FALLS MANAGEMENT Technical Assistance Program (TAP) Ohio Department of Health Division of Quality Assurance

1. FALLS MANAGEMENT Technical Assistance Program (TAP)Ohio Department of HealthDivision of Quality Assurance

2. What Will We Do Today? Discuss: • What is a fall? • Who is at risk? • What could the causes be? • Ideas for investigation • What interventions/care planning could help? • Possible ways to approach falls as a facility • Ideas for assuring that interventions are in place • When will you re-evaluate the resident? • How will you know that your program is working?

3. What Is A Fall? A fall, as defined by the MDS, includes the following: • An intercepted fall is still a fall. • A fall without an injury is still a fall. • When found on the floor, unless there is evidence to suggest something else, the most logical conclusion is that it was a fall.

4. What Is A Fall? (Continued) • The distance to the next lower surface is not a factor in determining if a fall occurred or not. (Rolling off the bed or mattress that is close to the floor is still a fall) • The point of calling these incidences a fall is to identify and communicate resident problems or potential problems so that staff will consider and implement interventions. (RAI Version 2.0 Manual) – revised December 2002 – page 3-146 – 3-147

5. Why Study Falls? • Approximately 51% of residents in LTC fall annually • About 10% to 20% of nursing home falls cause serious injury • About 1800 fatal falls occur among nursing home residents in the U.S. each year • Two thirds of lawsuits filed against nursing homes are associated with falls and related fractures

6. Consequences of Falls • Mild to severe injury • Increased morbidity and mortality • Loss of independence • Fear • Decreased activity • Decreased quality of life

7. Changing Our Thinking • Falls are no longer assumed to be “accidents” that either can not be prevented or are due to the faller. • Falls research indicates falls are a “non-specific sign or symptom” that represents an underlying condition. • Most falls are due to a combination of physical, life-style, environmental and social factors that can be assessed and may be modified to decrease fall risks. Alabama Quality Assurance Foundation 08/06/01

8. Initial Fall Assessment • Comprehensive and as immediate as possible the day of admission • Would include all the known high risk factors/categories • Initiation of immediate interventions for each individual risk identified • It may be necessary to initiate interventions until more resident behaviors and habits can be observed by monitoring

9. Initial MDS Quarterly After each fall Change of condition or function, new acute illness or worsening of any diagnoses, new or increased pain Fall Assessment/Re-assessment

10. Fall Assessment/Re-assessment(Continued) • Review all interventions that are in place and if they are working. • Make changes to those that are no longer effective. • Implement new interventions according to individual risk and “R” behaviors that have been identified. • All of the same risk factor categories should be reassessed. • In addition, all previous falls for each individual resident should be reviewed to identify the specific cause of the fall for this resident.

11. Fall Risk Assessment and Tools • Some facilities utilize a point system to assign fall risk • Some facilities initiate standardized interventions for those residents identified as being at risk for falls.

12. Fall History Social Needs/Motivation for Moving Mental/Cognitive Status Ambulation/Gait Ability Standing/Transfer Ability Bowel/Bladder Continence Wandering Behavior Adaptive Equipment Footwear Bed/Chair Vision Change in Condition Medications Diagnoses Categories of Risk Factors Known to Cause Falls:

13. Fall History • “R” has had no prior falls • “R” is a new admission within the first 72 hours • “R” has a known history of falls with the likelihood of falling again • “R’ has the likelihood of falling again for the same reason • “R” has a history of falls with various injuries • “R” frequently falls, but no injuries thus far • “R” has an increase in frequency of falling • “R” has a diagnosis of Osteoporosis increasing risk of fracture and has a frequent fall history

14. Social Needs/Motivation For Moving • “R” has never slept well at night • “R” worked the afternoon shift and did not go to sleep till after midnight • Resident worked the night shift • “R” woke early routinely for any variety of reasons (farmer, fixed spouse breakfast, etc.)

15. Mental/Cognitive Status • “R” has no cognitive impairment • “R” has recall problems • “R” has impaired short term memory • “R” mental status varies over the course of the day • “R” is unable to understand/comprehend • “R” consistently knows own safety needs: Y N • “R” consistently knows their own abilities: Y N

16. Ambulation/Gait Ability • “R” has a steady gait • “R” is dependent, but will call for assistance • “RS” gait is unsteady, but will call for assistance • “Rs” gait is unsteady, but usual for the resident – no falls • “Rs” gait is unsteady, has a history of falls, and does not remember to call for assistance or will not call for assistance • Is this “R” safe to be left alone in the bathroom? Yes or No

17. Standing/Transfer Ability • “R” is able to stand/transfer independently • “R” is unable to stand/transfer unassisted • “R” is unable to stand/transfer unassisted and makes attempts to get up • “R’ is unable to stand/transfer unassisted and does not remember to call for assistance • “R” is unable to stand/transfer unassisted, but makes no attempts to get up

18. Bowel/Bladder Continence • “R” is continent • “R” is known to be incontinent • “R” manages incontinence per self with steady gait • “R” attempts to manage incontinence per self with unsteady gait and/or memory problems • “R” is incontinent, but will wait and call for assist to toilet • “R” has a new order or an increased dose of a diuretic

19. Wandering Behavior • “Rs” gait is steady when wandering • “Rs” gait becomes unsteady when resident becomes tired • “R” is unable to identify when tired or when gait becomes unsteady

20. Adaptive Equipment (cane, walkers, special shoes, etc.) • “R” utilizes the ambulatory aide correctly • “R” utilizes the ambulatory aide correctly with a steady gait • “R” utilizes the ambulatory aide incorrectly, but with a steady gait • “R” utilizes the ambulatory aide incorrectly with an unsteady gait

21. Footwear (fit, heel height, soles, stockings, socks) • “Rs” shoes appear to fit and no other shoe problems are noted • “Rs” shoes do not appear to fit • “Rs” heel height does not cause an unsteady gait or potential for an unsteady gait • “Rs” thick rubber type soles may stick during ambulation • “Rs” thick soles may not allow for distinction of floor transitions • “Rs” soles may be slick on wet or non-carpeted floors • “R” wears stockings or socks that would be slick on non-carpeted floors

22. Bed/Chair • “Rs” feet can touch the floor when sitting on the side of the bed • “Rs” feet can touch the floor when in a specified chair • “Rs” feet can touch the floor when in the chair in his/her room • “Rs” chair has no arms and the “R” falls asleep while sitting, leans or is unsteady when rising from a chair. • “R” sits in proper body alignment (three right angles – hip, knee, ankle)

23. Vision (glasses) • “R” has glasses • “Rs” glasses are for distance or just for reading? • If for distance and need to be worn, “R” wears them without removing them • If for distance and need to be worn, “R” wears them but removes them and forgets to put them back on • “R” has an unsteady gait without glasses on • “R” almost misses the edge of the chair/bed when sitting

24. Change in Condition • “R’ has no change in their cognitive status • “Rs” cognitive status has changed – complete another full fall risk assessment • “Rs” functional status has changed – complete another full fall risk assessment • “R” has pain: new or increased • “R” has a new acute illness • “R” has a worsening of any diagnosis • “R” has new low blood pressure

25. Medications • “R” is receiving no new or changed medications • “R” is receiving new medications • “R” is receiving new medications with side effects that may contribute to falls • “R” is receiving an increased dose of medication with side effects that may contribute to falls Types of medications that may contribute to falls: antipsychotics, anti-anxieties, hypnotics, anti- depressants, cardiovascular, laxatives and diuretics

26. Diagnoses • “R” has a diagnosis of Seizures – controlled or uncontrolled • “R” has a diagnosis of Stroke – what has been affected – memory, behavior, legs, arms, hands, etc. • “R” has a diagnosis of Parkinson’s, Huntington’s Chorea, Multiple Sclerosis – stable or changing • “R” has a diagnosis of Vertigo – controlled or uncontrolled • “R” has a history of Cardiac Arrhythmias/Anemia – controlled or uncontrolled heart rate or B/P

27. A Different Look • Risk Factors – Individualized Interventions • Consistency • In-service • Algorithms • Protocols • Flow Charts • Tools • Etc.

28. Case Study History: 84 year old female with cognitive impairment admitted one month ago for strengthening after exacerbation of CHF. Diagnoses: Alzheimer’s Disease, Congestive Heart Failure (CHF), Glaucoma and Arthritis. Admission: Ambulates with a walker and needs to be reminded to use her walker. Physical Therapy three times a week. Two days ago discharged to restorative nursing. Wears prescribed shoes to aid balance. Social History: Husband died 1 month prior to admission. Dementia began after husband’s death. Husband worked on the railroad and had to be at work at 5:00 am. Mrs. Anderson arose every morning at 4:00 am to cook breakfast.

29. Case Study (Continued)Nursing Assessment • Usually continent, but has occasional episodes of incontinence. Ambulates and toilets self. • Not oriented to day and time. Forgets that her husband has died. • Eats 50% of meals and needs reminded to drink fluids. • Fall risk care plan: Remind to use walker; make sure she wears glasses; place shoes within reach. • Previous fall one week ago. Found on the floor beside her bed at 4:00 a.m. Added to care plan after fall: Remind to call for help at night when getting out of bed.

30. Fall Scene Information • STNA who found resident: Resident was found on the floor by her bed when doing hourly checks at 5:00 a.m. Observed one of the resident’s shoes to be on and the other to be off. There was a wet area on the floor underneath her. The resident told the STNA that her husband needed to have his breakfast and she was going to the kitchen. • Scene: Glasses were broken and were found on the floor beside her. The tissue around the resident’s left eye was red and swollen. The resident’s walker tip was found in the corner of the room. • Roommate: Saw resident having difficulty putting her shoes on. The resident’s glasses are always dirty. I’ve never seen her use the call bell. Her walker looks wobbly.

31. Ideas For Investigation • Assess for: • All risk factors • Vital signs • Injury • Evaluate for pain • Look at the environment (clutter/equipment) • Describe the fall scene • What was the resident attempting to do

32. Ideas For Investigation (Continued) • Was the resident incontinent • Evaluate the equipment being used • Interview all staff • Don’t forget to interview family members • Review previous fall data for this resident • Evaluate previous social history • Review the plan of care

33. Ideas For Investigation (Continued) • Review the incident report – did it work for you? • Consider including on your incident/investigation report the following: • Open ended interview questions to family and resident • Asking Staff: What do you think caused this fall? What was implemented to prevent a repeat fall from the same cause? • Time of last meal • Time of day • Medications received prior to fall • Glare or wet floor • New furniture arrangement • Foot wear • Was the resident in a crowd of people

34. Ideas For Investigation (Continued) • Make appropriate referrals • Add to tracking system • Put monitoring system in place - to communicate interventions - to assure that placement of interventions is monitored

35. Tracking System • Keep a spreadsheet with the information you need • Examples: • Resident • Location of fall • Time of fall • Type of adaptive equipment used • Any other information you want to collect (ie: incontinent at time of fall, foot wear in use, type of floor surface where fall occurred, call light within reach and functioning or not) • What new interventions were instituted

36. Care Plan • Workable • Usable • Up-to-date

37. Ideas to address the execution GAP!! • Use back of wardrobe to list interventions • Hold in-services regarding specific residents and their individualized interventions • Have a check-off list for staff to use – computer or otherwise • Place the check-off list on a clip board at the nurses’ station • Staff member (designated or administrative) check for presence of interventions (monitoring) • Will there be consequences for the staff if the interventions are not in place?

38. Falls Prevention Performance Improvement Project Implementation Strategies for Most Popular Solutions • Implementing a falls decision guide • Using an internet bulletin board to solicit ideas regarding how to care for frequent fallers through Ohio KePRO • Keeping fall diaries for each resident using an Excel spreadsheet • Using activities as part of falls program • Involving all staff in decision making • Assessing residents for pain using a pain rating scale • Determining the expectations of the resident’s family prior to admission • Identifying potential safety hazards by testing various room layouts

39. Falls Prevention Performance Improvement Project Additional Solutions • Adapt the resident’s environment to eliminate safety hazards • Assess hems of clothing and bedspreads • Use of non-slip type coasters under bed wheels • Develop a “No pedal/No push” policy • Complete an assessment of need for foot pedals • Apply bedside mats to wall with Velcro when not in use • Apply front anti-tippers to wheelchairs • Apply tape on wall to mark correct bed height

40. Falls Prevention Performance Improvement ProjectMonitoring • 72 Hours • Initial High Risk • 15 Minute, One-On-One, Family • Preventative Maintenance • Designated Staff • New Way of Thinking

41. Falls Prevention Performance Improvement Project Universal Safety Considerations Consider inside and outside environment • Use non-skid floor wax • Ensure thresholds are no higher than ½ inch and beveled • Paint uneven surfaces • Ensure adequate room lighting • Ensure loose carpet, tiles or linoleum are repaired • Install bathroom safety equipment • Ensure appropriate bed height, chair and toilet height • Clean up spills immediately • Reduce non-emergency paging • Create and maintain a clear path to the bathroom

42. Other Falls Management Program Considerations • Identify all products used by your facility to manage falls • Incorporate pictures and names of your products in your new hire orientation • Ensure manufacturers’ instructions for devices and equipment are available and followed • Develop parameters to guide the appropriate use of products used by your facility to manage falls • Designate a staff member to do the initial fall assessment upon admission

43. Other Falls Management Program Considerations (Continued) • Consider reviewing all falls every day at your stand up meeting and observe the scene of the fall • Consider a weekly fall meeting with an interdisciplinary team • Identify frequent fallers for staff • Consider implementing universal environmental fall precautions facility-wide • Consider development of a preventive maintenance program for consistent environmental fall risk observation • Consider developing a method to ensure effectiveness of your program

44. Fall Trivia Questions • If you find a resident lying on the floor, is it considered a fall? • What is the execution gap? • Who should be on the falls management team? • Who would you interview after a fall? • Name an intervention new to you. • If you take a newly confused resident to the bathroom what would you do? • Are all interventions appropriate for all residents? • Why would you need to try a new intervention for a resident? • What would you do if you think you have already tried everything you can think of to prevent another fall?

45. By working together, you can do this!

46. THANK YOU!

47. Bibliography • Slide 5 - Falls and Fall Prevention in Nursing Homes, Alabama Quality Assurance Foundation, August 6, 2001 • Slide 5 - We Care. Notes for Slide presentation, AMDA Clinical Practice Guidelines (CPCs) for Falls and Osteoporosis, Slide #3 • Slide 5 - Scott, RN, Vicky et al, A review of the Literature on Best Practice in Falls prevention for Residents of Long Term Care Facilities, September 2003 • Slide 6 - Hart-Hughes, Stephanie et al, An Interdisciplinary Approach to Reducing Fall Risks and Falls, Journal of Rehabilitation, 2004, Volume 70, No. 4, 46-51 • Slide 12 - Annals of Internal Medicine – Fall in the Nursing Home – Rubenstein et al. 121 (6):442. • Slide 12 - Premier 2006, Inc – Fall Prevention (http://www.premierinc.com/all/safety/resources/falls/)