person centered care falls restraints FINAL - ANHA

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A Core Intervention to

Reduce Falls and Restraints

Objectives

1. Increase safety awareness2. Increase competencies in

person-centered care, evidence based processes and promising p p gpractices to reduce falls and restraints

3. Incorporate the resident’s life story, customary routines and preferences into the resident’s care as an intervention to reduce falls and physical restraints

Advancing Excellence gin

America’s Nursing Homes

Fall 2012

QAPIQAPI

Why is Nursing Home QAPI Important?

1. It’s the right thing to do.

2. Affordable Care Act strengthens QAPI requirements in nursing homes.

www.nhqualitycampaign.org

q g

3. With the shift to MDS 3.0 and the change in quality measures, nursing homes are more accountable than ever for quality.

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• Reactive• Single episode• Organizational mistake• Prevents something from happening again

• Proactive• Aggregate Data• Organizational process• Improves overall performance

Quality AssurancePerformance

Improvement


happening again• Sometimes anecdotal• Retrospective• Monitoring based on audit• Sometimes punitive

performance• Always measureable• Concurrent• Monitoring is continuous• Positive change

Our Working Hypothesis…

If you have good organizational workplace practices and good care planning practices the good clinical


planning practices, the good clinical outcomes will follow and the staff/residents/families will be happy.

A Model for Change

OutcomesOutcomes

Care PlanningCare Planning

Person-centered Care

Organizational Workplace Practices

First, Build the Foundation…

d A bl C l

Consistent Assignment

StableStaff

Hiring Practices

Evidence- Based Care Practices

StaffEngagement

Competency

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Organizational Workplace Practices

Just and Accountable Culture

Strong Leadership

Pressure UlcersStaff StabilityHospitalizations

“New” AE Goals - 2012

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MobilityPerson-Centered

Care andDecision-Making

ConsistentAssignment

InfectionsMedications(Antipsychotic

use)

Pain Management

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Person-Centered Care Planning and Decision Making

• Keeps the person at the center of the care planning and decision-making process.

• Promotes choice, purpose and meaning in daily life. A hi hi h t ti bl l l f h i l• Achieves highest practicable level of physical, mental and psychosocial well-being

• Care plans are revised on ongoing basis to reflect a person’s changing needs.

• Staff adapts to each resident’s changing needs regardless of cognitive abilities.

Getting to know the resident as a person …

beyond the diagnosis

•Prevent falls• Reduce physical

restraints

Know the Person

• Improve behaviors• Reduce

antipsychotics

Know the Journey

• Life Story•Customary

Routines•Preferences

Life Story

•Tell us about your childhood•Tell us about your adult life•Tell us about your usual day•Tell us about your usual day•What are your expectations of

life while living here?

Customary Routines

•Morning Routine•Meals•Sleep•Sleep•Bath /shower time•Routine daily schedule•Habits

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Personal Preferences

www.musicandmemory.org

MDS 3.0: Customary Routines

Section F

The best care plan is of little value unless it is

accessible, understandable and easily utilized by the direct care

provider.

I-Centered Care Plans

Long Range Goal Long Range Goal To live the remainder of my life

with dignity, to my fullest potential, in a safe and

comfortable environment

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I Centered Care Plans

Psychosocial: Mood and BehaviorI have a history of being unnecessarily suspicious of my

family and staff. I have had this difficulty for many years and take medication to assist me and also see a psychiatrist routinely. I have Schizoaffective disorder. This causes me to have delusional thoughts which cause me to become fearful. Staff should approach me slowly and gently. I respond better if staff takes a slow, loving, reassuring approach in helping me with my cares.


www.nhqualityCampaign.org

The same person takes care f th id t


of the same resident every time he or she is on duty…


Builds caring relationships

Earlier detection of changes


Improves staff accountability

Improves communication

Improves clinical outcomes


Improves staff stabilityTurnoverVacancy ratesCall-offs

Staff Stability

• Staff work in the nursing home long enough to learn each resident’s needs and preferences.

• Residents are more comfortable with caregivers who know their personal preferences and

i i dcaregiving needs.

•A stable staff allows the nursing home to benefit from experience and knowledge that staff gains over time, increasing the overall competence and confidence of staff, while building strong bonds between residents and caregivers.

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Staff Stability and Consistent Assignment

Reduces risk of falls

Reduces use of hospitalizations related to adverse events

R d f i i tReduces use of inappropriate antipsychotic medications for dementia-related behaviors

Reduces use of restraints

Staff Stability and Consistent Assignment

•Ensures that residents receive medications that are needed and appropriate for their medical condition.

•Promotes use of alternative non-pharmacological interventions that may be better suited for residents who otherwise would likely be treated with antipsychotic medications.

Staff Stability andConsistent Assignment

•Enhances and maintains mobility (range of motion, bed mobility, transferring, walking, elimination of physical restraints, wheelchair mobility, and reduction of fall risk) as a part of daily care to help maintain a person’s function as well as physical and psychological well-being.

• Improves health and quality of life by increasing freedom of movement and activity.

What Can You Expect in Next Six Months?

• Changes to the Website– List of registrants limited to “Phase 2”

and inclusion of date first registeredRequired log-in to access tools


– Required log-in to access tools– “Preview Page” to highlight new tools

and resources as they are developed– New look and new feel to the website

Changes

• Addition of “process” measures. • Website entry for each goal and integration

with nursing home –wide QAPI


• Increased feedback from the website for use by Performance Improvement Committees

New Tools for Each Goal

• Data Gathering Tool • Up-to-date Consumer and Staff Fact

Sheets


• Probing Questions• Case Studies• Interactive Website

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Definition of Participation

“An AE Campaign participant enters data on the AE website for at least two goals at least one month out of each of


goals at least one month out of each of the last three quarters.”

Reducing Falls

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 pchronic 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(LOC) and spontaneous recovery

– May only account for 4% of all falls, but newer research suggests it may be more than that

What is a fall?

CMS Answer-An episode where a resident lost

hi /h b l d ld his/her balance and would have fallen were it not for staff intervention. In other words, an intercepted fall is still a fall.

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The presence or absence of resultant injury is not a factor in the d fi iti f f ll A f ll ith t definition of a fall. A fall without injury is still a fall.

• When a resident is found on the floor, the facility must investigate and implement interventions to prevent another incident prevent another incident.

• Unless there is evidence suggesting otherwise, the most logical conclusion is a fall has occurred.

• The distance to the next lower surface,(in this case the floor) is not a factor in determining whether a fall has occurred. whether a fall has occurred.

• If a resident rolled off a bed or mattress that was close to the floor, this is a fall.

Statistics

• 35-40% of community-dwelling, generally healthy adults over age 65 fall annually

• Rates are higher after age 75Rates are higher after age 75• In nursing homes and hospitals, rates

are almost three times higher • (1.5 falls per bed)• 50% of people who fall 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 • 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 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

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Complications from Falls

• Abrasions, contusions, lacerations, bruising• Hemorrhage [internal and external

bleeding]• Anemia, secondary to bleeding• Concussion, Subdural hematoma• Subdural hematoma• Fracture, sprain, or dislocation• Fear of falling resulting in loss of confidence,

decreased independence and social isolationAMDA Clinical Practice Guideline Falls and Fall Risk, 2003

Risk FactorsI

In studies focused on nursing home residents, the risk factors most commonlyassociated with falls were:

Hi t f f ll–History of falls–Muscle weakness–Gait or balance deficit–Use of assistive devices–Visual deficit

Additional Risk Factors

Additional risk factors for falls in nursing home residents were:

–Arthritis– Impaired ADL–Depression–Cognitive impairment–Age over 80 years

• Intrinsic factors Physiological changes with age, disease processes, iatrogenesis,

di ti bi timedications or a combination

• Extrinsic factorsTypes of activity, hazards and demands of the environment

• Anticoagulants• Antidepressants• Anti epileptics

• Diuretics• Narcotic analgesics• Non steroidal anti

Associated with Injury from Falling

Medications

• Anti-epileptics• Anti-hypertensives• Anti-Parkinsonian

agents• Benzodiazepines

• Non-steroidal anti-inflammatory agents [NSAIDS]

• Psychotropics• Vasodilators

Intrinsic Risk Factors

• Syncope • Fear of falling• Dizziness• Incontinence• Incontinence• Depression• Generalized weakness • Any acute illness; often infection,

delirium, dehydration. If not detected early…

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Intrinsic Risk Factors

• 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

Extrinsic Risk Factors

• 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 t tistation

• Type of setting not appropriate or cannot meet needs for adequate assessment and supervision of a particular resident (caregivers not trained in how to redirect or intervene with dementia residents)

Extrinsic Risk Factors

• Adaptive equipment lacking or used inappropriately (e.g., walker too low)

• Lack of restorative program; lack of • Lack of restorative program; lack of exercise and routine ambulation to maintain function

• Use of restraints (physical, chemical) resulting in decreased activity, de-conditioning (Dimant, 2003)

Environmental Risk Factors

•Lighting•Equipment

Floors•Floors•Bedrails•Furniture

Falls Management Program (FMP)

• Immediate response

• Long-term management

• Quality improvement and risk management

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The Falls Management Program

A program of the• Center for Health in Aging and• Emory University Division of Geriatric

Medicine and GerontologyMedicine and GerontologyDepartment of Medicine

• Developed and supported by the Agency for Healthcare Research and Quality (AHRQ)

Vanderbilt Falls Program

Builds upon the previous work of Dr. Wayne Ray and colleagues at Vanderbilt University School of MedicineA thAuthors:

Jo A. Taylor, R.N., M.P.H.Patricia Parmelee, Ph.D.Holly Brown, M.S.N., A.P.R.N. – B.C.Joseph Ouslander, M.D.

Culture of Safety

• Starts with administrator and leadership• Open communication built on trust • Non-judgmental• No blame or shame• Monthly reports of falls openly shared with

administrator and leadership• Clearly defined policies/processes and

enforcement• Staff empowerment to correct problems• Data-Set goals then track and trend

Teamwork

• Administrator • Falls reduction champion • Direct care/service provider• Therapists/other professionals• Director of nursing/nursing staff• Resident and family

The Process

• Create a falls team • Set a goal• Formal routine meetings using good

meeting process with action plan and minutesminutes

• Education and awareness• Track and trend data• Share progress toward goals• PDSA and root cause analysis• Celebrate progress and share lessons

learned

Be the Fortune Teller of Falls

Past history of a fall is the single best predictor of

future falls.

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Fall Response

Eight Steps1. Evaluate and monitor the

resident for 72 hours2. Investigate fall circumstances3. Record circumstances,

outcome and response

Fall Response

4. Alert the physician/family5. Implement an immediate

intervention within first 24 intervention within first 24 hours

6. Complete a falls assessment and obtain orders

Fall Response

7. Develop a plan of care8. Monitor for compliance with

plan and resident response

Important

• Document a review of systems in the nursing notes every shift for 72 hours after fallfor 72 hours after fall

• Reference resident’s response to the fall

Very Important

•Most important information for root cause analysis and for root cause analysis and future planning is obtained at time and immediately after the fall

Very Important

•Avoid negative responses or blaming blaming

•Problem solve with direct care providers

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Very Important

At the time of the fall•Record circumstances•Resident outcomes•Staff response

TRIPS Form

•The TRIPS form makes this easy•TRIPS completed by the nurse

at the time of the fallat the time of the fall• Later reviewed by risk

manager, falls coordinator, DON and administrator

Root Cause

•Use the term “unknown”sparingly

•Root cause is your greatest friend in falls management

CAA: Fall(s) Alert the Physician

•The “FAX Alert” form makes this easy

R t i i th di l d•Retain in the medical record

•Form designed to ensure prompt notification of physician supported by documentation

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Immediate Intervention

• An immediate intervention is put in place by the nurse during the same shift that the fall occurred

• Document the immediate response in the nurses notes and plan of care

• Intervention usually obvious after completing the TRIPS form

Falls Assessment

The five areas of risk accepted by the literature as being associated with falls include:

1 Medications1. Medications2. Orthostatic hypotension3. Poor vision4. Impaired mobility5. Unsafe behavior

Complete the Falls Assessment

• The “Falls Assessment” form makes this easy!

• Because the Falls Assessment will include referrals for further professional interventions, contact referrals immediately

• The “Primary Care Provider” FAX Report and Orders” and “FAX Back Orders” forms make this easy! Retain a copy on the medical record

Develop a Plan of Care

• Use the Falls Assessment along with any orders and recommendations to develop the plan of care

• The “Fall Intervention Plan” makes this easy because interventions are grouped in the same five areas of risk as covered in the Falls Assessment

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Monitor Resident Response

The “Falls Intervention Monitor” makes this easy

Good interventions = no fallsIneffective interventions = more falls

Additional Assessment Tools

•Mobility and Transfer Assessment

•Wheelchair Screen•Wheelchair Screen•Unsafe Behavior Worksheet•Living Space Inspection tool

Quality Improvement

FMP Log Those who fall Those with a history of falls Those who trigger for falls

Quality Improvement

•Process audits

•Educational tools

•Engineer Inspection Tool

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Addressing Staff Non-Adherence

• Documented staff re-education• Employee counseling • Incentive programs: falls bingo • Regular staff education programs• Regular staff education programs• Education with employee

orientation• Effective communication of

resident status changes

GOOD PROCESSES = GOOD OUTCOMES

Effective Communication

•Avoid ambiguity-the processes are not optional

•Avoid work around culture

•Avoid working in silos

Involving Residents and Families

• Identify high risk residents on admission

• Discuss with resident and family• Educate!• Get their input• Set REALISTIC goals

Risk Management

• Good care plan well executed• Involve direct care providers • Set realistic goals• Consistent use of forms• Know the high risk factors• Incorporate risk into the care plan• Make sure that practice follows

policy!

What Do Residents Want Most?

• Quality of life, not just quality of care• Staff who are respectful & well trained• Most of all: Staff who care

– “They want to help.”– “They are kind and good to me.”– “There are enough of them.”– “They are friendly and cheerful.”– “They are patient & have time for

me”.

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Why Do We Use Restraints?

Why Do We Use Alarms? Why Do We Use Antipsychotics?

• “We’ll get a deficiency for not protecting the resident”.

• “We are trying to protect the id t f f lli ”

y g president from falling”.

• “The family demands it”.

• “We have tried everything. We don’t know what else to do”.

LOOK AT ME

A Person‐Centered Approach to Reducing Restraints Among Residents

with Difficult Behaviors

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OBJECTIVES

Describe the demographics of dementia and the prevalence of difficult behaviors in nursing homes

Define a difficult behavior Define a difficult behavior

Assess and identify the root cause of difficult behaviors and restraint use

Develop a person‐center plan of care for residents with difficult behaviors

DEMENTIA

Memory

Thinkingg

Behavior

Communication

DEMOGRAPHICS

Over 5.3 million with dementia in the US

7th leading cause of death

15‐20% of all people over 65 have 5 0% of all people over 65 havedementia

50‐90% of nursing home residents living with dementia will have problem behaviors caused by cognitive impairment

RISKS

Advancing age

Heredity

F lFemale

African‐American and Hispanics

Lower educational level

ALZHEIMER’S DISEASE

www.aboutalz.org

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BROKEN BRAIN

•Ability to remember

•Ability to understand what is being said

•Ability to use words and language

•Ability to control impulses, temper and moods

DIFFICULT BEHAVIOR

Disruptive

Threat to safety and/or

well‐being of self or others

Interferes with peaceful lodging of others

Finding the root cause is critical to

the effective management of

difficult behaviors.

“ Most agitated behaviors are manifestations of unmet needs."

Cohen‐Mansfield, J. (2000) Nonpharmacological management of behavioral problems in persons with dementia: The TREA model.,

Alzheimer’s Care Quarterly; 1(4):22‐34

Physical Physical

Unmet Unmet NeedsNeeds

BEHAVIORh lh l

Life Long Habits and Life Long Habits and PersonalityPersonality

Environment

Direct Direct Effects of Effects of DementiaDementia

BEHAVIORPsychosocialPsychosocial

PHYSICAL FACTORS

Hunger

Thirst

Dehydration

Medications

Cardiovascular

Infectionehydration

Elimination

Constipation

Pain

Infection

Blood sugar

Sleep

Comfort/Security

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PSYCHOSOCIAL FACTORS

Delusions

Hallucinations

Depression

Frustration

Confusion

Depression

Loneliness

Boredom

Fear & Insecurity

ENVIRONMENTAL

Noise and alarms

Too much or too little stimulation

Lighting

Li i d d Limited exposure to outdoors

Unfamiliar surroundings

Inconsistent caregivers

Confusing routines

Caregiver approach!

THREE TYPES

Aggressive behaviors ‐ hitting, kicking, pushing, scratching, tearing things, biting, spitting, cursing, or verbal aggression

Physically non‐aggressive behaviors ‐ pacing, inappropriate dressing and undressing, trying to get to a different place, handling things inappropriately, general restlessness, and repetitious mannerisms.

Verbal and vocal agitated behaviors ‐ complaining,

constant requests for attention, negativism, repetitious sentences or questions, and screaming.

Aggressive Correlates with

Medical Psychosocial

Male, cognitive impairmentPoor quality of social relationships and sleep problems

Environmental Appears to be a response to an intrusion of personal space, as in social situations, or when resident is in close contact with another person, as during bathing, and when person is cold.

PhysicallyNon‐Aggressive

Correlates with

Medical Psychosocial

Cognitive impairment, moderate to high ADL impairment, relatively good health, sleep problems, and past stress.

Wandering and pacing: resident in Environmental corridor and near nurses' station,

normal conditions of light, noise and temperature (suggesting that these behaviors are self‐stimulation activity and not responses to environmentally induced discomfort).

Verbally agitated Correlates with

Medical and psychosocial

Environmental

Females, depression, poor health, pain, relatively cognitively intact, poor quality of social relationships, and sleep problems.

When residents are alone, or physically restrained, in the evening, or during ADLs, especially toileting and bathing (suggesting that these behaviors are associated with discomfort, pain or unmet social needs).

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ABOUT YOU MDS 3.0

Section C Cognitive Function

Section D Mood

Section E BehaviorSection E Behavior

Section F Preferences

Section J Pain

CAA: COGNITIVE LOSS DEMENTIA UNDERSTANDING THE BEHAVIOR

Where does it happen?

When does it happen?

Who is involved?

How does it start?

How does it stop?

What is said or done in response to the behavior?

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STEPS‐ DEVELOPING CP INTERVENTIONS

1. Start by knowing the resident

2. Consistent assignment

3. Next consider physical causes ‐ thirst, h b th i lhunger, bathroom, pain, sleep

4. Eliminate environmental triggers

5. Minimize environmental change

6. Provide daily routine and structure (minimize change)

INTERVENTIONS: GENERAL GUIDELINES

Distraction through meaningful activities

Control amount of stimulation

Access to outdoors importantp

Not every intervention works with every resident

Not every intervention works every time

Be flexible

CALMING INTERVENTIONS

Walking outdoors

Sunshine

Gardeningg

Aquarium

Warm lighting

Water features

Therapeutic touch and gentle massage

SENSORY ENHANCEMENTS

Music appropriate to preference and behavioral tendency

Sing‐a‐longs

IPod Project www.musicandmemory.org

Aroma therapy

Warm lighting

No overhead paging or alarms

Therapeutic sounds

CREATIVE AND COGNITIVE ENHANCEMENTSArt

Memories in the Making www.alz.org

Gardening

Storytelling

Timeslipswww.timeslips.org

www.cognitive dynamics.org

Daniel Potts MD

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The EDGE ProjectElectronic Dementia Guide for

ExcellenceExcellencewww.health.ny.gov/diseases/

conditions/dementia/edge/

“It takes TWO to tango or tangle!” Teepa Snow

COMMUNICATION

Visual

Auditory

Tactile‐Touch

COMMUNICATION

Friendly and kind‐ not bossy or critical

Don’t argue

Simple, brief and 2‐3 word instructions

Use preferred name Use preferred name

Use familiar terms and phrases

Use visual cues, gestures and demonstrations

Consider visual and auditory impairments

Use assistive devices if available

THE TOUCH OF GOD’S LOVE

Handshakes, hugs and hand‐holding

Touch for attention during taskstasks

Tactile guidance

Hand under hand assistance

BATHING WITH A BATTLE

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LET’S GO TO THE BATHROOM

Stand up

Turn

Walk

Sit

I will wait for you to finish

dTurn

I’m going to help you with your slacks

Stand

I’m going to help you with your slacks….etc

Look beyond my

behavior…

Look at me.

Liz Prosch

AQAF

Two Perimeter Park South

SSuite 200

Birmingham, AL 35243

[email protected]

This material was prepared by AQAF, Alabama’s Medicare Quality

Improvement Organization, under t t ith th C t f M di & contract with the Centers for Medicare &

Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

Services. Contents do not necessarily reflect CMS policy. 10SOW-AL-C7-12-39.

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person centered care falls restraints FINAL - ANHA