Transcript Fall
Making The Number of Falls Fall Mara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ Director of Nursing Spaulding Nursing & Therapy Center, North End Boston, MA Objectives: By the end of this presentations, participants will be able: Identify characteristics that increase fall risk Describe the value in individualizing care plans to reduce the risk of falls Compile, analyze, and trend data to determine patterns of falls Discuss how trending data can be used to reduce risk of future falls Definition “FALL” “An event which results in a person unintentionally coming to rest on the ground or another lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard.” Tinetti et al., 1988 Who falls? #1 risk factor = History of falls Confused Medicated Impaired senses Incontinent/Urgency Use of adaptive devices Elderly Falls are often multifactorial. Where do they fall? In the Community: 35%-40% all 65+ y fall once or more/yr 25% of 70+ years fall/yr 35% of 75+ years fall/yr 20%-30% of falls result in severe injuries (ex. hip fx, head injuries) A leading cause of death amg cmty elders Where do they fall? In Hospitals: 0.6-2.9 falls/year per bed 4-12 falls per 1000 pt bed days Where do they fall? In Nursing Homes: A 100-bed SNF typically has 100-200 falls/yr Bwt 50%-75% all SNF residents fall/yr Avg is 2.6 falls per person/yr 4-12 falls per 1000 pt bed days 1800 die/yr from falls in nsg homes Trend but consider: Some falls may not be preventable without jeopardizing the elder’s dignity &/or compromising function. Trend but consider: 0% fall rate is a problem Under reporting? Are residents immobile? Hey! I think he just moved, add one more! Who falls? #1 risk factor = History of falls Confused Medicated Impaired senses Incontinent/Urgency Use of adaptive devices Elderly Falls are often multifactorial. Multifactorial Falls Medical conditions Medications Impaired vision & hearing Assistive Devices Psychiatric conditions Intrinsic Factors Environment Social Issues Extrinsic Factors Incident Report: Keep it: Brief Easy Relevant Our form: Spaulding Nursing & Rehabilitation Center, North End EVENT REPORT FORM Date: Use this form for all events other than med events Time: Location of occurrence: Name: If not a resident: Visitor Outside vendor/clinician Employee (If yes, position & dpt): Resident condition at assessment (Check all that apply): At baseline Oriented x 3 Orient x 2 Orient x 1 Variable Confused Anxious Reliable historian Resisting assist If not a resident, phone #: If not a resident, address: Describe the event (what happened, how was it discovered, how pt was first observed): _________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Describe any known contributing factors: ___________________________________________________________________ _________________________________________________________________________________________________ ___________________________________________________________________________________________________ For all falls, complete FALL INVETSTIGATION WORK SHEET, collect WITNESS STATEMENTS, & call a HUDDLE! Other environmental issues noted: At time of event Resident was: Dry/Continent Incontinent of Urine Feces Catheter in use Leg strap . . INDICATE ON BODY LOCATION OF INJURY/INJURIES: Type of injury: Use # or arrows to locate Laceration Hematoma Abrasion Burn Swelling No apparent injury Complain / Shows signs of pain (with or without visible injury) Pain Rate 1-10 . Other – specify: . NURSE’s NOTE with VS written YES & OrthoVS for all falls YES . . Fall investigation form: Spaulding Nursing & Therapy Center, North End FALL INVESTIGATION WORKSHEET Resident Name: VS when found: Date of fall: Time of fall: Note: If pt unable to stand, sit, or cooperate with VS assmt, document this in the Nurses’ Note. (temp x 1 only) Lying: BP: Sitting: BP: Standing: BP: AP: Resp: Temp / route: AP: Resp: Temp / route: AP: Resp: Temp / route: Pt’s statement: . PRIOR TO THE FALL: Where last seen? .. How long since last seen: Dark Light Floor: Dry Wet Barefoot Regular socks Non-skid socks Slippers Shoes/sneakers Tied Untied Lighting: Shoes: Activity prior to fall: Continence: Dry Incont of urine Incont of feces Time since last void/toileting . Catheter Leg Bag Mental Status (MS) Prior to Fall: Equipment in Care Plan: Equip. in use at time of Fall: Oriented X 3 Oriented X 2 Oriented X 1 Forgetful Poor Safety Awareness Impulsive Lethargic Restless/Agitated MS varies Other (describe): Describe MS after Fall): No change Change: : Cane Walker Wheelchair Seat belt Brace (type): Gait belt Side rail(s)-how many Mechanical lift Other: Cane Walker Wheelchair Seat belt Brace (type): Gait belt Side rail(s)-how many Mechanical lift Other: . . In-place Connected Sounding If not sounding: . Turned ‘off’ Low/dead battery Alarm: Type of alarm: . Within reach Call bell functioning: Ringing Hall light on Not working Call bell: . . . . . . Fall investigation form: 2nd half of page Check all that apply: Change in med, dose or schedule in past 72 hrs Fall within the last 30 days Acute change of condition: Recent change of function: . . This event was witnessed: No Yes – Have staff witness(es) complete WITNESS STATEMENT FORM Yes – If witnessed by another resident or visitor, document their observations on WITNESS STATEMENT FORM Evaluation: This fall is thought to be due to: Cardiovascular condition Neuromuscular condition Notes & Care Plan: Orthopedic condition Cognitive condition Other (describe): ___________________ Vision impairment Environmental condition ___________________________________ The care plan is updated based on this assessment. Nurse initials Signature of person completing this worksheet: Nurse’s note written about this fall. Nurse initials Date: _______________________ HUDDLE : Spaulding Nursing & Therapy Center, North End Huddle Worksheet Patient’s name: Time of fall: Location of fall: Time Huddle was called: . . . . . Report of what happened: . Report of intervention: Rehab Screen needed: Yes Type of service needed: PT No OT Members Present at Huddle: 1. 2. 3. 4. SLP Huddle in Progress Join the HUDDLE! Help prevent the next fall! How are we doing? We did a terrific job in preventing falls in August! FALLS May ‘10 June ‘10 19 falls 24 falls 15 residents 15 residents – 1 resident fell 5 times! July ‘10 25 falls 13 residents – 1 resident fell 5 times! August ‘10 11 falls 8 residents Mr SS fell twice. Mr EM fell three times. Let’s do even better in September. Join the HUDDLE on your unit. Help us prevent the next fall. Thank you for all your hard work & care! Trend but consider: Fall numbers will rise while “frequent fallers” are in the house & fall when they leave. ay ar 2010 ep t ay ar 2011 ep t N ov S Ju ly M M Ja n N ov S Ju ly M M Ja n Our fall data: 30 25 20 15 10 5 0 Our fall data: 30 25 20 All Falls 15 10 Falls with injuries 5 0 n Ja M ar ay M ly u J 2010 S t ep N ov n Ja M ar M ay ly u J 2011 pt e S N ov Trending all events: 1-May 2 2-May 2-May 4-May 4-May 5-May 5-May 5-May 4 3 4 4 Employee Elopement Allegation Other Other Skin If yes,injury type Bruise Fall See log* Rpt DPH EVENT BY TYPE Rsdt-Rsdt Resident Yes Time No Unit Date FALL / RELATED INJURIES 7:35a Bernard 10:10a Carolyn 11:30a Dora 2:00p Edward 1 2 5:15p Geraldine 3 12noon Howard Bruise1 1 1 Other 1Skin 1 1 1 1 1 1 1 abrasion 4 7:10p Kate 3 2:30a Louise TOTALS 1 1 1 Other/Misc 7 4 3 c/o hip pain seated in corridor for observation; witnessed evt: pt rose from chair & fell to left rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb Employee 0 1 2 2 See Employee Event Log Roommate summoned staff; rsdt found on floor beside bed; rsdt report tried to go back to bed w/o help missing hearing aide found on floor outside of room; said going to work; no injury; restless 1 Allegation 1 3-May Spilled hot soup in lap; denies pain; area pinkened immediately post event In main DR; tried to help peer to her seat; witnessed fall to knees Elopement 8-May 1 leaned forward from WC and fell to floor; laceration on eyebrow sent to ER; wound sutured Bruise found on posterior hand; phlebotomy draw yesterday Fall from toiled during BM Skin tear noted on LLE; rsdt says bumped on leg rest of WC 1 1 See Med Event log Resident-to-Resident 1 STAFF: Frost, Frank 6-May 3 3:15p Imogen 6-May 4 2:00p Joyce 7-May 4 6:20p Kate 7-May Notes & Other Events Anne Med event if yes, date See Med Event log 0 0 1 1 2 Trending all events: 1-May 2 2-May 2-May 4-May 4-May 5-May 5-May 5-May 4 3 4 4 8-May Employee Elopement Allegation Other Other Skin Bruise If yes,injury type Anne 7:35a Bernard 10:10a Carolyn 11:30a Dora 2:00p Edward 1 1 1 2 5:15p Geraldine 3 12noon Howard 1 1 4 7:10p Kate 3 2:30a Louise TOTALS 1 1 1 1 1 1 1 1 1 1 7 4 All falls 3 See Med Event log 1 3-May See Employee Event Log Spilled hot soup in lap; denies pain; area pinkened immediately post event In main DR; tried to help peer to her seat; witnessed fall to knees 1 abrasion Roommate summoned staff; rsdt found on floor beside bed; rsdt report tried to go back to bed w/o help missing hearing aide found on floor outside of room; said going to work; no injury; restless 1 1 1 Notes & Other Events Med event if yes, date leaned forward from WC and fell to floor; laceration on eyebrow sent to ER; wound sutured Bruise found on posterior hand; phlebotomy draw yesterday Fall from toiled during BM Skin tear noted on LLE; rsdt says bumped on leg rest of WC 1 STAFF: Frost, Frank 6-May 3 3:15p Imogen 6-May 4 2:00p Joyce 7-May 4 6:20p Kate 7-May Fall See log* Rpt DPH EVENT BY TYPE Rsdt-Rsdt Resident Yes Time No Unit Date FALL / RELATED INJURIES seated in corridor for observation; witnessed evt: pt rose from chair & fell to left rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb c/o hip pain See Med Event log 0 1 2 2 0 With or w/o injury 0 1 1 2 Fall Risk Assessment Tools: Valid? For what population? In what setting? But if nearly every one is at risk. . . . . is it useful??? What’s been tried? Staff education Reprimands for high fall rates Rewards for low fall rates Falling Stars & Falling Leaves Colored bracelets or socks Bed & chair alarms Restraints Falling Stars/Leaves On door jams, foot boards, bracelets, care cards Be realistic Policies Forms & Documentation Interventions What’s been tried? Staff education Reprimands for high fall rates Rewards for low fall rates Falling Stars & Falling Leaves Colored bracelets What Colored slippers Bed & chair alarms Restraints else? Lots strategies work Most do work In the SHORT TERM To sustain results, best = QI principles Trending Sharing trends with staff Varied reminders & education “Borrow ideas” from other SNFs For example: Mind your ‘P’s! Tend to the pain. Toilet the patient. Reposition for safety & comfort. Place within reach. Things plugged into pts. PAIN POTTY POSITION PERSONAL ITEMS PLUGS Prevent the next fall. Reasons to limit restraint use #1: RESTRAINTS DO NOT REDUCE FALL RATES Reasons to limit restraint use #2: RESTRAINTS MAY INJURE OR KILL PATIENTS Reasons to limit restraint use #3: RESTRAINTS JEOPARDIZE SURVEY RESULTS Reasons to limit restraint use Increase risk of complications Skin breakdown Isolate Decrease mobility Injure Disorient Risk death Liability Frighten F-Tags Remember when? 1980’s Admission orders: PRN Tylenol PRN MOM PRN Haldol PRN Vest restraint Miles & Irvine, 1992 S Miles, S Miles, S Miles, 1996 When falls occurred pre-OBRA: Nurse assessed for gross injuries Nurse put bandage on boo-boo Nurse tied Mrs B to her chair Nurse tied chair to the handrail When falls occurred post-OBRA: MDS prompts consideration: Facility QI trending: Infection? Location? Medication? Time? Glasses/vision? Equipment? etc. Personnel Respond to trends: Staff education Address “not-my-patient” syndrome Toileting schedules Activities EVERY one involved? Nurses & Nsg Mgt Nursing Assistants Restorative Aides PTs & OTs Resident Resident’s family Maintenance staff Housekeepers Dietitians Dietary aides Staff Development Pharm Consultant Administrator Medical Director Facility-wide interventions All staff involved Remove clutter Assess staff competence w/ transfers Assess staff competence w/ equipment Assess, address & reassess individuals Individualize interventions Consider the falls: Clinically? From what position? Where? When? Circumstances? Falls from what position? Falls from BED ↓ Falls from CHAIR ↓ Falls from STANDING ↓ Benefit from PT? Need assistive devices? Develop menu of possible interventions Falls where? Bedroom? En route toilet? Toilet? Outside? Activities? Falls when? During night? Early AM? Late afternoon? Bwt dinner & bed? After certain activity? Change of shift? Summary: For individual: Assess Educate Address Reassess Re-address For population: Assess/trend Educate Address Continue to monitor Re-address Summary: “Falling itself is not a diagnosis but a symptom of multiple underlying diseases, the effects of certain medications …, and /or environmental hazards or obstacles that interfere with safe mobility” (Tideiksarr, 1993) Summary: Therefore, individual assessments must be frequent and interdisicplinary. And each rsdt’s care plan must also be frequently reviewed and interdisicplinary. Summary: And… Trending must be continuous, thoughtful, & interdisciplinary. Facility-wide interventions must be thoughtful, interdisciplinary, & continuously reviewed, reinforced, and changed as trending indicates. Summary of strategies: Include ‘front line’ staff in developing care plans Include ‘front line’ staff in changing practice Trend falls Share fall trends with staff Periodic and varied in-services Fliers (in staff-access areas) Be creative Share/adopt strategies from other facilities Discussion. . . To reach Mara: Mara Aronson, Director of Nursing Spaulding Nursing & Therapy Center, North End 70 Fulton Street Boston, MA 02109 (617) 726-9702 [email protected]