Transcript Evaluation and Management of Falls in the Elderly

Management of Falls and
Restraints in Long Term Care
Alice Bonner, APRN-BC, GNP, FAANP
Director of Clinical Quality
Massachusetts Extended Care Federation
[email protected]
Definition of a Fall
• Unintentional coming to rest on the floor,
ground or other lower level
• Or unintentional change in position,
occurring where a “fit person” could have
resisted the external hazard
But Beyond that Definition…
• Falling is a clinical entity in its own right,
most commonly due to the accumulated
effect of multiple chronic disabilities and
potentially is preventable if the causative
factors are recognized in individual patients
(Tinetti, 1986)
Definition of Syncope
• What is syncope?
– A type of fall associated with transient loss of
consciousness (LOC) and spontaneous recovery
– May only account for 4% of all falls, but newer
research suggests it may be more than that
One Problem with Falls is
“under-reporting,” some of which
may come from failure to
recognize when a fall has actually
occurred. Test your knowledge
with the following questions
from the Centers for Medicare
and Medicaid Services (CMS)…
Definition of a Fall
CMS RAI Version 2.0 Q & A’S
March 2001
Question 2-22:
Should the following situations be recorded as
“falls” in items J4 “Fell in the past 30 days”
or J5 “fell in the past 31-180 days”?
(Question 2-22 continued)
• a) resident lost their balance, and was lowered to
the floor by staff.
• b) resident fell to the floor, but there was no
injury.
• c) resident was found on the floor, but the means
by which he/she got to the floor was unwitnessed.
• d) resident rolled off a mattress that was on the
floor.
• Here are the answers…
CMS’s Answer:
All of those scenarios should be reported
as a fall…
From A Program Perspective...
• Do you have corporate/executive/administrator
support for a falls prevention program?
• Has your organization looked at what is in place
right now, and where the gaps are in falls
prevention in your building?
• Are there policies in place for fall risk assessment?
• Is all staff aware of the policies?
• Are the policies followed?
From A Program Perspective...
• Are residents assessed immediately (on, or even
prior to, admission), and reassessed when
indicated?
• Are you using a standardized fall risk assessment
tool?
• Is the risk assessment reflected in the care plan?
• Do you know how the risk assessment is
communicated to direct care staff?
• Is someone on staff accountable for collecting data
and monitoring systems?
Case Study
• Friday night was busy. There were four new
admissions to the subacute unit. One of the
new admissions was an 84 year old man, s/p
CVA; history of DM, CHF, COPD,
Dementia. The nurse did not have time to
complete all of the assessments on her 3-11
shift. The falls assessment was only
partially done.
Case Study
• What is the most important individual action that
the nurse on the next shift can take?
• What is the most important aspect of the nursing
home’s policy to insure that this situation does not
result in resident injury?
• How can nursing leadership and administration
insure that problems come to their attention so that
they can be addressed?
Now let’s look at some statistics
that can help you convince other
staff, residents and families why
falls prevention is so important
Some Statistics
• 35-40% of community-dwelling, generally
healthy adults over age 65 fall annually
• Rates are higher after age 75
• In nursing homes and hospitals, rates are
almost three times higher (1.5 falls per bed)
• 50% of fallers do so repeatedly
Statistics
• Injury is the 5th leading cause of death over
age 65 and most fatalities are related to falls
• 2-5% of falls result in fractures; 1% are hip
fractures in the over 65 population
• In nursing homes, 10-25% of falls result in
fracture, laceration, or hospitalization
Statistics
• Fall-related injuries recently accounted for
6% of all medical expenditures for persons
age 65 and older
• Fall-related injuries may cost up to 20
billion dollars/year in acute care and
institutionalization
• 40% of nursing home admissions are at
least in part related to falls
Fall prevention is a priority for
nursing home residents. Why is
the identification of risk factors
important in this effort?
Risk Factors for Falls
in Nursing Home Residents
• In studies on nursing home residents, the
risk factors most commonly associated with
falls were:
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Muscle weakness
History of falls
Gait or balance deficit
Use of assistive devices
Visual deficit
Risk Factors for Falls
in Nursing Home Residents
• Additional risk factors for falls in nursing
home residents were:
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Arthritis
Impaired ADL
Depression
Cognitive impairment
Age over 80 years
In addition to looking at overall
risk factors, it is also useful to
break down risk factors into
intrinsic and extrinsic
components
Intrinsic and Extrinsic Risk
Factors
• Intrinsic factors (physiological changes with
age, disease processes, iatrogenesis,
medications or a combination)
• Extrinsic factors (types of activity, hazards
and demands of the environment)
• At least 50% of falls are multifactorial
Potential Intrinsic Risk Factors
• Disorders of gait and/or balance
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decreased step height or step length
wide base gait
decreased speed
increased time in double support
increased spatial-temporal stride to stride
variability
– increased body sway
Potential Intrinsic Risk Factors
• Disorders of gait and/or balance
– painful (antalgic) gait
– joint instability (knees, ankles)
– weak quadriceps
– weak dorsiflexion
– poor back flexibility
– symptoms when turning or extending the neck
(Tinetti, 1986)
Potential Intrinsic Risk Factors
• Most common predictors of balance
problems
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difficulty rising from a chair and sitting down
instability on first standing
staggering on turning
short, discontinuous steps
step to step variability
Potential Intrinsic Risk Factors
• Knee, hip, foot deformities and/or associated pain;
arthritis, myopathy
• Sensory impairment (decreased vision, hearing)
• Neuromuscular diseases (CVA, dementia,
Parkinson’s)
• Cognitive impairment (poor judgment, safety
awareness) doubles the risk of falls in some
studies
Potential Intrinsic Risk Factors
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Peripheral neuropathy
Orthostatic hypotension
Postprandial hypotension (Aranow 1997)
Total number of chronic diseases/conditions
Total number of medications (>3 or 4)
– types of medications (class IA antiarrhythmics, digoxin,
diuretics; psychoactive medications, anticholinergics).
Alcohol use
(Leipzig, JAGS, January, 1999)
Medication Categories More Commonly Associated with
Injury from Falling
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Anticoagulants
Antidepressants
Anti-epileptics
Anti-hypertensives
Anti-Parkinsonian agents
Benzodiazepines
• Diuretics
• Narcotic analgesics
• Non-steroidal antiinflammatory agents
[NSAIDS]
• Psychotropics
• Vasodilators
-AMDA Clinical Practice
Guideline Falls and Fall Risk,
2003
Potential Intrinsic Risk Factors
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Syncope/dysrhythmias
Fear of falling
Dizziness
Incontinence
Depression
Generalized weakness, deconditioning
Any acute illness; often infection, delirium,
dehydration. If not detected early…
…she could end up in the ER
Potential Intrinsic Risk Factors
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Age over 80 years
History of falls
Use of an assistive device
Dependent in two or more ADLs
Total number of risk factors for falls
Potential Extrinsic Risk Factors
• Lack of, inappropriate or ill-fitting footwear
– fit
– heel height and width
– type of sole
• Low heel, firm sole (Tinetti, 2003)
– collar height
• High collar increases balance (Lord, 1999)
– 2004 and 2005 studies confirm earlier results
– Risk is highest is for patients who wear NO footwear
Potential Extrinsic Risk Factors
• Lack of, inappropriate or ill-fitting clothing (no
belt, pants too long, can’t get clothes off fast
enough for toileting)
• Room too far from caregiver’s/nurse’s station
• Type of setting not appropriate or cannot meet
needs for adequate assessment and supervision of
a particular resident (e.g., subacute caregivers not
trained in how to redirect or intervene with
dementia residents)
Potential Extrinsic Risk Factors
• Adaptive equipment lacking or used
inappropriately (e.g., walker too low)
• Lack of restorative program; lack of
exercise and routine ambulation to maintain
function
• Use of restraints (physical, chemical)
resulting in decreased activity,
deconditioning (Dimant, 2003)
What makes staff think about
using restraints?
• Fear of being cited by surveyors for failure to
“protect” resident from harm?
• They think they will work to protect the resident
from harm?
• They think it is better than not using them?
• They think it might prevent other problems
(wandering, residents getting into altercations)?
• They think it will help them to better care for other
residents?
What should staff be thinking about?
• Root cause – why was the resident trying to get
up, walk, lean over, engage in an activity – in the
first place????
• What kinds of behaviors did they engage in prior
to coming to the nursing home? Any patterns?
• What pushes their buttons?
• What makes them tick?
• Have we gotten all the possible information from
family or other informants?
What is a root cause analysis?
Person-Centered Care
Model
Community
Regulations
Financial Resources
Leadership
Family
General Guidelines for Use of Physical Restraints in Long Term
Care:
1.Identify medical symptoms
2.Assess and diagnose the cause of the symptoms (discuss situation with
medical provider)
3.Evaluate the goals of care in the context of resident’s wishes and goals,
and include the resident or surrogate in the care planning process
4.Develop a care plan for the underlying cause of the symptoms
5.Determine if this use of a treatment or device, which may be
considered a restraint, is appropriate in the context of the resident’s
condition and circumstances
6.Determine the potential risks, complications and negative outcomes of
using the restraint
7.Obtain a physician or other appropriate licensed practitioner’s order
8.Apply treatments, devices and interventions correctly
9.Anticipate and prevent risks, complications and negative outcomes
10.Continually assess the care plan
11.Monitor for the development of complications
12.Measure and assess the use of restraints with a goal to reduce or
eliminate use
-Dimant, 2003
Guidance to Surveyors on Restraint Use
• May not be used for discipline or convenience
• A device may constitute a restraint for one
resident and not for another
• May be used in medical or psychiatric
urgent/emergent situations (short-term)
• Full explanation to resident/family on risks and
benefits of restraints
• Facility may not use restraints just because health
care proxy or guardian requests it, or because
physician writes an order
Guidance to Surveyors on Restraint Use
• Least restrictive form of restraint must be used
• Other alternatives that were tried and the outcomes must be
documented, sometimes multiple times. There is no magic
answer on this question, nor is there consensus or best
practice or guideline, except to individualize to each
resident
• Systematic plan for care planning and evaluation of
restraints, including restraint reduction plan must be
documented in policies and procedures (facility-wide) and
in individual care plans (see www.medqic.org for some
ideas)
Federal F tags on Restraint Use
• Ftag: “Each resident will receive, and the facility
provide, the necessary care and services to attain
or maintain the highest practicable physical,
mental and psychosocial well-being, in accordance
with the comprehensive assessment and plan of
care”
• Ftag: “The facility must ensure that the resident
environment remains as free of accident hazards
as is possible and each resident receive adequate
supervision and assistive devices to prevent
accidents”
Another Case Study
• Mrs. Lopez is an 89 year old resident of a special
care (dementia) unit. She has Lewy body
dementia, CHF, COPD, DJD, GERD. Prominent
features of her dementia are psychomotor
agitation, unsteadiness and stiffness. She
repeatedly self-rises, has no safety awareness,
does not remember any attempts to redirect her.
She has had 9 falls in the past month, mostly in
self-attempted transfers.
Another Case Study
• On 3-11 on Friday night, Mrs. Lopez is
found on the floor in her room, next to her
bed. The nurse finds her while conducting
her med pass. The nurse establishes that the
resident has no injuries and proceeds to
complete a post-fall assessment form. How
should the nurse begin a root cause analysis
on this case?
Another Case Study
• How would you care plan for falls in this
resident? Who should be at the table?
• If this resident has had 10 falls now, should
she be restrained? Why? Is there any
evidence that restraining her will make her
safer? How will you make this decision?
• What position do you think an outside
observer might take on this case?
Environmental Factors Associated with
Falling
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Dim lighting
Poor or weak seating
Glare
Use of full-length side
rails
Uneven flooring
Bed height
Loose carpet or throw rugs
Inadequate assistive
devices
-AMDA Clinical Practice Guideline
Falls and Fall Risk, 2003
• Wet or slippery floor
• Inappropriate footwear
• Lack of safety railings in
room or hallway
• Malfunctioning
emergency call systems
• Lack of grab bars in
bathrooms
• Poorly fitting or incorrect
eye wear
• Poorly positioned storage
areas
Conflict between freedom and
safety
• The resident wants their fuzzy slippers, even
though they have fallen 3 times in them because
they do not fit correctly. Her favorite niece gave
them to her.
• The resident is only mildly demented, but does not
clearly understand the risk of a hip fracture and
what the consequences might be
• What should the facility do?????
Resident Self-Determination
• Do residents have a right to make a “bad”
decision regardless of the potential harm?
Resident Self-Determination
• If a resident can communicate clearly and can be
determined to be cognitively intact, then that
resident’s wishes can be known with some degree
of confidence and this can be verified by several
people (family members, friends, colleagues,
social workers, psych professionals, nurses,
physicians)
• This person’s wishes can be acted upon with
reasonable confidence
• This is not always the case with cognitively
impaired residents…
Finding the Balance
• These are not questions with easy answers
• We must strive to continue discussions about
resident-centered care, about careful listening and
evaluation of each individual using as much input
as we can get
• We must be mindful of the fact that historically the
healthcare system has been paternalistic
• In moving to resident-centered care, we must not
throw out the positive changes in care practices
that can be adjunctive within a social model
From A Program Perspective...
• Is equipment available, even on the off shifts? Is it well
maintained?
• Are forms for documenting fall risk and interventions
available?
• Does every staff member feel accountable for preventing
falls?
• Is there a culture of safety and not of blame, so that people
feel comfortable reporting falls and fall related problems?
• Is there a champion and a falls prevention team?
No, not these guys…
Here is your champion!
From A Program Perspective...
• Are CNAs involved? Do they have CNA care plans or fall
assessment tools for ADL safety?
– Quick Tips Badge
• Is feedback provided on successful strategies?
– Hospitality Aids (Rhode Island)
• Is data shared with staff? (post in shower room!)
• When the CNAs reassess residents if the resident’s
status/condition changes, how is this communicated to the
nurse and provider (NP/MD), and CNAs on the next shift?
• Do nurses listen attentively to CNAs?
• Do all providers read each others’ notes or share
information with other departments?
From A Program Perspective...
• Are non-nursing staff involved?
• Are non-nursing staff encouraged to prevent
falls and communicate risks?
• Are non-nursing staff valued for what they
bring to fall prevention?
• Do people work in silos, or do they
collaborate and communicate openly?
• “Adopt-a-resident” program facility-wide
What might surveyors be looking
for in fall prevention care plan?
• Is the plan individualized? Does it make
sense for that resident?
• Is it realistic?
– Don’t say “q15 minute checks” if you don’t
have the staff to do it!
– Be careful about how specific you make your
care plan – if it is written in the care plan, it
must be done
What might surveyors be looking
for in fall prevention care plan?
• Words or phrases to watch out for:
– “resident will be supervised at all times”
– “monitor resident for falls”
• What does that mean? How often? By
whom?
– Better choice: just list specifically the things
that you WILL do (toileting every 2 hours,
provide drink and snack in between meals,
ambulate resident between meals/care, etc.)
What might surveyors be looking
for in fall prevention care plan?
• Is the care plan communicated to frontline staff?
Is it simply on paper, or is it really being
communicated and being done consistently?
• What happens if someone unfamiliar with the
resident has to care for that resident for one shift?
What is the back up system or safety net to
communicate what that resident needs during that
shift?
What might surveyors be looking
for in fall prevention care plan?
• Are all departments involved?
• Is the family involved?
• Are staff reading each others’ notes and
sharing information?
• Is there detailed documentation of what was
discussed with resident and/or family and is
this revised as needed?
OK. So we’ve discussed intrinsic
and extrinsic risk factors, and
how to prevent falls. We know
the interdisciplinary team is
critical. Where do we go from
here to put a program together?
BREAK?
Several literature reviews have
demonstrated basic, general
principles that lead to the best
outcomes in preventing nursing
home falls. All of those
approaches include the following:
Comprehensive Risk Assessment
Targeted Interventions
Individualized Plan of Care
Comprehensive Risk Assessment
Includes
• A complete falls history
– any recent falls; whether any associated injury,
fracture, etc.
– estimate of frequency of falls
– qualitative information from
patient/family/caregivers on nature of falls, any
identifiable patterns or triggers (location, time
of day, activity)
– follow up before the trail is cold
Comprehensive Risk Assessment
Includes
Identification of all potential intrinsic and
extrinsic risk factors
– Screening tool for
• New admission
• Post-fall assessment form (beyond the
incident report)
Post Fall Review Process
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Immediate Investigation
Root Cause Analysis
Falls Committee
System of Communication
Medical Assessments/Rehabilitation Screens
Care Plan Modification
Implement Changes
Follow Up
Falls Committee
• Multidisciplinary Team
– Administrator
– DON
– ADON
– Unit Manager designates staff (nurse, CNA)
– Rehabilitation Director/Assistant (team leader)
– MDS Coordinators
– Social Service, activities, other departments as
appropriate
– Witness (if available)
– Family(?)
Resident Fall
• Nursing supervisor completes investigation and
fills out incident report and post-fall assessment
form (or one combined form)
• Interviews individuals who may have witnessed
the fall
• Interviews resident and/or family if applicable
• Notifies falls committee via voice mail box and
reports incident to unit manager
Good Detective Work is Needed!
Falls Committee Meeting
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Initiated within 24 hours of fall
Consistent meeting time (8:30AM)
Mandatory attendance
Keep it short!
Follow up from previous meeting
Current incident report reviewed
Classify Fall (nine categories) and collect other
relevant data
• Set up plan and implement necessary changes
Falls Classification
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Environmental
Resident non adherence
Staff non adherence
Acute medical decompensation
– UTI
– Pneumonia
• Medication related
• Progressive functional decline
– Dementia
– Parkinsons
• Equipment malfunction
• Isolated incident
• Not classified
Falls Classification (some ideas)
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Location (unit)
Location within the unit (bathroom, dining room)
Time, day of week
Predisposing event
Other antecedents
Footwear, clothing, assistive devices
Staffing issues
Family issues
Psychosocial issues
Post Fall Follow Up
• Ongoing education and reeducation of all
staff
• Ongoing communication on the problem of
falls in this individual resident
• Ask the resident, family and staff, “what do
you think?”
• ASK THE CNAs WHAT THEY THINK!!!
Don’t leave the provider out! The
NP, PA or MD can use a
guideline or template to
document his/her workup of falls.
A sample page of the American
Medical Director’s Association
(AMDA) guideline follows…
Checklist for Assessing Fall Risk and Post-fall Review
AMDA Clinical Practice Guideline Falls & Fall Risk 2003
Factors
Fall risk
After a fall
Falls history
Review history of previous falls
Review history of previous falls
Underlying illness and
problems
Assess for presence of underlying
medical condition that predispose to falls
Assess for presence of orthostatic
hypotension and conditions predisposing
to it
Assess for presence of underlying
medical conditions affecting balance,
causing dizziness or vertigo
Assess for presence of underlying
medical conditions that increase injury
risk from falls
Review the status of any medical
conditions that predispose to falls
Assess for presence of orthostatic
hypotension and manage predisposing
conditions
Review status of any underlying
medical conditions affecting balance,
causing dizziness or vertigo
Assess status of underlying medical
conditions that increase injury risk
from falls
Medications
Review for medications that could
predispose to falls; especially diuretics,
cardiovascular medications, antihypertensives, anti-psychotics, antianxiety agents, sleeping medications,
anti-depressants
Reduce dosages or eliminate such
medications
Review for presence of medications
that could predispose to falls; adjust
dosage or stop medication as indicated
Review for recent changes in
medication regimen
How is the PCP notified of a fall?
• What if a covering provider receives the
message?
• Primary care provider must be in the loop
and should provide on site evaluation within
a reasonable period of time
• What information is important to
communicate to the PCP about a fall?
How is the PCP notified of a fall?
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Use the post-fall assessment tool as a guide
Always consider change from baseline
Always relay family or staff concerns
Always mention if the resident is on
warfarin or other anticoagulant
• Mention other recent changes (medication
changes, recent illness, other falls)
Comprehensive Risk Assessment
Includes
• Complete medication review, including
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new medications
dosage adjustments
recently discontinued medications
attention to medications requiring levels
(digoxin, phenytoin, etc.)
– eyedrops, topicals
– alternative/homeopathic remedies
Comprehensive Risk Assessment
Includes
• Comprehensive examination; targeted areas
to include
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orthostatic vital signs
neurological exam (gait)
MMSE
vision exam
musculoskeletal exam (lower extremity joint function)
cardiovascular exam
careful exam of affected/injured area
Some nurses, NPs, physicians
and CNAs may not know how to
correctly take orthostatic vital
signs. Each facility should have a
policy on this, and it should be
included in orientation materials
and annual competencies.
Comprehensive Risk Assessment:
Examination
• Dr. Mary Tinetti demonstrated that the physician’s standard
neuromuscular exam alone fails to detect predictors of falls
(Tinetti, 1988)
• Some type of functional assessment must be used.
Examples include:
– Get up and go (not timed in LTC patients)
– Tinetti performance oriented assessment of mobility
(POAM) (Tinetti, 1986)
– Berg test for gait and balance
Functional Assessment and Tests
of Gait and Balance are
Generally Performed by
Rehabilitation Staff (PT, OT). It
is critical that findings are
shared with nursing, activities
and direct care staff as soon as
they are known!
Comprehensive Risk Assessment:
Diagnostic Testing
• Highly individualized
• Laboratory tests
– usually want to rule out infection, dehydration, drug
toxicity
– CBC, CP7, drug levels, u/a c&s
– TSH
• Cardiology workup may include EKG, holter monitor
• Radiology
Comprehensive Risk Assessment
Final assessment should list all
possible causes of falls in this
particular patient.
Targeting Interventions Based on
Specific Problems
http://www.medqic.org
Go to Physical Restraints
Go to Tools
To to Restraint Reduction Assessment and
Alternatives Help Guide
-orFalls Management Program (FMP)
Targeted Interventions
Individualized Plan of Care
• First, determine if risk is high and
immediate action needs to be taken
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1:1 with staff, family or sitter
Team conference for brainstorming
Consider speaking with PCP
Obtain input from family on what has worked
in the past
– Listen, listen, listen
Targeted Interventions
Individualized Plan of Care
• Do you think these issues could be related to falls?
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Interactions with staff
Pain
Comfort
Contentment
Anger, guilt
Urgency, incontinence
Sleep
Constipation
Targeted Interventions
Individualized Plan of Care
• Address specific intrinsic risk factors identified in
the work up
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consider causes of behaviors
treat or manage orthostatic hypotension
correct metabolic imbalances
treat infection or dehydration
treat pain
consider nutritional issues
determine underlying cause for delirium or confusion
see restraint reduction guidelines and tables (Medqic)
Targeted Interventions
Individualized Plan of Care
• Reduce/eliminate/alter medications
whenever possible
• Follow these general guidelines
Medication Principles to Reduce
Fall Risk
• Reduce the total number of medications given
• Asses the risks and benefits of each medication
• Select medications least associated with
orthostatic hypotension
• Prescribe lowest effective doses
• Reassess risks and benefits at each regulatory visit
and as needed
– AMDA Clinical Practice Guideline Fall and Fall Risk
2003
Targeted Interventions
Individualized Plan of Care
• Consider PT/OT screens or evaluations for
problems with gait or balance, need for muscle
strengthening program, seating systems or
assistive/adaptive equipment or environmental
assessment
• Transfer, gait, balance training; strengthening,
ROM exercises; habituation exercises for
vestibular problems
• Exercise, exercise, exercise!
Targeted Interventions
Individualized Plan of Care
• Environmental adaptations might include
– low bed
– AFO, brace, splint, walker,
cane
– different seating system
– specialized floor mats
– raised toilet seats
Alarms
Chair alarm
Personal alarm
Bed alarm
No studies prove value
Must weigh risks and benefits
May be helpful for some residents and
harmful for others
Consider for short, but not for long term use
Targeted Interventions
Individualized Plan of Care
• Environmental adaptations might include
– siderails for positioning
– different bedroom
– nightlight at night, keeping BR
door ajar
– non-skid strips for floor
– rearranging room (Hofman, 2003)
– external hip protectors
Activities
• How are activities related to falls?
– Knowing previous patterns of behavior
• What is the role of the activities staff in fall
prevention? Do other staff read activities
notes, especially admission info?
• Maintenance? Housekeeping? Dietary?
• Family?
• What is the “All Hands on Deck” program?
• What is the “Walk to Dine” program?
Meaningful Activity
Exercise is Critical!
Look for hazards in the
environment and make changes!
The Hospital Bed Safety
Workgroup
www.fda.gov/cdrh/beds/
And
http://ute.kendaloutreac
h.org/learning/Hospital
BedSafetyWorkgroupH
BSW.aspx
Targeted Interventions
Individualized Plan of Care
• Create an individualized care plan on admission, using the
MDS, developed by interdisciplinary team to address all
risk factors
• Design and implement interventions, monitor and evaluate
outcomes. Update MDS with increase, decrease in falls.
Update care plan if risk factors or condition changes
• Consider the inter-relatedness of other MDS items and fall
prevention (incontinence, depression, pain)
• Continuous efforts are required to sustain benefit of
interventions (Taylor, 2002)
Successful Fall Prevention and
Restraint Reduction Strategies
• Sensory stimulation room or activity drop in
center for sundowners or those with
behaviors at certain times
• Staffing analysis with reallocation of staff to
activities or 3-11 or other pattern
• Weekly walk rounds with medical director
• Weekly environmental rounds with rehab
• Ruby slippers (for hospital and subacute)
Person-centered Approaches to Fall
Prevention
• Consistent staffing is the most
critical element!!!
Reward Ideas from Direct Care
Staff, CNAs, Non-nursing staff,
Residents and Families
Effective Communication
•
•
•
•
Avoid ambiguity
Avoid work around culture
Avoid working in silos
Encourage shift to shift communication and
interdepartmental communication
Involving Residents and Families
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•
•
•
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Identify high risk residents on admission
Discuss with resident and family
Educate!
Get their input
Set REALISTIC goals
Preventing Litigation
• Care plan should be comprehensive and
interdisciplinary
• Involve primary care providers (MD/NP/PA)
• Set realistic goals
• Insure consistent documentation
• Know the high risk categories and the high risk
residents
• Make sure risks are incorporated into the care plan
• Make sure that practice follows policy!
Internet Resources
Patient/Family Education
Materials
The National Center for Injury Prevention and
Control Division of Unintentional Injury
Prevention
4770 Buford Highway, NE, Mailstop K-63
Atlanta, GA 30341
http://www.cdc.gov/ncipc
Patient/Family Education
Materials
www.healthinaging.org/agingintheknow
http://www.niapublications.org/engagepages/P
reventing_Falls_and_Fractures.pdf
National QIO Falls Management
Program
• Has many downloadable forms, including policies
and procedures
• Can be easily adapted or customized to your
facility
www.medqic.org
Enter falls management program as a search term
Summary
• Fall-related injury prevention and restraint
reduction are both important goals
• Management and leadership need to be committed
to reducing both falls and restraints
• Begin with an assessment of where your facility is
now, where the gaps are, and how you will
implement the first phase of your program
What are Residents, Family and Staff Seeking?
• Quality of life, not just quality of care
• Staff who are respectful and well trained
• Most of all: Staff who care
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–
–
–
–
“They want to help.”
“They are kind and good to me.”
“There are enough of them.”
“They are friendly and cheerful.”
“They are patient and have time for me.”
– National Citizens' Coalition for Nursing Home Reform (NCCNHR), 1985
– Tellis-Nayak and Tellis-Nayak, 2005
Summary
• Who will be on the fall/restraint team?
• Who will be the falls champion?
• How will this fit with the culture of safety
and resident-centered care at your facility?
• How will the message be communicated to
frontline staff, families, residents?
• How will new staff be oriented and how
will annual competencies be determined?
Summary
• Ongoing monitoring and re-evaluation of
your results
• Manage with your DATA
• Communication!!!!
• Teamwork!!!!!!!!!!
• Documentation!!!!
Thank you for being a falls
champion!
Alice Bonner, APRN-BC, GNP
[email protected]