnership for healing with even the most challenging patients.

This client, we’ll call him Joe, entered Veranda not only with multiple physical ailments, but emotional distress as well. Angry, depressed and unwilling to participate in therapy upon admission, Joe seemed determined to do anything but listen to his therapists. One can understand his frustration: After living independently in a mobile home community, now Joe required total assist for all mobility and ADLs and was eating a modified diet of mechanical soft food and honey-thick liquids.

With persistence and continual education on the benefits of therapy, we began to create a rapport with Joe. Once we turned that corner, Joe became an active participant in his treatment program and began to see progress, albeit slow. The road was long and winding leading up to Joe’s discharge, to say the least. During his stay, Joe was transferred to hospital three times due to multiple medical issues. While there, he went into both respiratory and cardiac arrest and was put on a ventilator.

Joe’s therapists remained dedicated to his treatment despite the bumps in the road. Physical therapy included functional exercise tolerance, BLE strengthening and coordination, standing balance facilitation and gait training. Our occupational therapists worked on NMR, BUE strength, sitting balance, UE coordination, self-care training and e-stim for pain management. Lastly, SLP treatment included oral motor retraining and dysphagia treatment.

After four months of hard work, Joe was discharged home and now lives alone and independently with all ADLs. He ambulates without an assistive device, eats a regular diet with thin liquids, manages his own finances and drives his own car. While we are thrilled with the outcome of Joe’s treatment, we are even happier that he has reclaimed his life and makes the time to visit us frequently at Veranda. Joe never fails to express his gratitude that our therapists did not become discouraged despite the initial challenges. To this, we would say, it is our great pleasure to serve clients like Joe and help them emerge from treatment with a new lease on life.

When 42-year-old Heather entered Park Manor Rehabilitation Center in Walla Walla, WA, she had already experienced more struggles than many people twice her age. With a medical history of diabetes mellitus and lower-back pain, Heather had visited the emergency room due to pain in her right lower extremity — at the time, thought to be sciatic pain. An MRI was negative for a herniated disc; however, an X-ray confirmed she had necrotizing fasciitis.

Heather’s diagnosis led to her transfer to Kadlec Medical Center, where the wound was debrided and a wound vac put in place. After receiving antibiotic treatment, she was life-lighted to Harborview Medical Center in Seattle for further care, which included debridement of the right thigh, calf and gluteal area, perineum and groin through four separate incisions. Admitted to the ICU, intubated and placed in a coma for four weeks, Heather underwent a total of 12 debridement surgeries.

During this time, Heather also developed VRE. Her family was told she had less than a 15 percent chance of survival. Despite the odds, Heather persevered and stayed at Harborview for a total of seven weeks. From there, her journey began with Park Manor Rehab for post-acute care.

With some prior experience as a CNA, Heather was high-functioning at admission and had been living with her daughter in an apartment on the ground floor. She was (I) with all ADLs, including bathing. Additionally, she was (I) with all IADLs, including driving. As for her functioning levels at evaluation, she required 100 percent mod assistance for grooming from her bed as well as maximum assistance with toileting, upper body dressing, bed mobility and transfers. She was dependent for lower body dressing and bathing and unable to ambulate.

The team at Park Manor enlisted the collaborative efforts of physical and occupational therapy to get Heather on the road to wellness. A combination of electrical stimulation and short wave diathermy in physical therapy worked to increase circulation in order to promote wound healing. Meanwhile, occupational therapy worked on increasing Heather’s upper extremity strength and coordination, activity tolerance and improving her ability to participate in functional tasks.

Upon discharge 96 days later, Heather had achieved modified independence with ambulation, grooming, toileting and upper-body dressing. She required standby assistance with lower-body dressing, minimal assistance with bathing, and modified independent or standby assistance with transfers. Perhaps most astounding was the remarkable healing of her wounds. In fact, when she went to a final appointment to schedule a skin graft for her right lower extremity prior to discharge, her doctor decided instead to suture the last remaining opening, and no skin graft was required.

Heather was discharged home to her apartment with home health services initially. Later, she returned to Park Manor for outpatient therapy. Although Heather’s necrotizing fasciitis case was complex, it served as a benchmark by which to design future treatments. Park Manor has since received two more cases of necrotizing fasciitis and also has seen an increase in patients with extensive wounds and wound vacs, which we have treated successfully with the high-volt e-stim. As for Heather, we are happy to see her continuing to make great strides in her recovery!

For patients with a terminal illness such as cancer, hospice is not the only answer — and certainly not the best one in many cases. That’s something Northeast Rehabilitation Center in San Antonio, TX, learned firsthand in working with Patient P., a woman who presented with stage III lung cancer and whose chemotherapy treatment had proved ineffective. When told by her doctors that she needed to consider hospice, P. refused — and those of us at Northeast Rehabilitation and Healthcare Center stepped in to provide rehabilitation services.

P. entered our facility with multiple confounding factors, including aspiration pneumonia, neuropathy, COPD, poor trunk control, Hx of hip fx with resultant leg discrepancy, a peg tube and oxygen dependency. Moreover, she weighed just 80 pounds and was both emotionally and financially devastated by her diagnosis. To make matters worse, her husband needed to work and was therefore unavailable to assist her during the day. P. simply was overwhelmed and wanted to be at home.

Doing our best to create a home away from home for P., the team at Northeast Rehab took an interdisciplinary approach that included occupational, physical and speech therapy. For occupational therapy, we emphasized BUE strengthening exercises, sitting balance, progression from Hoyer to sliding board transfers, wheelchair mobility, coordination and feeding. Physical therapy focused on bed mobility, BLE strengthening, balance, trunk control, transfer training, sitting and standing tolerance, and wheelchair mobility. Lastly, speech therapy included laryngeal elevation exercises to increase airway protection, positioning during and after PO intake, nutrition, and swallow strategies and training. Needless to say, we all had a busy schedule, especially P.!

The three teams collaborated frequently to continue encouraging P. along her journey, reinforcing a positive approach and reminding her daily of her progress in each discipline. Although P. would become discouraged at times, we would invite her to reframe her thinking and notice how far she had come since admission. Gradually, P. began to realize that each incremental gain was another step toward reaching her larger goal of going home.

Indeed, it truly was a team effort that enabled P.’s positive outcome and ability to return home after being in our facility for 55 days. At the time of discharge, she required Min A for standing pivot transfers, SBA for bed mobility, and SBA/CGA for dressing and toileting. She was (I) with self-feeding and grooming/hygiene, her endurance had increased from less than one minute to greater than 30, and she was able to propel her own wheelchair. With her family trained on transfers and a home exercise program, P. went home on a regular diet and thin liquids with no further need for a peg tube.

P.’s success in the cancer rehabilitation program not only improved her quality of life and allowed her to go home with her family, but also allowed for greater visibility and credibility of the program with insurance companies and with the medical community. We negotiated with P.’s insurance provider for maximum visits and also received more patient referrals to our facility as a result of working with P.

In addition, our own rehab team increased their understanding of rehab for terminally ill clients. As evidenced with Patient P., working with these residents is often one of the most rewarding and inspirational experiences we could ever have.

Sometimes, one new piece of equipment makes all the difference for a patient. Take, for instance, the case of one resident at Mountain View Rehabilitation and Care Center (MVR) who was admitted following a right middle cerebral artery aneurism, with coil embolization of aneurism, aneurism perforation and resultant subarachnoid hemorrhage. Hospitalized for three and a half months prior to admission at MVR, Patient R. entered our facility with multiple challenges preventing her from living a more independent life. However, with our therapists’ patient and caring approach, plus the addition of a Barihab table to her treatment routine, R. has made incredible strides in her recovery.

At admission, R. had a host of challenges to overcome, among them:

• Severe right-side neglect causing her to persist in twisting her trunk to the left and grabbing the bed sheets and bed rails on her left side
• Inability to maintain an upright position for more than five minutes
• Total dependent standing pivot transfer with a left prosthetic limb, requiring two therapists due to R.’s severe retropulsion and falling to the left
• Peg tube for feeding with NPO
• Two therapists required for bed mobility, including rolling and transferring from supine to sitting at the edge of the bed
• Total dependency for all dressing, hygiene and grooming

Before joining us at MVR, R. had received some rehab services at the hospital, but she had failed to make any progress. Her situation changed once our therapists began to work with her and encourage progress throughout her ups and downs.

Initially, R. required transfer with a Hoyer lift and had difficulty remaining seated in her wheelchair because she was sliding or squirming out of it. Therapists continued to work with her on standing pivot transfers, balancing from sitting, and sitting balance on the treatment mat in the therapy gym. Eventually, R. progressed to standing by positioned parallel bars close to the high-low table.

The game-changer came about when MVR acquired a Barihab table and began to incorporate it into R.’s therapy regimen. Because the table provides greater security, R. felt less fear of falling, and over time, she gained greater confidence in her own mobility. She now stands using the Barihab table and self-supports with her UEs while ambulating through the parallel bars, then transitions to a FWW and walks 35 to 40 feet while wearing her left prosthetic limb.

Says Sam Wipf, OTR/L (DOR), “We have just opened a new world of possibilities with the Barihab table, no question about it.”

R.’s family and therapists agree that the table has enabled a remarkable recovery for the resident. Among her many accomplishments, she is now self-feeding on a mechanical soft diet, no longer requires a bed pan and needs one person for toileting, ambulates with a FWW across the rehab gym and into the hallway, and is completing the majority of her transfers with a standing pivot approach with one person.

The Barihab table has proved to be an invaluable addition to MVR’s therapy program — one that continues to benefit patients like R. and others. “I can now stand residents who I never thought I would ever be able to stand,” says one therapist.

Adds one family member of another patient: “He actually stood for 10 minutes. He hasn’t stood for months.”

Another therapist perhaps sums up our sentiments about the Barihab table most succinctly: “Why didn’t we know about this before?” Now that we know, we expect to continue using the Barihab table for many of our patients who are mobility-challenged.