Transcript Falls in Nursing Homes

Falls in Nursing and Personal
Care Homes
Looking at Culture and Collaboration
Paula A. Bracken, PCHA, MHA
Affinity Health Services, Inc.
November 30, 2010
PHCA Webinar
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Overview
The Elderly and where they live
 Falls definition and MDS 3.0
 Regulations
 Various Risk Factors & Interventions
 What difference does a change in culture
make?
 We need a different approach
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The Elderly
Community-Dwelling
Personal Care / Residential
Nursing Home
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Falls
A very broad issue with many factors
involved
 There is no simple solution
 Falls are a result of complexities within a
person as well as within the environment
in which they dwell
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Falls
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Definition
◦ An unintentional change in position coming to
rest on the ground, floor or onto the next
lower surface – MDS 3.0
 Examples  Coming to rest on the foot rests of a wheelchair
 Knees give out and the person has to be lowered
to the floor
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MDS 3.0
G0300: Balance During Transitions and
Walking
 G0400: Functional Limitation in Range of
Motion
 G0600: Mobility Devices
 G0900: Functional Rehabilitation Potential
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Impaired Balance -planning for care
Evaluate
 Assess to identify all risk factors
 Care Plan to Prevent further decline in
function and/or return of function
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◦ Depends on resident-specific goal(s)
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MDS 3.0
J1700 :Fall History on Admission
 J1800: Any Falls Since Admission or Prior
Assessment (OBRA or PPS), whichever
is more recent
 J1900: Number of Falls Since Admission or
Prior Assessment (OBRA or PPS), whichever is
more recent
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Falls – planning for care
Evaluate potential need for further
assessment and intervention
 Evaluate the environment
 Evaluate staffing in relation to residents at
risk for falls
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Consequences of falling
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Injury
◦ 20-30% suffer serious injuries
◦ 2-6% suffer fractures
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Fear of falling in daily life activity
Restricted mobility and activity
Loss of independence
Increased social isolation
Admission to residential care/nursing home
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Falls are
Most frequent accident in PC/AL and
NHs
 40% of all NH residents fall each year
 Several fall 1+ times
 35% occur with those who cannot walk
 10-20% cause serious injuries
 Fall history / fall injury before admission
 Prevalence of falls in NH higher than among
community-dwelling elderly
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Inadequate supervision
Frequently cited by state in both PC and
NHs
 Occurs when there is failure to
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◦ Recognize signs and symptoms of fall risk
◦ Intervene appropriately
◦ Plan interventions to prevent future falls
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Personal Care Homes
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Prevalence of falls depends on
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Population characteristics
Personal Care Home practices
Staff skills
Systems established
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Nursing Home Regulation &
Practices
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The Nursing Home
Institutional by nature and background
 A medical-model that focuses on tasks
and routine
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The Institutionalized Culture
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The underlying “risk factor”
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F 252 Environment
◦ “a homelike environment is one that deemphasizes the institutional character of the
setting . . .A personalized homelike
environment recognizes the individuality and
autonomy of the resident . . . .
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Institutionalized Culture
Standardized “treatments”
based on
medical dx
Schedules and routines designed by and
for staff
Task-oriented work and rotation of
assignments
“sterile” environment
Activities only available when activity staff
are on duty
-Pioneer Network, 2008
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Typical Interventions
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Investigate incident first
◦ Ideally - details from investigation determine
what interventions are put into place
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Alarms
◦ Chair
◦ Bed
◦ Motion detect
Padded mattress beside bed
 Shoes on, etc.
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F 323 Accidents
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The facility must ensure that the resident
environment remains as free of accident
hazards as is possible; and each resident
receives adequate supervision and
assistance devices to prevent accidents.
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Accidents and Supervision
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Falls related to
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Alarm use or misuse
Misuse of Equipment
Improper Supervision and Assistance
Lack of proper Assessment
Lack of new interventions
Poor communication
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Why not Alarms?
False sense of security
 Residents learn to turn them off
 Can malfunction; battery goes out
 A Dignity issue
 Contributes to institutionalized
atmosphere
 Survey deficiencies related to alarms
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Why not Alarms?
Staff respond to the alarm and not the
resident
 Creates confusion from startling noise
which increases agitation
 Everyone can become desensitized
 Potentially “immobilizes” resident
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◦ Decline in ADLs
◦ Can act as a “restraint”
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Interrupts sleep
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Why not Alarms?
Wide spread and long-term use
 A false-assurance for staff
 Startles the resident
 Constrains resident from normal
re-positioning movements – may
contribute to
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◦ Pressure sores
◦ Weakened muscles
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Examples of deficiencies
Alarm did not sound
 Nurse aide forgot to turn alarm on/attach
alarm to resident
 Resident turned alarm off
 Resident removed clothing to which
alarm attached
 Lack of monitoring alarms
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Conclusion
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There is a lack of evidence that support
the use of alarms to prevent falls
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Alarms cannot be used in place of
supervision
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Institutionalized care demoralizes the
individual and contributes to poor clinical
outcomes
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Therefore Change is Needed
“… A “homelike” or homey environment is
not achieved simply through enhancements
to the physical environment. It concerns
with striving for person-centered care
that emphasizes individualization,
relationships, and a psychosocial
environment that welcomes each resident
and makes her/him comfortable . . .”
- CMS, 2009
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Interventions and approaches
Considering Culture and Collaboration
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S.e.r.v.i.c.e. - A Leadership model
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Service
Education
Respect
Vision
Inclusion
Communication
Enrichment
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Leadership is "the art of influencing and engaging
colleagues to serve collaboratively toward a shared
vision”
◦ -S. Gilster, “Changing Culture, Changing Care”, 2009
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Collaboration
“a team, with each individual contributing
unique talents in such a way that all are
used to accomplish the goals and vision.”
 “people coming together as one . . . To
create a culture or outcome consistent
with the vision”
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-S. Gilster, “Changing Culture, Changing Care”, 2009
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What does “Person-Centered”
mean?
The Person is the focus
 Build relationships among care-givers
 Gain insight to individualize care routines
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Knowing residents and relating to them as an
individual allows for spontaneity and creativity
in the approach
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Person-Centered Approach
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Puts the Resident first, and tasks second
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Identify patterns of resident needs
◦ Toileting, walking, stretching, pain treatment
◦ Identify discomfort related to positioning
◦ Change staffing patterns on 3-11 to better
meet resident needs
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Person-Centered Culture
Resident- Choice is critical
 Meeting the personal wishes of the
resident helps to create the foundation
for care-giving relationships
 Direct care staff can have input into the
care-planning for a resident
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Other Positive Culture-Oriented
Approaches
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PHI National ◦ A “Relationship-centered" culture that first and
foremost supports Resident choices and all
relationships
 Supervisor – Staff
 Staff- Staff
 Staff – Resident
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Core skills, particularly those related to
communication, problem-solving and
relationship building are needed
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Results are a far more empowering and
satisfying environment for both staff and
residents
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When you individualize care, you
minimize the need for alarms
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Changing Care Routines
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Mornings – allow to sleep in – individualize care
routine per person - this will affect other systems and
processes, such as meals, when medications are given,
when treatments are done, etc.
Bladder care – individualize- follow patterns
 Medication Pass – a nursing task – can change
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medication policies for administration time from
◦ “8 a.m.” to “upon rising”
◦ BID to “upon rising” and “before dinner”
◦ TID to “upon rising”, “before lunch” and “before bed”
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Changing Care Routines
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Suppositories – do not awaken early to give – go
back to the basics – high fiber & fluids & exercise
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Pain management – individualize
◦ MDS 3.0 – tells us characteristics of a resident’s pain
and it’s affect on function and mood
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Foodservice – Provide a time range
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(i.e. ) 8 a.m. – 10 a.m. - personalize service
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A Resident “Right” to a Safe
Environment
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It is the Right of a Resident to live in a safe,
structured, and predictable environment:
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Designed around the needs of the person
Safe and well lit,
Offer areas for walking or wandering,
Be uncluttered,
Be pleasant
Provide a structured schedule of activities and
meals
◦ Stimulating the senses, yet providing a sense of
security
 Bell & Troxel, 1997
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Environmental Re-design
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If it is financially feasible, an internal
environment that is re-designed to
facilitate the
◦ Supervision of residents
◦ Movement of individuals throughout the area
◦ Creation of a homelike environment that
resembles more of a “home” versus an
institution – smaller gathering places
According to the Pioneer Network, more
documented research in this area is needed
-Pioneer Network, 2008
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Neighborhoods vs. ‘Units’
Resembles a town
 Rooms are a “home”
 Community or “country” kitchen
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◦ Creation of a “hearth” – place to gather
◦ Improved intake and nutrition – overall health
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Therapy and Activities as an
Intervention
Provides supervision
 Exercise improves blood circulation
 Increase strength and endurance
 Improved sense of well-being
 Improved sense of self-worth
 Improved function
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Treatment and Prevention of
Osteoporosis in LTC Setting
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Based on Clinical Practice Guideline from
AMDA
◦ Dx. of Osteoporosis , Osteomalacia or
Osteopenia
◦ Order a Vitamin D level (25-OH- D3 or 25hydroxy D3)
 Sufficient is 32 ng/ml or greater 25 –OH-D3
Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term
Care Setting, 2009
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Institute measures to improve
function
Encourage exercise to increase muscle strength
in leg muscles
 Use restorative services to improve strength,
balance and ambulation
 Discontinue or reduce medications that affect
balance or level of consciousness
 Administer Vitamin D and Calcium supplements
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Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting,
2009
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Treatment and Prevention of
Osteoporosis in LTC Setting
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To Maintain or improve Calcium Balance
◦ Calcium
 Calcium Carbonate
Calcium Citrate
Vitamin D
 Cholecalciferol (D3)– best absorbed
 Ergocalciferol (D2)
 1,25 di-hydroxyvitamin D
Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting,
2009
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Treatment and Prevention of
Osteoporosis in LTC Setting
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Anti-resorptive Medications
◦ Calcitonin
◦ Raloxifene
◦ Bisphosphonates
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Anabolic Medications
◦ Parathyroid hormone
Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting,
2009
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When not to treat Osteoporosis
Terminal condition /palliative care
 Unable to tolerate pharmacologic tx
 Unwilling to accept treatment
 Has been tx’d with Biphosphonates for
past 5 years
 Patient is non-weight bearing and requires
maximal care
 No evidence of Treatment efficacy
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Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009
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Fall Risk Assessment
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Assess characteristics of the resident
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Hx. of a fall
Recent illness and multiple co-morbidities
Dx. Osteoporosis and/or Vitamin D deficiency
Medications and drugs that impact balance,
cognition, etc
◦ Restorative nursing
◦ Therapy received
◦ MDS 3.0 data and process
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Example of an Intervention Program
using a Fall Risk Assessment
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General /Medical Assessment
Fall Risk Assessment
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At Admission
After a Fall Incident
At the request of a health-care professional
On a change in condition
Periodic review
 Fall Prevention Meeting – evaluate Medical and
Fall Risk Assessment data together
From Neyens et al. (2008)
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Fall Prevention Team Evaluate
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Fall Prevention Activities
◦ General – Facility-related
◦ Specific – Resident-related
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Fall Prevention Meeting
◦ Evaluate general and specific fall prevention
activities
◦ Minimum twice a year
From Neyens et al. (2008)
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Individual Fall Prevention Activities
Anticipating the circumstances & causes
of falls
 Critically reviewing medication intake
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◦ Type, number, dose and time of intake
Individually designed exercise programs
 Careful reassessment of need for assistive
aids
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◦ Promotion of correct use of these aids
From Neyens et al. (2008)
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Investigation
Keep it “Person-centered” – not just a
process
 Critical thinking of what went wrong
 Details surrounding the incident
 Current interventions during the incident
 New interventions added after
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◦ Add to care plan
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We can no longer take a cookie-cutter
approach to addressing the issue of Falls and
expect improvement
“Insanity is doing the same thing
over and over again, and
expecting different results.”
-Albert Einstein
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Making Changes
Trial changes in one area
 Trial one change at a time
 Communicate to all involved the “what”
and “why” of the change
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◦ i.e. - to Reduce Falls, Improve Care, etc
Track and Trend Fall data for evidence of
reduction
 Evaluate and Re-adjust accordingly
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References
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American Medical Directors Association. Osteoporosis and Fracture
Prevention in the Long-Term Care Setting Clinical Practice Guideline.
Columbia, MD: AMDA 2009
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Bell, V. & Troxel, D. (1997). The Best Friends Approach to Alzheimer’s Care.
Baltimore, MD: Health Professions Press, Inc.
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Bishop, M. D., et al, (2010). Improved Fall-Related Efficacy in Older Adults
Related to Changes in Dynamic Gait Ability. American Physical Therapy
Association. Retrieved November 1, 2010 from
http://ptjournal/apta.org/content/90/11/1598
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Clemson, L, et al. (2008). Environmental Interventions to Prevent Falls in
Community-Dwelling Older People: A Meta-Analysis of Randomized Trials. J
Aging Health, 20:954, Sage Publications. Retrieved November 1, 2010 from
http://jah.sagepub.com/content/20/8/954.refs.html
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CMS Internet Training. (2007) From Institutional to Individual Care Part III:
Clinical Case Studies in Culture Change. Retrieved from
http://www.cmstraining.info/pubs/VideoInformation.aspx?cid=1061
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References
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Centers for Medicare & Medicaid Services. (2009). Code of Federal
Regulations. State Operations Manual, Appendix PP.
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Glister, S.D., (2005). Changing Culture, Changing Care: S.E.R.V.I.C.E .
FIRST. Cincinnati Book Publishing, Jarndyce & Jarndyce Press
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Neyens, J. C. L. , et al., 2009. A multifactorial intervention for the
prevention of falls in psychogeriatric nursing home patients, a randomized
controlled trial. Age and Ageing, 38:194+. Oxford University Press.
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Social Care Institute for Excellence. (2005). SCIE Research Briefing 1:
Preventing falls in care homes. Retrieved November 1, 2010 from
http://www.scie.org.uk/publications/briefings/briefing01/index.asp
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Pioneer Network, 2008. Creating Home Background Paper. Retrieved July
1, 2010 from http://www.pioneernetwork.net/Data/Documents/CreatingHome-Bkgrnd-Paper.pdf
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