Can This Fall Be Prevented?

Demi Haffenreffer, RN, MBAEmail: demi@consultdemi.net

OUTLINE Risk Factors Creating a Culture of Safety

Components of a good fall management program Requirements and Common Citations Assessment and Care Planning Resident Centered Care

When an accident happens What constitutes a fall? Conducting thorough investigations & assessments Implementing measures & updating the care plan

Quality Improvement

RISK FACTORS Anticipated vs. Unanticipated risk factors

Anticipated risk factors are those factors we should address before the resident falls

Measures are implemented after an unanticipated risk factor becomes known

Unanticipated risk factors Seizures, resident to resident behaviors, arrhythmias, CVA,

TIA, a pure accident Anticipated risk factors

Fall History Confused or possible lethargy related to med Unsteady gait or weak transfer Syncope or orthostatic hypotension Other Internal or external risk factors

RISK FACTORS

Anticipated Internal Risk factors: Cardiovascular Neuromuscular/functional Orthopedic Perceptual/Sensory Overall poor health Psychiatric or cognitive

RISK FACTORS

Anticipated External Risk Factors: Medications Appliances or devices Environmental Equipment issues Environment overall or situational hazards Poor assessment and care planning Poor communication Lack of staff knowledge

Components of a good Fall Prevention Program

Goal Driven Prevent avoidable accidents Prevent repeat falls Prevent major injuries Provide quality person-centered care Prevent citations Prevent legal actions Good communication systems Satisfied customers – residents and employees

Components

System is consistent Become a learning organization and

acknowledge high risk and error prone nature of the work we do & the people we work with

Good, consistent investigation/assessment procedures when a resident falls

Simple documentation system Blame free error reporting system but

individuals accept responsibility

Components

Assessments of risks on admission, quarterly & with condition changes

Many prevention strategies (including equipment) available to staff – including restraints as a last resort (however the program is based on a restraint free environment)

Education & orientation Multidisciplinary

Continuous Quality Improvement activities to identify problem/strength areas and improve

Common citations

Investigation/assessment not thorough and does not identify all risk factors.

Investigation/assessment not timely – resulting in another incident/fall before interventions put in place.

Investigation/assessment and interventions not based on facts or incident.

Citations continued:

Interventions not followed. Lack of supervision No investigation/assessment of accident

occurred – no new preventive plan.

Assessment and Care Planning

Upon Admission: Preliminary assessment with immediate measures

discussed with the resident & implemented Orientation of the room with an observation of how the

resident interacts with the environment Increased supervision/observation during the first few

days/evenings/nights Obtain a general history of past falls – establish trends Develop an initial care plan

Assessment and Care Planning

A comprehensive assessment within 14 days Assess and proactively implement person and

environmentally centered measures to prevent accidents

Person-centered care plan approaches What does the resident want?

Person-centered care

Begins with the investigation Resident involved &

informed of data collected, options, risks and benefits of each option

Resident decision Documentation of

assessment/cause & resident choices

Care planning Reevaluation & cp updates

What Constitutes a Fall?

Alleged fall, unwitnessed Fall Lowering to the floor Preventing a fall Rolling off a low mattress

When to complete an investigation / assessment? Alleged fall, unwitnessed Fall Resident found in a

dangerous or risky situation: Climbing out of bed Other

Culture of Safety Old Approach

Resident falls Minimal investigation

w/ much paperwork Incident report Implement an

intervention 24-hour report Move on

New Perspective Resident falls Investigative process is

thorough & consistent w/ as little paper as possible

Incident report & stepped investigative process

24-hour report Evaluation of

interventions / CQI

Conducting thorough investigations Initial step – often

performed by Charge Nurse Immediate protection of

resident as indicated Begin data collection per

guidelines Examine area and

equipment Conduct staff interviews Determine if care plan was

followed as written Gather first impressions Implement initial action &

communicate

Conducting an investigation continued: Second step – often completed by the RN Care

Manager Clinical assessment of possible causes

Medications Medical Cognitive or sensory Environment Psychosocial Physical functioning

Conducting an investigation continued: Third step - Ongoing data gathering by RN Care

Manager and/or a department head Incident trending based on prior incident information or

log Has this happened before? Similarities/differences? What was implemented in the past? Initial identification of root cause Staff assignments Other more complex environmental issues

Conducting an investigation.

Fourth Step - Analyze data What is the data telling you?

Report suspected abuse/neglect How can this be prevented from happening again? Utilize CAA guidelines to assist with assessment and

investigation. Use Interdisciplinary team Summarize findings Communicate

Conducting an investigation continued:

Fifth step – CQI and the 5 Why’s Analyze all incidents monthly in order to identify

trends and implement action plans (education, policy changes, etc.) for the safety of the entire facility and facility population (residents, staff & families)

Trending and Root Cause Analysis Possible system issues:

Physician orders not followed Care plan not followed Failure to assess risk and care plan Standards of practice not followed Resident preference not honored Illness, diagnosis related

Trending and Root Cause Analysis System issues continued:

Staff orientation Staff on break Staff training Equipment mal-function Environment/maintenance/housekeeping hazard

Trending and Root Cause Analysis Action plans for root cause(s) trends

Staff education Staff counseling Resident education Family education Change in system e.g. orientation program Environmental changes QA surveillance change Process improvement team

What to for? Falls What was resident doing?

Rising? Sitting? In bed or out of bed? During assisted transfer? To chair or from chair?

Indicate type of chair Brakes on w/c/bed Chair too low Foot rests appropriate

Self ambulating?

What to for? Falls continued: What was resident doing?

Reaching Assisted ambulation Sliding/leaning forward out of chair

Location & time of fall? Side rails?

Up, down, per care plan? Malfunctioned

Time since last voided/toileted? Call light within reach? Call light on? Time since last meal?

What to for? Falls continued: Environment/equipment a factor?

Failed or misused adaptive device? Device out of reach? Faulty equipment? Furniture? Clutter? Lighting/glare? Water on floor? Uneven floor or if outside uneven pavement?

What to for? Falls continued: Mobility alarm on? Functioning? Removed by

resident? Type of footwear?

Non-skid shoes Slippers Socks only Shoes Barefoot

What to for? Falls continued: Care Plan followed as written? Assigned staff on break? Staff in orientation? Medical factors e.g. Parkinson’s Vital signs – BP lying and sitting Diabetic? Check blood sugar

What to for? Falls continued:

Medications Any new medications? Meds in last two hours? Psychoactive Hypertension Sedative/hypnotic Narcotic

If unknown origin Interview all staff and visitors going backwards in time to

determine possible time frame for event

What to for? Falls continued: Physical functioning

Gait Upper torso weakness

Vision/sensory – glasses/hearing aide on? Need for contrasting colors?

Pain? Sitting too long? Seating Assessment done? Tired?

Falls Investigation Guides

Overview Guide Environmental Guide

Falls investigation Guides

Medication Guide Communication Guide

Case Example # 1

Background: A woman fell at home after getting caught in her small dog’s leash resulting in a fractured right hip. Following a surgical Open Reduction Internal Fixation (ORIF, hip pinning), she was admitted for skilled rehabilitative services secondary to the ground level fall. She is alert and oriented and has not experienced any memory loss.

In the skilled rehab facility, the resident had a fall at bedside after attempting to self transfer from bed while attempting to go to the bathroom due to urinary urgency. The resident was found with a skin tear to her left hand and abrasion to her left knee. The resident was immediately evaluated/assessed for injury, treatment needs and to assure comfort and safety.

Resident has a history of Congestive Heart Failure and is on diuretic therapy.

She has Hypertension and is on two different anti-hypertensive medications.

She is also on Coumadin as a preventative post surgery measure.

The physician was notified and a treatment to left hand skin tear was ordered as well as an x-ray to her left knee and her right

Begin Falls Investigation Guide

Gather 1st impressions Indentify Possible Causes

Use Communication Guide

Ensure necessary communication of information (i.e., to staff/management, family, physician, etc.)

Use Environment and Equipment Investigation Guide

Review factors related to environment and equipment

Use the Medication Investigation Guide

Review factors related to medication use

Resident Falls

The resident was witnessed resting in her bed at 1030.

The staff heard her call out at 1115. The fall was not witnessed by staff. The aide who found the resident stated that she was on her

left knee, that her left hand was bleeding, and that her right leg was extended straight and in alignment with her body.

The resident does not complain of any increase in right hip pain and her recent surgical incision is intact to her right hip. Does state she has pain to her left knee, which was found to have an abrasion, and her left hand, where a 3 cm skin tear was found and was bleeding.

The resident does not use side rails. The resident’s wheel chair was beside her bed but tipped

forward. The resident stated that she went to sit in her wheel chair

because she became dizzy on standing. Her wheel chair was tipped forward behind her and the brakes were not locked.

Figure 3: RCA/Causal Tree Diagram

Some Interventions

Non-slip surfaces Lights are automatic Raised toilet seats Half rails- arc rails – transfer poles Lower beds – Hi/low beds better Automatic bed controls Trapezes – merry walkers, etc

Some Interventions

Bedside commodes Easy to use call lights Infant monitors Pressure pads Non-slip socks/shoes Night lights Assistive devices/Equipment close by Increased supervision during time likely to fall

Some Interventions

Toilet schedules Let them sleep Familiarity Concave mattresses or bolsters Eliminate clutter Drug reductions Locks on movable equipment that work Assess them for pain & treat

Some Interventions

Benches so residents can rest Level surfaces Chair cushions and other non-slip

surfaces/wedges Move them closer Keep things in reach on their dominant side Eliminate the shine

Some Interventions

Activities Physician consults (including psych;

audiology, visual & medical) Hip protectors, helmets, knee and elbow

protectors Therapy or restorative care Restraints & alarms - consideration as a last

resort

MAY ALL YOUR SURVEYS BE SUCCESSFUL & ALL

YOUR RESIDENTS & STAFF WELL CARED FOR!