Center for Nursing and Rehabilitation

1. Center for Nursing and Rehabilitation Enhancing Resident Safety via a Fall Reduction Initiative Speakers: Dr. Saka Kazeem, MD, CMD Dr. Phyllis Quinlan, RN-Bc, PhD

2. SPEAKER DISCLOSURE None of the speakers for the Center of Nursing & Rehabilitation have any relevant financial relationship with any vendors of products or programs mentioned in this presentation.

3. OBJECTIVES At the end of the presentation the participants will be able to: Outline an approach for reviewing a Facility’s current Fall Management Program so as to identify opportunities for improvement Identify two approaches to reducing falls in the subacute resident population Identify 3 approaches to reducing falls in the cognitively challenged resident population Explain the value of an Interdisciplinary approach to resident safety

4. Introduction The Center for Nursing & Rehabilitation, located in the Prospect Heights section of Brooklyn, New York, is a 320 bed not-for-profit facility and a member of the Center Light Health System. The Facility has a dedicated 40 bed CARF accredited Subacute Care Unit, 40 beds allocated for medically complex residents and the remaining 240 beds serve the needs of resident with a variety of physical co-morbidities and cognitive challenges.

5. Background Data: October 1 through December 31, 2010 Total of 73 falls • 66 = un-witnessed • 6 = witnessed • 1 = lowering the resident to the floor • Time of peak incident was 7:00pm and 9:00pm (38) • Peak location as the resident’s room • 25 falls occurred on the subacute rehabilitation unit • 9 on the medically complex unit • Remainder occurred on those units with cognitive challenges residents

6. Background A Fall Management Program was in existence • Screening tool • Supporting policy and procedure • Availability of low beds • Floor mattresses • Bed/chair alarms • Four (4) residents had least restrictive restraints Objective Improve resident safety and quality of care by reducing the incident of resident falls by 25% over the calendar year October 2010 through October 2011

7. Background Reviewed current assessment tools, policy/procedures, internal occurrence investigation tool & methods used for investigating fall events. Goal = Ensure current practice is comprehensive, aligns with a best practice approach and is in compliance with the LTC Code of Federal Regulations for Accidents & Restraints . Fall Risk Screen/Assessment Tool risk screening elements were adequate for determining a risk for falling; however the tool did not quantify the risk with a numerical value such as, less than 4 = low risk; greater than 10 = high risk The tool revised to include an assigned numerical value that would highlight the severity of the resident’s risk and drive critical thinking and the need for immediate action. Once the resident was screened to be at risk for a fall, the tool/procedure did not lead the nurse to interventions to facilitate quick and easy initiation of a fall management plan of care. 26 Nursing Interventions for Fall Management and 15 Nursing Interventions for Safe Resident Transfer developed by the Interdisciplinary Team and added to the back of the tool as an immediate resource and for user convenience. The policy/ procedure for Fall Management updated to include these management approaches. Ten Steps to Follow when a resident experiences a fall were also added to the procedure to standardized the staff’s response to a fall event.

8. Cycle One Falls in the subacute care unit were linked to rehab residents resisting need to call for assistance when they needed to use the toilet. Black toilet seats were installed in the unit as an out-of-the-box-approach to reducing the risk of falls in the bathrooms. Goal = enhance the depth perception for resident by providing visual contrast between the white toilet fixture and the neutral bathroom flooring. The staff in-serviced in concepts of falls management and trained in revised documentation tools, policy and procedures A review of the internal occurrence investigation tool and methods used for investigating fall events did not reveal a need to modify current practice

9. Cycle Two Data: January through March 31, 2011 • Total of 76 falls • 73 = unwitnessed • 2 = witnessed • 1 = lowering the resident to the floor • Peak incident = hours of 7:00pm and 9:00pm • Peak location as the resident’s room =40 • 13 falls occurred on the subacute rehabilitation unit • The remainder occurred on those units with cognitive challenged residents The Facility was improving its fall management with subacute rehabilitation patients but the challenge of addressing this safety issue effectively in the cognitively challenged residents went largely unanswered

10. Cycle Three A back to basics approach to fall management in the cognitively challenged resident was adopted: Toileting patterns were reassessed and revised An overlay mattress with built-in side guards was trialed with success in managing those residents compelled to try to get out of bed unassisted Overlay mattress was not a restraint, had an exit Signaled bed boundaries & slowed ability to get OOB & offered additional time to respond to bed alarms Overlay mattress adopted throughout Facility as need identified Residents were re-evaluated for restorative rehabilitation Requisitions focused on need for evaluation of physical functional deficits, balance and transfer abilities; with emphasis on bed to wheelchair and toilet transfer skills

11. Cycle Three Review of several cognitively challenged residents who had a history of falls raised a question about adequate pain management in those residents with behavioral components to their presentation The Facility’s pain assessment tool and procedure were reviewed and revised to include the PainAD (advanced dementia) pain scale. Each cognitively challenged resident’s was then reassessed for pain using the PainAD scale Pain management in this population was enhanced and, in several cases, the use of psychotropic medications was reduced or discontinued The staff of the Therapeutic Recreation Team was challenged with enhancing the programs offered to this population during the peak fall event hour of 7:00pm to 9:00pm Resident care plans were revised to include all revised interventions

12. Cycle Four Data: April 1 through June 30, 2011 Total 48 falls • 45 = unwitnessed • 3 = witnessed • Peak incident was hours of 7:00pm and 9:00pm • Peak location was the resident’s room = 14 Clearly success had been achieved in managing fall events in the cognitively challenged resident Challenge = sustain this achievement

13. Cycle Five Data: July 1 through September 30, 2011 Total of 34 falls • 32 = unwitnessed • 2 = witnessed • Peak incident shifted to the day shift (28) with the peak location remaining as the resident’s room • 6 occurred on the subacute rehabilitation unit & remainder occurring on units with cognitively challenged residents 5 residents had least restrictive restrains in place to manage the resident’s inability to recognize their safety needs. Every effort was made to ensure that the key elements of these approaches to fall management were maintained as the Facility transitioned into using an electronic medical record 

14. Cycle Five

15. Feasibility The feasibility of this Initiative was high. It required an interdisciplinary review of the Facility’s current practice in managing resident falls and collaborative thinking.

16. GENERALIZABILITY: The approaches outlined in this Initiative can easily be implemented by any other Long Term Care facility Review of current risk screening/assessment tool Revise policy/procedure to align with identified revisions Review current internal investigation tools and methods In-service the staff in fall management concepts and revised approaches Review new products available to maintain resident safety that can best address your facility’s identified areas of need. Review the resident’s toileting patterns and revise as necessary Age-related depth perceptions changes can be a factor in maintaining safety Review pain management assessment approaches in those residents with cognitive challenges and identified behavioral issues to ensure that pain is not misaddressed as an ongoing behavioral issue Therapeutic Recreation team is a vital component in addressing resident safety during off hours Review policies and procedures addressing restraints to ensure best practice and compliance Share the results of your efforts Celebrate your success!!

17. Outcomes Our objective was to decrease resident falls by 25% over the calendar year October 2010 through October 2011.. Peak fall incidents 76 occurred during January 1, through March 31, 2011. By June 30, 2011, the quarterly incident of falls was reduced to 48. This equates to a 37% rate reduction. By September 30, 2011 the quarterly incident of falls was reduced to 36. This achievement equates to a 53 % reduction.

18. Outcomes The Center for Nursing and Rehabilitation employs the Resident Centered Approach as its care delivery model The staff had a high sense of commitment to maintaining resident safety by decreasing the rate of resident fall occurrence as demonstrated by our outstanding outcomes Conventional and creative approaches were utilized by the Interdisciplinary Team The cost of the black toilet seat was $29.45 per seat. Eighteen (18) seats were changed for a total cost of $530.10. The cost of the overlay mattress was $234.99. A total of 76 mattresses were ordered from the end of 2010 through September 30, 2011 for a total cost over 10 months of $17,859.24. These purchases did not present any additional cost to the Facility. Administration collaborated with Nursing and Housekeeping to reallocate existing identified monies to allow for the purchase of adequate numbers of black toilet seats and overlay mattresses to address resident needs

19. The impact on the quality of care and service at CNR was improved as outlined in the following: Staff knowledge base and skills were enhanced on the subject of fall management and restraints. Staff knowledge base and skills were enhanced in the area of pain assessment in residents with cognitive challenges and behavioral management issues. User friendly screen/assessment tools were developed. The concept of an Interdisciplinary approach to Resident Centered Care was anchored. There was a 53% reduction in the quarterly number of falls over a one year period. Pain management for all residents was enhanced. (CFR 483.20) There were no citations for resident safety in the 2011 Annual State Survey Satisfaction surveys demonstrated a resident/family satisfaction rate over 90%.

20. References 1. AMDA Clinical Practice Guideline, 1998 (revised 2003). Falls and Fall Risk. Available at: http:// www.amda.com. 2. Bonner, A. RN, GNP, FAANP. (2006). Falling into Place: A Practical Approach to Interdisciplinary Education on Falls Prevention in Long-Term Care. Annals of Long Term Care. Volume 14, Number 6. An online article retrieved from Google on the World Wide Web http://www.annalsoflongtermcare.com/attachments/5778. 3. Burland, E. (2008). Improving Care at the Front Lines: An Evaluation of a Fall Management Program in a Personal Care Home Population. An online article retrieved from Google on the World Wide Web http://www.longwoods.com/content/19663 4. Feinsod, F. MD, Capezuti, E. PhD, RN, & Felix, V. BS, PT. (2008). Reducing Fall Risk in Long-Term Care Residents Through the Interdisciplinary Approach. An online article retrieved from Google on the World Wide Web http://www.annalsoflongtermcare.com/article/4365 5. Herr, K. PhD, RN, FAAN, Bjoro, K. RN, PhDc, Decker, S. PhD, APRN-BC. (2006). Tools for Assessment of Pain in Nonverbal Older Adults with Dementia: A State-of-the-Science Review. Journal of Pain and Symptom Management; Volume31, Issue 2. An online article retrieved from Google on the World Wide Webhttp://www.sciencedirect.com/science/article/pii/S0885392405006111 6. Warden, V. RN, Hurley, A, RN, DNSc, FAAN, Volicer, L MD, PhD, FAAN. (2003). Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of American Medical Directors Association; Volume 4, Issue 1. An online article retrieved from Google on the World Wide Web http://www.sciencedirect.com/science/article/pii/S1525861004702583