Carole Eldridge, MSN, RN, CNAA, BC

Long-Term Care Risk Management:

A Guide to Prevention, Assessment, and Response

RESIDENT FALLS

Long-Term Care Risk Management: Resident Falls: A Guide to Prevention, Assessment, and Response �

Contents

About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Chapter �: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �

The problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Why is long-term care a target for litigation and increased insurance costs? . . . . . . . . . . . . . . . . . . . . . . . . . 4

The solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2: Risk Factors for Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Nonmodifiable intrinsic risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Modifiable risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Psychological and cognitive risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Extrinsic risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Chapter 3: Modifications Based on Risk Factor Identification: Preventing Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Functional risk factor modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Medication modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Psychological and cognitive modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Environmental modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Alarm warning systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Residents still may fall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Chapter 4: Fall Prevention Programs . . . . . . . . . . . . . . . . . . . . . . . . . 55

Contents

Long-Term Care Risk Management: Resident Falls: A Guide to Prevention, Assessment, and Response2

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Developing a fall prevention program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Educating staff, residents, and family members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Track and trend systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Sample facility-wide fall-prevention programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Fall prevention program check-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Falls documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Chapter 5: Fall Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8�

Fall response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Questions to ask . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Witnessed and assisted falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Unwitnessed falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

First aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Deciding when to transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Head injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Recommended nurse documentation for falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Appendix 1: Resident Fall Response Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Appendix 2: Nursing Fall Protocol Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Appendix 3: Fall Protocol Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Appendix 4: Full Response Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Appendix 5: Neurological Assessment (Following Head Injury) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

IntroductIon

Chapter 1:

Long-Term Care Risk Management: Resident Falls: A Guide to Prevention, Assessment, and Response �

The problem

Falls are the leading cause of accidental death among adults aged 65 and older. More than one-third of older adults

fall each year, with 20%–30% suffering injuries that reduce mobility, decrease independence, and increase the risk of

premature death. Those facts alone make fall prevention one of the most important things seniors and their caregiv-

ers can do to promote the health and well-being of residents of long-term care facilities.

The following other facts show the importance of this issue of fall prevention:

• Falls cause the majority of fractures suffered by older adults

• Falls are a leading cause of traumatic brain injuries

• People aged 75 and older who fall are four to five times more likely to be admitted to a long-term care facility

for a year or longer

• Falls play a major role in 40% of nursing-home admissions

• 10,000 deaths in older adults each year are attributed to falls

• Among older adults, falls are the most common cause of nonfatal injuries and hospital admissions

for trauma

IntroductIonC

ha

pTe

r

1

Chapter 1

Long-Term Care Risk Management: Resident Falls: A Guide to Prevention, Assessment, and Response�

The CosTs

Beyond mortality, the most significant cost of falling is the diminished quality of life, confidence, mobility, and

independence of older adults. Many other costs are easier to quantify:

• Emergency departments treated 1.6 million seniors for fall-related 353,000 of whom were

hospitalized1

• There are approximately 360,000–480,000 fall-related fractures among older adults each year 2

• Hip fractures, the fall-related injuries that cause the most severe health problems, cost Medicare approximately

$2.9 billion in 19913

• Most patients with hip fractures stay in the hospital for about a week; up to 25% remain institutionalized for

at least one year4

Why is long-Term Care a TargeT for liTigaTion and inCreased insuranCe CosTs?

Across many industries, plaintiffs’ attorneys and insurance companies look at several factors when considering the

potential for liability. Businesses that are susceptible to lawsuits and insurance claims typically have the following

characteristics in common:

• They provide services that are potentially dangerous and could cause harmful mistakes

• They are subject to intense scrutiny by state and federal regulatory agencies, the public, and

the media

• They feature complex, interdependent systems supported by multiple processes and disciplines

Long-term care features each of these characteristics. Plaintiffs’ attorneys can view long-term care as a source for

potentially significant financial recovery, and insurance carriers can see the industry as a source of significant poten-

tial losses.

Introduction

Long-Term Care Risk Management: Resident Falls: A Guide to Prevention, Assessment, and Response �

The soluTion

There is no one-size-fits-all solution to the problem of long-term care facility residents falling. There is, however,

a single main goal that every senior and every long-term caregiver should work toward: prevention. Although it

may not be possible to prevent every fall, most falls are preventable. Each fall prevented is one less potential injury,

fracture, head trauma, or death. The goal of this training manual is to help long-term care employees learn how to

prevent as many falls as possible, thereby preserving residents’ mobility, qualify of life, and independence as long as

possible.

referenCes

1. Web-based Injury Statistics Query and Reporting System, www.cdc.gove/ncipc/wisqars, the Centers for Disease

Control and Prevention, 2001.

2. “Hip fractures in the elderly: a worldwide projection.” Osteoporosis International 1992;2(6):285-9.

3. “Incidence and costs to Medicare of fractures among Medicare beneficiaries aged >65 years—United States, July

1991-June 1992.” Morbidity and Mortality Weekly Report 1996; 45(41):877-83.

4. “Recovery from hip fracture in eight areas of function.” Journal of Gerontology: Medical Sciences 2000;55A(9):

M498-507).

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