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Falls – Risk Assessment and Prevention in Long Term Care

According to CMS, falls among nursing home residents occur frequently and repeatedly. It was reported that between 10-27% of all nursing home residents were noted to have a recent fall. About 1,800 older adults living in nursing homes die each year from fall-related injuries and those who survive falls frequently sustain hip fractures and head injuries that result in permanent disability and reduced quality of life. About 2-10% of nursing home falls cause serious injuries. Falls result in disability, functional decline and reduced quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation.

Common causes of falls in long term care include:

  • Muscle weakness and walking or gait problems are the most common causes of falls among nursing home residents. These problems account for about 24% of the falls in nursing homes.
  • Environmental hazards in nursing homes cause a significant number of falls among residents. Such hazards include wet floors, poor lighting, incorrect bed height, and improperly fitted or maintained wheelchairs.
  • Medications can increase the risk of falls and fall-related injuries. Drugs that affect the central nervous system, such as sedatives and anti-anxiety drugs are of particular concern. Fall risk is significantly elevated during the three days following any change in these types of medications.
  • Other causes of falls include difficulty in moving from one place to another (for example, from the bed to a chair), poor foot care, poorly fitting shoes, and improper or incorrect use of walking aids.

Organization Culture of Safety

Resident safety should be a top priority within the facility and have clearly defined safety and accountability components. Administration should stress the importance of resident safety and facility commitment to a culture of safety at orientation, and ongoing.

Fall Prevention Plan

Develop a comprehensive Fall Prevention Plan that addresses the safety and quality needs of its resident population. Address the following elements in the Plan.

  1. Establish a Falls Prevention Team comprised of clinical and non-clinical personnel that assesses all factors contributing to the fall event such as environment, equipment, medication factors and interventions in place at the time of the fall; recommends interventions and changes to plan of care to prevent repeat fall; meets on a regular basis to evaluate the fall prevention program and recommend improvements to the program.
  2. Implement a Fall Risk Assessment Policy that includes:
    1. Criteria for Risk Assessments
      • On admission to the facility
      • On any transfer from one unit to another within the facility
      • Following any change of status (including change in medications)
      • Following a fall
      • On a regular interval, such as monthly, biweekly or daily
    2. Use of a Fall Risk Assessment Tool. Not all risks are captured by a scale making it extremely important to track data and evaluate the efficacy as it relates to the specific population of residents. Examples of tools for adults include:
      • Hendrich Fall Risk Assessment
      • Berg Balance Scale
      • Dynamic Gait Index
      • Tinettii Balance and Gait Evaluation
      • Get Up and Go test
      • Time Up and Go (TUG)
      • Morse Fall Scale
    3. Factors that contribute to a risk for falls:
      Intrinsic Factors
      • Recent history of falls
      • Poor eyesight
      • Extremity weakness (arthritis; muscle weakness; impaired sensory function)
      • Unsteady gait/balance
      • Use of ambulation assistive aids (cane, walker)
      • Elimination concerns (excessive nighttime urination, incontinence)
      • Altered cognition (dementia; depression; agitation)
      • Fear of falling
      • Multiple medications
      • Medication side effects
      Extrinsic Factors
      • Toilets (no grab bars, wrong height)
      • Furnishings (bed/chair height)
      • Floors (carpeting, polished floors or wet floors)
      • Assistive devices
      • Bed rails
      • Clutter in resident rooms or hallways
      • Inadequate lighting in hallways and resident rooms
      • Poorly fitting footwear
      • Equipment failure
  3. Develop Organization-wide Intervention Strategies.
    • Perform environmental safety rounds to confirm resident areas are well-lit, uncluttered, free of spills, locked doors are locked when attended, handrails are secure, assistive devices work properly, etc
    • Consider use of bed-check alarms, sitter programs, Falling Star, Falling Leaf or other program that provides visual and auditory warnings for fall risks
    • Provide low beds and non-slip footwear. Lock moveable equipment
    • Implement an exercise program and routine medication regimen review
    • Establish a Rapid Response Team for responding to resident falls
  4. Provide Intervention Strategies specific to the resident identified at risk for falls.
    • Develop a resident-specific plan of care
    • Communicate clearly and effectively the implemented plan of care to all members of the care team: shift-to-shift hand-off communication
    • Document implemented interventions
    • Include the resident in the care planning process
    • Educate resident and family on resident plan of care
  5. Establish a Policy on Post-fall Management that addresses the following:
    • Assessment
      • Patient evaluation
      • Vital signs (supine, sit, stand), neurological assessments as appropriate
      • Determine extent of injury
    • Required Notifications and Communication of Findings
      • Provider
      • Leadership/Administration
      • Family
    • Documentation of Event
    • Document factually and objectively what occurred
    • Documentation of Assessment
      • Vital signs, Conscious, Loss of Consciousness
      • Physical assessment: deformities, bruises, cuts, other injuries
      • Treatment provided and response
    • Information gathering (consider the following)
      • Time of day
      • Usual or unusual activity, addressing bowel or bladder urgency
      • Position or attempted position at time of fall: standing/bending; alone or in a crowd
      • Flooring conditions: Glare; Wet; Obstacles; New furniture
      • Pattern to falls
      • Can the Resident duplicate what they were doing during the fall
      • Activity Resident was performing at the time of the fall
      • Staff communication
      • Staff distraction
      • Resident impairments (cognition, hearing), language, behavior
    • Re-evaluation of care plan with interventions
    • Revised action plan
      • Develop with multidisciplinary team
      • Evaluate to determine if it can be applied not only to the patient but organizationally
    • Follow-up: Action Plan adherence by staff and resident
  6. Provide annual and ongoing Falls Prevention Education. Include the following topics in the educational program:
    • Staff responsibilities
    • Fall-related outcomes
    • Risk factors
    • Risk assessments and post-fall assessment
    • Intervention and prevention strategies
    • Documentation requirements
  7. Evaluate the Falls Prevention Plan. Implementing and sustaining an active Falls Prevention Program, which incorporates quality and safety findings as industry accepted and validated methods and interventions, can assist facility success in reducing fall occurrences. Require the following:
    • Analysis of falls data including but not limited to total falls, falls with or without injury, residents sustaining more than one fall, survey findings related to falls, patient and family satisfaction, and litigation related to falls
    • Evaluation of data to determine if necessary changes related to an individual resident may be applied organizationally, improving safety for all residents
    • Implement identified changes and interventions
    • Adherence to Fall Program Components, including assessment, notification, and comprehensive documentation of all aspects of the post-fall workup and subsequent patient monitoring

Resources:

Minnesota Falls Prevention Initiative – Risk Factor Assessment Tools: http://www.mnfallsprevention.org

Agency for Healthcare Research and Quality, The Falls Management Program, A Quality Improvement Initiative for Nursing Facilities: http://www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm

Centers for Disease Control, Injury Prevention & Control: Home and Recreation Safety, Falls among Older Adults: An Overview: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

Oregon Patient Safety Commission, Long Term Care Falls Investigation Toolkit: http://oregonpatientsafety.org/docs/reports/Falls-Investigation-Guides.pdf

Accidents and Supervision F-Tag 323: Clinical practice Guidance on the Utilization of Fall Alarms for Residents at Fall Risk: http://www.stanleyhealthcare.com

Quality Insights of Pennsylvania, Patient Safety Initiative, Development of a Falls Reduction Program in Long Term Care: http://www.qipa.org/getfile/abc19e29-9644-40a2-8b3e-27b67c0832ac/Falls-SLP.aspx?chset=f8403050-f866-4cb9-b79d-3dea20e539ed

Veterans Administration National Center for Patient Safety: http://www.patientsafety.gov/SafetyTopics/fallstoolkit/notebook/completebooklet.pdf

CMS Nursing Home Data Compendium, 2015 Edition; www.cms.gov/mediare/provider-enroll