Can This Fall Be Prevented?

1. Can This Fall Be Prevented? Demi Haffenreffer, RN, MBA Email: demi@consultdemi.net

2. OUTLINE • Risk Factors • Creating a Culture of Safety • Components of a good fall management program • Requirements and Common Citations • Assessment and Care Planning • Resident Centered Care • When an accident happens • What constitutes a fall? • Conducting thorough investigations & assessments • Implementing measures & updating the care plan • Quality Improvement

3. RISK FACTORS • Anticipated vs. Unanticipated risk factors • Anticipated risk factors are those factors we should address before the resident falls • Measures are implemented after an unanticipated risk factor becomes known • Unanticipated risk factors • Seizures, resident to resident behaviors, arrhythmias, CVA, TIA, a pure accident • Anticipated risk factors • Fall History • Confused or possible lethargy related to med • Unsteady gait or weak transfer • Syncope or orthostatic hypotension • Other Internal or external risk factors

4. RISK FACTORS • Anticipated Internal Risk factors: • Cardiovascular • Neuromuscular/functional • Orthopedic • Perceptual/Sensory • Overall poor health • Psychiatric or cognitive

5. RISK FACTORS • Anticipated External Risk Factors: • Medications • Appliances or devices • Environmental Equipment issues • Environment overall or situational hazards • Poor assessment and care planning • Poor communication • Lack of staff knowledge

6. Components of a good Fall Prevention Program • Goal Driven • Prevent avoidable accidents • Prevent repeat falls • Prevent major injuries • Provide quality person-centered care • Prevent citations • Prevent legal actions • Good communication systems • Satisfied customers – residents and employees

7. Components • System is consistent • Become a learning organization and acknowledge high risk and error prone nature of the work we do & the people we work with • Good, consistent investigation/assessment procedures when a resident falls • Simple documentation system • Blame free error reporting system but individuals accept responsibility

8. Components • Assessments of risks on admission, quarterly & with condition changes • Many prevention strategies (including equipment) available to staff – including restraints as a last resort (however the program is based on a restraint free environment) • Education & orientation • Multidisciplinary • Continuous Quality Improvement activities to identify problem/strength areas and improve

9. Common citations • Investigation/assessment not thorough and does not identify all risk factors. • Investigation/assessment not timely – resulting in another incident/fall before interventions put in place. • Investigation/assessment and interventions not based on facts or incident.

10. Citations continued: • Interventions not followed. • Lack of supervision • No investigation/assessment of accident occurred – no new preventive plan.

11. Assessment and Care Planning • Upon Admission: • Preliminary assessment with immediate measures discussed with the resident & implemented • Orientation of the room with an observation of how the resident interacts with the environment • Increased supervision/observation during the first few days/evenings/nights • Obtain a general history of past falls – establish trends • Develop an initial care plan

12. Assessment and Care Planning • A comprehensive assessment within 14 days • Assess and proactively implement person and environmentally centered measures to prevent accidents • Person-centered care plan approaches • What does the resident want?

13. Person-centered care • Begins with the investigation • Resident involved & informed of data collected, options, risks and benefits of each option • Resident decision • Documentation of assessment/cause & resident choices • Care planning • Reevaluation & cp updates

14. What Constitutes a Fall? • Alleged fall, unwitnessed • Fall • Lowering to the floor • Preventing a fall • Rolling off a low mattress

15. When to complete an investigation / assessment? • Alleged fall, unwitnessed • Fall • Resident found in a dangerous or risky situation: • Climbing out of bed • Other

16. Culture of Safety • Old Approach • Resident falls • Minimal investigation w/ much paperwork • Incident report • Implement an intervention • 24-hour report • Move on • New Perspective • Resident falls • Investigative process is thorough & consistent w/ as little paper as possible • Incident report & stepped investigative process • 24-hour report • Evaluation of interventions / CQI

17. Conducting thorough investigations • Initial step – often performed by Charge Nurse • Immediate protection of resident as indicated • Begin data collection per guidelines • Examine area and equipment • Conduct staff interviews • Determine if care plan was followed as written • Gather first impressions • Implement initial action & communicate

18. Conducting an investigation continued: • Second step – often completed by the RN Care Manager • Clinical assessment of possible causes • Medications • Medical • Cognitive or sensory • Environment • Psychosocial • Physical functioning

19. Conducting an investigation continued: • Third step - Ongoing data gathering by RN Care Manager and/or a department head • Incident trending based on prior incident information or log • Has this happened before? • Similarities/differences? • What was implemented in the past? • Initial identification of root cause • Staff assignments • Other more complex environmental issues

20. Conducting an investigation. • Fourth Step - Analyze data • What is the data telling you? • Report suspected abuse/neglect • How can this be prevented from happening again? • Utilize CAA guidelines to assist with assessment and investigation. • Use Interdisciplinary team • Summarize findings • Communicate

21. Conducting an investigation continued: • Fifth step – CQI and the 5 Why’s • Analyze all incidents monthly in order to identify trends and implement action plans (education, policy changes, etc.) for the safety of the entire facility and facility population (residents, staff & families)

22. Trending and Root Cause Analysis • Possible system issues: • Physician orders not followed • Care plan not followed • Failure to assess risk and care plan • Standards of practice not followed • Resident preference not honored • Illness, diagnosis related

23. Trending and Root Cause Analysis • System issues continued: • Staff orientation • Staff on break • Staff training • Equipment mal-function • Environment/maintenance/housekeeping hazard

24. Trending and Root Cause Analysis • Action plans for root cause(s) trends • Staff education • Staff counseling • Resident education • Family education • Change in system e.g. orientation program • Environmental changes • QA surveillance change • Process improvement team

25. What to for? Falls • What was resident doing? • Rising? • Sitting? • In bed or out of bed? • During assisted transfer? • To chair or from chair? • Indicate type of chair • Brakes on w/c/bed • Chair too low • Foot rests appropriate • Self ambulating?

26. What to for? Falls continued: • What was resident doing? • Reaching • Assisted ambulation • Sliding/leaning forward out of chair • Location & time of fall? • Side rails? • Up, down, per care plan? • Malfunctioned • Time since last voided/toileted? • Call light within reach? Call light on? • Time since last meal?

27. What to for? Falls continued: • Environment/equipment a factor? • Failed or misused adaptive device? • Device out of reach? • Faulty equipment? • Furniture? • Clutter? • Lighting/glare? • Water on floor? • Uneven floor or if outside uneven pavement?

28. What to for? Falls continued: • Mobility alarm on? Functioning? Removed by resident? • Type of footwear? • Non-skid shoes • Slippers • Socks only • Shoes • Barefoot

29. What to for? Falls continued: • Care Plan followed as written? • Assigned staff on break? • Staff in orientation? • Medical factors e.g. Parkinson’s • Vital signs – BP lying and sitting • Diabetic? Check blood sugar

30. What to for? Falls continued: • Medications • Any new medications? • Meds in last two hours? • Psychoactive • Hypertension • Sedative/hypnotic • Narcotic • If unknown origin • Interview all staff and visitors going backwards in time to determine possible time frame for event

31. What to for? Falls continued: • Physical functioning • Gait • Upper torso weakness • Vision/sensory – glasses/hearing aide on? • Need for contrasting colors? • Pain? • Sitting too long? • Seating Assessment done? • Tired?

32. Falls Investigation Guides Overview Guide Environmental Guide

33. Falls investigation Guides Medication Guide Communication Guide

36. Some Interventions • Non-slip surfaces • Lights are automatic • Raised toilet seats • Half rails- arc rails – transfer poles • Lower beds – Hi/low beds better • Automatic bed controls • Trapezes – merry walkers, etc

37. Some Interventions • Bedside commodes • Easy to use call lights • Infant monitors • Pressure pads • Non-slip socks/shoes • Night lights • Assistive devices/Equipment close by • Increased supervision during time likely to fall

38. Some Interventions • Toilet schedules • Let them sleep • Familiarity • Concave mattresses or bolsters • Eliminate clutter • Drug reductions • Locks on movable equipment that work • Assess them for pain & treat

39. Some Interventions • Benches so residents can rest • Level surfaces • Chair cushions and other non-slip surfaces/wedges • Move them closer • Keep things in reach on their dominant side • Eliminate the shine

40. Some Interventions • Activities • Physician consults (including psych; audiology, visual & medical) • Hip protectors, helmets, knee and elbow protectors • Therapy or restorative care • Restraints & alarms - consideration as a last resort

41. MAY ALL YOUR SURVEYS BE SUCCESSFUL & ALL YOUR RESIDENTS & STAFF WELL CARED FOR!