Qualilty Improvement for Senior Living Communities
GuideOne Risk Resources for Health Care
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W. Des Moines, IA 50265-3538



Are Your Resident Fall Policies and Procedures Enough?

Ask any carrier that provides general and professional liability insurance for nursing homes what drives their claims and they will likely tell you that it's resident falls, both in frequency and severity. Sadly, that answer should not be too surprising, considering the number of falls that occur. According to data from the Centers for Disease Control and Prevention (CDC):

  • Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported.
  • Between half and three-quarters of nursing home residents fall each year twice the rate of falls for older adults living in the community.
  • Residents often fall more than once, with an average of 2.6 falls per person per year.
  • About 35 percent of fall injuries occur among residents who cannot walk.

People in nursing homes are generally frailer than older adults living in the community. They are usually older, have more chronic conditions and have more difficulty walking. They also tend to have thought or memory problems, have difficulty with activities of daily living, and need help getting around or taking care of themselves. All of these factors are linked to falling.

In order to help reduce the frequency and severities of resident falls, providers should periodically take a good look at their policies and procedures to ensure they are doing everything they can to minimize occurrences of resident falls in their building.

  1. Risk Assessments

A fall risk assessment should be completed within 24 hours of admit as well as, quarterly, with any significant change, and after any fall.

Intrinsic and extrinsic risk factors will be involved and are described as follows:

Intrinsic Risk Factors include:

  • Cardiovascular problems (e.g. dysrhythmia, hypotension, etc.);
  • Neurological problems (e.g. cardiovascular accident, Parkinson's disease, seizure disorder, etc.);
  • Orthopedic problems (e.g. arthritis, status-post hip fracture, osteoporosis, osteomalacia, etc.);
  • Sensory or perceptual deficits that include age-related vision or hearing changes, dizziness, vertigo, etc.;
  • Normal aging changes in gait due to loss of muscle mass and strength, including decreased limb coordination and ability to raise feet very high;
  • Psychological and cognitive factors, such as depression, apathy, delirium, Alzheimer's disease or other dementia;
  • Medications, such as analgesics, anti-convulsants, anti-depressants, anti-hypertensives, sedatives, anti-anxiety, anti-psychotics, etc.; and
  • Pain, fear of falling, sleep disorders and incontinence.

Extrinsic Risk Factors – Observe how the resident:

  • Transfers to and from bed or chairs;
  • Ambulates;
  • Uses the bathroom handrails; and
  • Uses assistive devices, such as walkers or canes.
  1. Interventions

After the resident has been carefully assessed, interventions should be implemented that are individualized, according to the resident's needs. Interventions can include:

  • Provide a bowel and bladder program. Cue or assist the resident to the bathroom every two hours and before/after activities and meals.
  • Review medications. The resident's physician or pharmacist should evaluate if any medications that are associated with falls can be eliminated, reduced or given at a more opportune time. He/she also should check for any overlapping drug therapy, synergistic reactions or need for routine orthostatic hypotension monitoring.
  • Evaluate for acute illnesses. Urinary tract infection, hypoxia, transient ischemic attacks, etc.
  • Evaluate assistive devices. All walkers, canes, wheelchairs and other devices should be evaluated to ensure they are the appropriate type, height and weight. The resident also should be evaluated to ensure they know how to use the devices and they have the cognitive ability to correctly use them.
  • Adjust environmental risk factors. Check the resident's footwear, keep pathways clear of clutter, lock brakes on beds/wheelchairs before transferring a resident and make sure the toilet seat is low/high enough.
  • Provide adequate nutrition, hydration and supplements throughout the day as needed.
  • Provide meaningful activities. Work with the Activities Department to find what interests the resident and keep these items accessible near the nurse's station or in the room.
  • Provide restorative care programs for walking, exercising and strengthening. Keep the resident properly positioned in their bed, chair and wheelchair.
  • Utilize gait belts. These can be used while assisting residents with ambulation and transfers to minimize injuries if a resident begins to fall. Mechanical lifts should be used with residents who require extensive assistance. In-service training for staff should be provided that includes return demonstrations.
  • Consult therapies. A physical or occupational therapist may need to evaluate the resident and make recommendations regarding positioning devices, restorative programs or appropriateness for restraint usage (e.g. wedge cushions, etc.).
  • Answer call lights/alarms promptly. Always keep call lights within reach of the resident when in the room.
  • Provide added supervision, as able. Seat the resident near the nurse's station during the day and encourage socialization, as able. Alert staff to never leave the resident unsupervised when out of bed. Move the resident's room closer to the nurse's station, as able.
  • Use personal alarms attached to the resident's bed and wheelchair. If these are ineffective or the resident removes them, use motion sensor alarms.
  • Use plastic grips to assist the resident from sliding forward while in a wheelchair.
  • Place tennis ball-type devices on the legs of the walker to facilitate more of a gliding movement rather than a jerking movement.
  • Provide protective wear, such as elbow or knee pads, Geri-hips, etc.
  • Consider a Merry Walker to allow more independence.
  1. Communication

Once a resident has been identified as being at risk for falling and interventions have been implemented to minimize the risk, everything needs to be documented in the resident's chart and communicated to everyone involved with the resident's care, beginning with:

  • The resident's care plan – This should list all interventions that are used to minimize the potential for a fall. The interdisciplinary team, physician, pharmacist, therapists and responsible party or power of attorney for health care decisions need to be involved with the process.
  • Assignment sheets – All direct-care staff need to know which residents are at risk for falling and what interventions are needed to prevent an occurrence. A written assignment sheet may be helpful if the facility experiences a significant turnover in staff and agency help is used. Be careful to update sheets promptly when needed.
  • In-service training – Provide periodic training for nursing and direct-care staff regarding your fall prevention program. Include discussions on various medications, diseases and disorders associated with falls.
  1. Quality Assurance Auditing

Develop a safety committee composed of members from administration, nursing, environmental services and other pertinent parties. They should conduct regular environmental tours to identify hazards, check equipment and review incident reports as indicated, and recommend plans for improvement.

Source: Centers for Medicare and Medicaid: Appendix PP – Guidance to Surveyors for Long Term Care Facilities: F323 Accidents.

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