Fall Management and Restraint Reduction in Long Term Care

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Definition of a Fall. Unintentional coming to rest on the floor, ground or other lower levelOr 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 chronic disabilities and potentially is preventable if the causative factors are recognized in individual patients (Tinetti, 1986).

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Fall Management and Restraint Reduction in Long Term Care

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1. Fall Management and Restraint Reduction in Long Term Care Alice Bonner, APRN-BC, GNP, FAANP Director of Clinical Quality Massachusetts Extended Care Federation [email protected] 45 minutes to review all the literature on falls in ltc won’t plan on all the slides - just want to hit the highlights dovetails with other presentations at symposium time for Q&A will highlight best references along the way can’t read all charts - can get for you45 minutes to review all the literature on falls in ltc won’t plan on all the slides - just want to hit the highlights dovetails with other presentations at symposium time for Q&A will highlight best references along the way can’t read all charts - can get for you

2. 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

3. But Beyond that Definition… Falling is a clinical entity in its own right, most commonly due to the accumulated effect of multiple chronic disabilities and potentially is preventable if the causative factors are recognized in individual patients (Tinetti, 1986) This is true for both community dwelling and long term care patients, though it may be harder to prevent falls in nh patients for a variety of reasons more total risk factors fewer remediable risk factors (envirnomental factors) alone harder to isolate and identify which factors are most likely responsible for falls in each patient staffing issues environmental issues may be harder to control Still, the literatrue suggests that there are effective strategies for falls preventionThis is true for both community dwelling and long term care patients, though it may be harder to prevent falls in nh patients for a variety of reasons more total risk factors fewer remediable risk factors (envirnomental factors) alone harder to isolate and identify which factors are most likely responsible for falls in each patient staffing issues environmental issues may be harder to control Still, the literatrue suggests that there are effective strategies for falls prevention

4. One Problem with Falls is “under-reporting,” some of which may come from failure to recognize when a fall has actually occurred. Test your knowledge with the following questions from the Centers for Medicare and Medicaid Services (CMS)…

5. Definition of a Fall CMS RAI Version 2.0 Q & A’S March 2001 Question 2-22: Should the following situations be recorded as “falls” in items J4 “Fell in the past 30 days” or J5 “fell in the past 31-180 days”? In march 2001 HCFA further defined it’s definition of a fall in it’ Q&A section of their web page. It is now reflected in the “ CMS revised Long Term Care Assessment Users Manual, December 2002 edition”In march 2001 HCFA further defined it’s definition of a fall in it’ Q&A section of their web page. It is now reflected in the “ CMS revised Long Term Care Assessment Users Manual, December 2002 edition”

6. (Question 2-22 continued) a) resident lost their balance, and was lowered to the floor by staff. b) resident fell to the floor, but there was no injury. c) resident was found on the floor, but the means by which he/she got to the floor was unwitnessed. d) resident rolled off a mattress that was on the floor. Here are the answers…

7. CMS’s Answer: All of those scenarios should be reported as a fall… a) resident lost their balance, and was lowered to the floor by staff. This is the area that was unclear to the falls team at the Masonic Home prior to the clarification. They were not counting “lowered to the floor” as a fall.a) resident lost their balance, and was lowered to the floor by staff. This is the area that was unclear to the falls team at the Masonic Home prior to the clarification. They were not counting “lowered to the floor” as a fall.

8. From A Program Perspective... Do you have corporate/executive/administrator support for a falls prevention program? Has your organization looked at what is in place right now, and where the gaps are in falls prevention in your building? Are there policies in place for fall risk assessment? Is all staff aware of the policies? Are the policies followed?

9. From A Program Perspective... Are residents assessed immediately (on, or even prior to, admission), and reassessed when indicated? Are you using a standardized fall risk assessment tool? Is the risk assessment reflected in the care plan? Do you know how the risk assessment is communicated to direct care staff? Is someone on staff accountable for collecting data and monitoring systems?

10. Case Study Friday night was busy. There were four new admissions to the subacute unit. One of the new admissions was an 84 year old man, s/p CVA; history of DM, CHF, COPD, Dementia. The nurse did not have time to complete all of the assessments on her 3-11 shift. The falls assessment was only partially done. One of the nurses wanted to restrain the resident because “we just don’t have the staff to watch him and he’s unsafe.”

11. Case Study What is the most important individual action that the nurse on the next shift can take? What is the most important aspect of the nursing home’s policy to insure that this situation does not result in resident injury? How can nursing leadership and administration insure that problems come to their attention so that they can be addressed? Would you physically restrain this resident? Why or why not?

12. Now let’s look at some statistics that can help you convince other staff, residents and families why falls prevention is so important

13. Some Statistics 35-40% of community-dwelling, generally healthy adults over age 65 fall annually Rates are higher after age 75 In nursing homes and hospitals, rates are almost three times higher (1.5 falls per bed) 50% of fallers do so repeatedly Incidence in nursing home population 16-75% depending on the studies. Wide variationIncidence in nursing home population 16-75% depending on the studies. Wide variation

14. 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 hip fractures in the over 65 population In nursing homes, 10-25% of falls result in fracture, laceration, or hospitalization 20% of fatal falls occur in the 5% of elders living in nursing homes falls account for roughly 2/3rds of the liability/litigation in nursing homes20% of fatal falls occur in the 5% of elders living in nursing homes falls account for roughly 2/3rds of the liability/litigation in nursing homes

15. 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 billion dollars/year in acute care and institutionalization 40% of nursing home admissions are at least in part related to falls

16. Fall prevention is a priority for nursing home residents. Why is the identification of risk factors important in this effort?

17. Risk Factors for Falls in Nursing Home Residents In studies on nursing home residents, the risk factors most commonly associated with falls were: Muscle weakness History of falls Gait or balance deficit Use of assistive devices Visual deficit

18. Risk Factors for Falls in Nursing Home Residents Additional risk factors for falls in nursing home residents were: Arthritis Impaired ADL Depression Cognitive impairment Age over 80 years

19. In addition to looking at overall risk factors, it is also useful to break down risk factors into intrinsic and extrinsic components

20. Intrinsic and Extrinsic Risk Factors Intrinsic factors (physiological changes with age, disease processes, iatrogenesis, medications or a combination) Extrinsic factors (types of activity, hazards and demands of the environment) At least 50% of falls are multifactorial As we said, researchers moving away from “causes” and into risk factor identification. Studies have shown that comprehensive risk factor identification with individualized strategies for prevention for specific high risk patients in long termcare may be able to reduce injurious falls. Physiologic changes – reduced baroreceptor function, reduced elasticity & flexibility; Iatrogenics-tying down,weak from deconditioning Need more randomized controlled trials to substantiate earlier studies (Ray, Rubenstein)As we said, researchers moving away from “causes” and into risk factor identification. Studies have shown that comprehensive risk factor identification with individualized strategies for prevention for specific high risk patients in long termcare may be able to reduce injurious falls. Physiologic changes – reduced baroreceptor function, reduced elasticity & flexibility; Iatrogenics-tying down,weak from deconditioning Need more randomized controlled trials to substantiate earlier studies (Ray, Rubenstein)

21. Potential Intrinsic Risk Factors Disorders of gait and/or balance Most common predictors of balance problems difficulty rising from a chair and sitting down instability on first standing staggering on turning short, discontinuous steps step to step variability

22. Potential Intrinsic Risk Factors Knee, hip, foot deformities and/or associated pain; arthritis, myopathy Sensory impairment (decreased vision, hearing) Neuromuscular diseases (CVA, dementia, Parkinson’s) Cognitive impairment (poor judgment, safety awareness) doubles the risk of falls in some studies Vision: Recent studies suggest an urgent need for further research dollars on this - may be a bigger factor than we thought. 2001 JAGS Lord, Tinetti editorial Mention falls prevention legislation mculsky Need to know when to recommend cataract surger when to recommend avoidance of multifocal glasses with ambulation etc.Vision: Recent studies suggest an urgent need for further research dollars on this - may be a bigger factor than we thought. 2001 JAGS Lord, Tinetti editorial Mention falls prevention legislation mculsky Need to know when to recommend cataract surger when to recommend avoidance of multifocal glasses with ambulation etc.

23. Potential Intrinsic Risk Factors Peripheral neuropathy Orthostatic hypotension Postprandial hypotension (Aranow 1997) Total number of chronic diseases/conditions Total number of medications (>3 or 4) types of medications (class IA antiarrhythmics, digoxin, diuretics; psychoactive medications, anticholinergics). Alcohol use (Leipzig, JAGS, January, 1999) Most important is total number of medications=polypharmacy. Types of medications here have all been studied. Leipzig metaanalysis suggested: Strongest correlation is for psychoactive meds, which include sedatives, hypnotics, antidepressants, antipsychotics and benzodiazepines In terms of cardiac meds, strongest association is for class I antiarrhythmics and digoxin, diuretics. (CHANGE YOUR HANDOUT - should not say antihypertensives) Doesn’t mean you shouldn’t consider narcotics, antihypertensives and other medications as potentially increasing fall risk - just may not have been identified as unique risk factors Most important is total number of medications=polypharmacy. Types of medications here have all been studied. Leipzig metaanalysis suggested: Strongest correlation is for psychoactive meds, which include sedatives, hypnotics, antidepressants, antipsychotics and benzodiazepines In terms of cardiac meds, strongest association is for class I antiarrhythmics and digoxin, diuretics. (CHANGE YOUR HANDOUT - should not say antihypertensives) Doesn’t mean you shouldn’t consider narcotics, antihypertensives and other medications as potentially increasing fall risk - just may not have been identified as unique risk factors

24. Potential Intrinsic Risk Factors Syncope/dysrhythmias Fear of falling Dizziness Incontinence Depression Generalized weakness, deconditioning Any acute illness; often infection, delirium, dehydration. Some recent studies/programs tying together multiple geriatric syndromes and approaching prevention more comprehensively. In JAMDA (?), Jack Schnelle and colleagues tried an exercise program to improve continence and strengthen LE s at the same time - combine strategies to address two geriatric syndromes. Promising but costly approachSome recent studies/programs tying together multiple geriatric syndromes and approaching prevention more comprehensively. In JAMDA (?), Jack Schnelle and colleagues tried an exercise program to improve continence and strengthen LE s at the same time - combine strategies to address two geriatric syndromes. Promising but costly approach

25. Potential 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 Assistive device probably reflective of muscle weakness and/or gait/balance disorder ADLS possibly same +/- cognitive impairmentAssistive device probably reflective of muscle weakness and/or gait/balance disorder ADLS possibly same +/- cognitive impairment

26. Potential Extrinsic Risk Factors Lack of, inappropriate or ill-fitting footwear fit heel height and width type of sole Low heel, firm sole (Tinetti, 2003) collar height High collar increases balance (Lord, 1999) 2004 and 2005 studies confirm earlier results Risk is highest is for patients who wear NO footwear Big area for potential researchBig area for potential research

27. Potential Extrinsic Risk Factors Lack of, 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 station Type of setting not appropriate or cannot meet needs for adequate assessment and supervision of a particular resident (e.g., subacute caregivers not trained in how to redirect or intervene with dementia residents) Addressed in the comprehensive risk assessment and prevention studies (?) by Ray 1997 and Rubenstein (1990) Ray targeted environmental and personal safety, wheelchairs, psychotropic drugs and transferring and ambulation No good studies evaluating programs to reduce risk of falls in hospitalized patientsAddressed in the comprehensive risk assessment and prevention studies (?) by Ray 1997 and Rubenstein (1990) Ray targeted environmental and personal safety, wheelchairs, psychotropic drugs and transferring and ambulation No good studies evaluating programs to reduce risk of falls in hospitalized patients

28. Potential Extrinsic Risk Factors Adaptive equipment lacking or used inappropriately (e.g., walker too low) Lack of restorative program; lack of exercise and routine ambulation to maintain function Use of restraints (physical, chemical) resulting in decreased activity, deconditioning (Dimant, 2003) Lack of Restorative program Resnick Caring for the AgesLack of Restorative program Resnick Caring for the Ages

29. What makes staff think about using restraints? Fear of being cited by surveyors for failure to “protect” resident from harm/falls They think they will work to protect the resident from harm They think it is better than not using them They think it might prevent other problems (wandering, residents getting into altercations) They think it will help them to better care for other residents Lack of Restorative program Resnick Caring for the AgesLack of Restorative program Resnick Caring for the Ages

30. What should staff be thinking about? Root cause – why was the resident trying to get up, walk, lean over, engage in an activity – in the first place???? What kinds of behaviors did they engage in prior to coming to the nursing home? Any patterns? What pushes their buttons? What makes them tick? Have we gotten all the possible information from family or other informants? Lack of Restorative program Resnick Caring for the AgesLack of Restorative program Resnick Caring for the Ages

31. What is a root cause analysis?

34. Guidance to Surveyors on Restraint Use May not be used for discipline or convenience A device may constitute a restraint for one resident and not for another May be used in medical or psychiatric urgent/emergent situations (short-term) Full explanation to resident/family on risks and benefits of restraints Facility may not use restraints just because health care proxy or guardian requests it, or because physician writes an order

35. Guidance to Surveyors on Restraint Use Least restrictive form of restraint must be used Other alternatives that were tried and the outcomes must be documented, sometimes multiple times. There is no magic answer on this question, nor is there consensus or best practice or guideline, except to individualize to each resident Systematic plan for care planning and evaluation of restraints, including restraint reduction plan must be documented in policies and procedures (facility-wide) and in individual care plans (see www.medqic.org for some ideas)

36. Federal F tags on Restraint Use Ftag: “Each resident will receive, and the facility provide, the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care” Ftag: “The facility must ensure that the resident environment remains as free of accident hazards as is possible and each resident receive adequate supervision and assistive devices to prevent accidents”

37. Another Case Study Mrs. Lopez is an 89 year old resident of a special care (dementia) unit. She has Lewy body dementia, CHF, COPD, DJD, GERD. Prominent features of her dementia are psychomotor agitation, unsteadiness and stiffness. She repeatedly self-rises, has no safety awareness, does not remember any attempts to redirect her. She has had 9 falls in the past month, mostly in self-attempted transfers.

38. Another Case Study On 3-11 on Friday night, Mrs. Lopez is found on the floor in her room, next to her bed. The nurse finds her while conducting her med pass. The nurse establishes that the resident has no injuries and proceeds to complete a post-fall assessment form. How should the nurse begin a root cause analysis on this case?

39. Another Case Study How would you care plan for falls in this resident? Who should be at the table? If this resident has had 10 falls now, should she be restrained? Why? Is there any evidence that restraining her will make her safer? How will you make this decision? Would you use alarms on this resident? What interventions would you use in the care plan? Do you think some falls are not “avoidable?”

40. Environmental Factors Associated with Falling Dim lighting Poor or weak seating Glare Use of full-length side rails Uneven flooring Bed height Loose carpet or throw rugs Inadequate assistive devices -AMDA Clinical Practice Guideline Falls and Fall Risk, 2003 Wet or slippery floor Inappropriate footwear Lack of safety railings in room or hallway Malfunctioning emergency call systems Lack of grab bars in bathrooms Poorly fitting or incorrect eye wear Poorly positioned storage areas

41. Self-determination, freedom and safety The resident wants their fuzzy slippers, even though they have fallen 3 times in them because they do not fit correctly. Her favorite niece gave them to her. The resident is only mildly demented, but does not clearly understand the risk of a hip fracture and what the consequences might be What should the facility do?????

42. From A Program Perspective... Is equipment available, even on the off shifts? Is it well maintained? Are forms for documenting fall risk and interventions available? Does every staff member feel accountable for preventing falls? Is there a culture of safety and not of blame, so that people feel comfortable reporting falls and fall related problems? Is there a champion and a falls prevention team?

43. From A Program Perspective... Are CNAs involved? Do they have CNA care plans or fall assessment tools for ADL safety? Quick Tips Badge Is feedback provided on successful strategies? Hospitality Aids (Rhode Island) Is data shared with staff? (post in shower room!) When the CNAs reassess residents if the resident’s status/condition changes, how is this communicated to the nurse and provider (NP/MD), and CNAs on the next shift? Regular (weekly) review of all high risk residents for potential changes Do nurses listen attentively to CNAs? Do all providers read each others’ notes or share information with other departments?

44. From A Program Perspective... Are non-nursing staff involved? Are non-nursing staff encouraged to prevent falls and communicate risks? Are non-nursing staff valued for what they bring to fall prevention? Do people work in silos, or do they collaborate and communicate openly? “Adopt-a-resident” program facility-wide

45. What might surveyors be looking for in fall prevention care plan? Is the plan individualized? Does it make sense for that resident? Is it realistic? Don’t say “q15 minute checks” if you don’t have the staff to do it! Be careful about how specific you make your care plan – if it is written in the care plan, it must be done

46. What might surveyors be looking for in fall prevention care plan? Words or phrases to watch out for: “resident will be supervised at all times” “monitor resident for falls” What does that mean? How often? By whom? Better choice: just list specifically the things that you WILL do (toileting every 2 hours, provide drink and snack in between meals, ambulate resident between meals/care, etc.)

47. What might surveyors be looking for in fall prevention care plan? Is the care plan communicated to frontline staff? Is it simply on paper, or is it really being communicated and being done consistently? What happens if someone unfamiliar with the resident has to care for that resident for one shift? What is the back up system or safety net to communicate what that resident needs during that shift?

48. What might surveyors be looking for in fall prevention care plan? Are all departments involved? Is the family involved? Are staff reading each others’ notes and sharing information? Is there detailed documentation of what was discussed with resident and/or family and is this revised as needed?

49. Comprehensive Risk Assessment Targeted Interventions Individualized Plan of Care

50. Comprehensive Risk Assessment Includes A complete falls history any recent falls; whether any associated injury, fracture, etc. estimate of frequency of falls qualitative information from patient/family/caregivers on nature of falls, any identifiable patterns or triggers (location, time of day, activity) follow up before the trail is cold

51. Comprehensive Risk Assessment Includes Identification of all potential intrinsic and extrinsic risk factors Screening tool for New admission Post-fall assessment form (beyond the incident report) Tools that can help history taking As Medical Director, may want to provide helpful tools to promote comprehensive risk factor identification by other PCPs in the facility If the person has had falls in the SNF or has had new risk factors identified, want to pass on to the PCP and HHA for follow upTools that can help history taking As Medical Director, may want to provide helpful tools to promote comprehensive risk factor identification by other PCPs in the facility If the person has had falls in the SNF or has had new risk factors identified, want to pass on to the PCP and HHA for follow up

52. Post Fall Review Process Immediate Investigation Root Cause Analysis Falls Committee System of Communication Medical Assessments/Rehabilitation Screens Care Plan Modification Implement Changes Follow Up PCP notified. If fall is in the evening and covering MD notified nsg will contact PCP next day to ensure that they have been informed and can determine if resident needs to be examined after reviewing incident with nursing. In at least two studies the value of post-fall assessments has been reported. In one, new diagnosis were identified and led to a reduction in future falls. In another, patients evaluated by a NP had a 26% reduction in hospitalizations and hospital days over 2 years. (Rubenstein, 1990; Neufeld 1991).PCP notified. If fall is in the evening and covering MD notified nsg will contact PCP next day to ensure that they have been informed and can determine if resident needs to be examined after reviewing incident with nursing. In at least two studies the value of post-fall assessments has been reported. In one, new diagnosis were identified and led to a reduction in future falls. In another, patients evaluated by a NP had a 26% reduction in hospitalizations and hospital days over 2 years. (Rubenstein, 1990; Neufeld 1991).

53. Falls Committee Multidisciplinary Team Administrator DON ADON Unit Manager designates staff (nurse, CNA) Rehabilitation Director/Assistant (team leader) MDS Coordinators Social Service, activities, other departments as appropriate Witness (if available) Family(?) Rehabilitation team leader: established tracking form input data on all falls keep cumulative report and update for all staff monthly and annuallyRehabilitation team leader: established tracking form input data on all falls keep cumulative report and update for all staff monthly and annually

54. Falls Committee Meeting Initiated within 24 hours of fall Consistent meeting time (8:30AM) Mandatory attendance Keep it short! Follow up from previous meeting Current incident report reviewed Classify Fall (nine categories) and collect other relevant data Set up plan and implement necessary changes Follow up is the check and balance for assuring that changes have been implemented.Follow up is the check and balance for assuring that changes have been implemented.

55. Falls Classification Environmental Resident non adherence Staff non adherence Acute medical decompensation UTI Pneumonia Medication related Progressive functional decline Dementia Parkinsons Equipment malfunction Isolated incident Not classified Classifying falls into more specific categories has improved our ability to resolve certain problematic areas. eg staff non adherence,educate and counsel environmental, correct environment equipment malfunction obtain new equipment It has allowed us to track trends It has provided more accountability and thus has improved implementation of changes Classifying falls into more specific categories has improved our ability to resolve certain problematic areas. eg staff non adherence,educate and counsel environmental, correct environment equipment malfunction obtain new equipment It has allowed us to track trends It has provided more accountability and thus has improved implementation of changes

56. Falls Classification (some ideas) Location (unit) Location within the unit (bathroom, dining room) Time, day of week Predisposing event Other antecedents Footwear, clothing, assistive devices Staffing issues Family issues Psychosocial issues Classifying falls into more specific categories has improved our ability to resolve certain problematic areas. eg staff non adherence,educate and counsel environmental, correct environment equipment malfunction obtain new equipment It has allowed us to track trends It has provided more accountability and thus has improved implementation of changes Classifying falls into more specific categories has improved our ability to resolve certain problematic areas. eg staff non adherence,educate and counsel environmental, correct environment equipment malfunction obtain new equipment It has allowed us to track trends It has provided more accountability and thus has improved implementation of changes

57. Post Fall Follow Up Root cause analysis Ongoing education and reeducation of all staff Ongoing communication on the problem of falls in this individual resident Ask the resident, family and staff, “what do you think?” ASK THE CNAs WHAT THEY THINK!!!

58. Don’t leave the provider out! The NP, PA or MD can use a guideline or template to document his/her workup of falls. A sample page of the American Medical Director’s Association (AMDA) guideline follows…

59. Functional status, sensory status, psychological status, environmental status longer form You can use this, give the facility the Barbara Resnick postfall assessment tool for nursing Caring for the Ages April 2002Functional status, sensory status, psychological status, environmental status longer form You can use this, give the facility the Barbara Resnick postfall assessment tool for nursing Caring for the Ages April 2002

60. How is the PCP notified of a fall? Use the post-fall assessment tool as a guide Always consider change from baseline Always relay family or staff concerns Always mention if the resident is on warfarin or other anticoagulant Mention other recent changes (medication changes, recent illness, other falls)

61. Comprehensive Risk Assessment Includes Complete medication review, including new medications dosage adjustments recently discontinued medications attention to medications requiring levels (digoxin, phenytoin, etc.) eyedrops, topicals alternative/homeopathic remedies

62. Comprehensive Risk Assessment Includes Comprehensive examination; targeted areas to include orthostatic vital signs neurological exam (gait) MMSE vision exam musculoskeletal exam (lower extremity joint function) cardiovascular exam careful exam of affected/injured area When to refer: ophthalmology cardiology (?syncope or arrhythmia after initial testing…consideration for pacer) neuro - unclear etiology possibly vertigo, central vs peripheral problem When to refer: ophthalmology cardiology (?syncope or arrhythmia after initial testing…consideration for pacer) neuro - unclear etiology possibly vertigo, central vs peripheral problem

63. Some nurses, NPs, physicians and CNAs may not know how to correctly take orthostatic vital signs. Each facility should have a policy on this, and it should be included in orientation materials and annual competencies.

64. Functional Assessment and Tests of Gait and Balance are Generally Performed by Rehabilitation Staff (PT, OT). It is critical that findings are shared with nursing, activities and direct care staff as soon as they are known!

65. Comprehensive Risk Assessment: Diagnostic Testing Highly individualized Laboratory tests usually want to rule out infection, dehydration, drug toxicity CBC, CP7, drug levels, u/a c&s TSH Cardiology workup may include EKG, holter monitor Radiology

66. Comprehensive Risk Assessment Final assessment should list all possible causes of falls in this particular patient.

67. Targeting Interventions Based on Specific Problems http://www.medqic.org Go to Physical Restraints Go to Tools To to Restraint Reduction Assessment and Alternatives Help Guide -or- Falls Management Program (FMP)

68. Targeted Interventions Individualized Plan of Care First, determine if risk is high and immediate action needs to be taken 1:1 with staff, family or sitter Team conference for brainstorming Consider speaking with PCP Obtain input from family on what has worked in the past Listen, listen, listen Remember that up to 15% of falls in nursing home patients may have been caused by acute illnessRemember that up to 15% of falls in nursing home patients may have been caused by acute illness

69. Targeted Interventions Individualized Plan of Care Do you think these issues could be related to falls? Interactions with staff Pain Comfort Contentment Anger, guilt Urgency, incontinence Sleep Constipation Vanderbilt study - began in 14 NHs in Tennessee (Ray, 1997 JAMA – RCT - targeted four specific areas, interdisciplinary approach. Reduced proportion of recurrent fallers by 19%; injurious falls by 31% (not statistically significant). Extended to 112 homes by phase IV in concert with CDC, to see if program could be applied to a large scale intervention So what we can tell you today, in terms of information you can take back with you to your facility, is that comprehensive risk assessment programs such as the Vanderbilt falls prevention program can work. Certain facility characteristics need to be in place. No studies on nursing home interventions describe cost-effectiveness of the program. Need to examine what the costs are to facilities, and where the reduced costs are to insurers, as well as the quality of life benefits Conclusions: Need a champion - that’s you!Vanderbilt study - began in 14 NHs in Tennessee (Ray, 1997 JAMA – RCT - targeted four specific areas, interdisciplinary approach. Reduced proportion of recurrent fallers by 19%; injurious falls by 31% (not statistically significant). Extended to 112 homes by phase IV in concert with CDC, to see if program could be applied to a large scale intervention So what we can tell you today, in terms of information you can take back with you to your facility, is that comprehensive risk assessment programs such as the Vanderbilt falls prevention program can work. Certain facility characteristics need to be in place. No studies on nursing home interventions describe cost-effectiveness of the program. Need to examine what the costs are to facilities, and where the reduced costs are to insurers, as well as the quality of life benefits Conclusions: Need a champion - that’s you!

70. Targeted Interventions Individualized Plan of Care Address specific intrinsic risk factors identified in the work up consider causes of behaviors treat or manage orthostatic hypotension correct metabolic imbalances treat infection or dehydration treat pain consider nutritional issues determine underlying cause for delirium or confusion see restraint reduction guidelines and tables (Medqic) Remember that up to 15% of falls in nursing home patients may have been caused by acute illnessRemember that up to 15% of falls in nursing home patients may have been caused by acute illness

71. Targeted Interventions Individualized Plan of Care Reduce/eliminate/alter medications whenever possible Follow these general guidelines

72. Medication Principles to Reduce Fall Risk Reduce the total number of medications given Asses the risks and benefits of each medication Select medications least associated with orthostatic hypotension Prescribe lowest effective doses Reassess risks and benefits at each regulatory visit and as needed AMDA Clinical Practice Guideline Fall and Fall Risk 2003 There are five standard principles that are followed to reduce falls risk when performing a resident’s medication review.There are five standard principles that are followed to reduce falls risk when performing a resident’s medication review.

73. Medication Categories More Commonly Associated with Injury from Falling Anticoagulants Antidepressants Anti-epileptics Anti-hypertensives Anti-Parkinsonian agents Benzodiazepines Diuretics Narcotic analgesics Non-steroidal anti-inflammatory agents [NSAIDS] Psychotropics Vasodilators -AMDA Clinical Practice Guideline Falls and Fall Risk, 2003

74. Targeted Interventions Individualized Plan of Care Consider PT/OT screens or evaluations for problems with gait or balance, need for muscle strengthening program, seating systems or assistive/adaptive equipment or environmental assessment Transfer, gait, balance training; strengthening, ROM exercises; habituation exercises for vestibular problems Exercise, exercise, exercise!

75. Targeted Interventions Individualized Plan of Care Environmental adaptations might include low bed AFO, brace, splint, walker, cane different seating system specialized floor mats raised toilet seats

76. Alarms Chair alarm Personal alarm Bed alarm No studies prove value Must weigh risks and benefits May be helpful for some residents and harmful for others Consider for short, but not for long term use How do you reduce alarms in the facility?

77. Targeted Interventions Individualized Plan of Care Environmental adaptations might include siderails for positioning different bedroom nightlight at night, keeping BR door ajar non-skid strips for floor rearranging room (Hofman, 2003) external hip protectors

78. Activities How are activities related to falls? Knowing previous patterns of behavior What is the role of the activities staff in fall prevention? Do other staff read activities notes, especially admission info? Maintenance? Housekeeping? Dietary? Family? What is the “All Hands on Deck” program? What is the “Walk to Dine” program?

79. Use this set up for individual who roll from bed and are non ambulatory. May cause falls in ambulatory individuals Use this set up for individual who roll from bed and are non ambulatory. May cause falls in ambulatory individuals

80. Targeted Interventions Individualized Plan of Care Create an individualized care plan on admission, using the MDS, developed by interdisciplinary team to address all risk factors Design and implement interventions, monitor and evaluate outcomes. Update MDS with increase, decrease in falls. Update care plan if risk factors or condition changes Consider the inter-relatedness of other MDS items and fall prevention (incontinence, depression, pain) Continuous efforts are required to sustain benefit of interventions (Taylor, 2002) Vanderbilt study - began in 14 NHs in Tennessee (Ray, 1997 JAMA – RCT - targeted four specific areas, interdisciplinary approach. Reduced proportion of recurrent fallers by 19%; injurious falls by 31% (not statistically significant). Extended to 112 homes by phase IV in concert with CDC, to see if program could be applied to a large scale intervention So what we can tell you today, in terms of information you can take back with you to your facility, is that comprehensive risk assessment programs such as the Vanderbilt falls prevention program can work. Certain facility characteristics need to be in place. No studies on nursing home interventions describe cost-effectiveness of the program. Need to examine what the costs are to facilities, and where the reduced costs are to insurers, as well as the quality of life benefits Conclusions: Need a champion - that’s you!Vanderbilt study - began in 14 NHs in Tennessee (Ray, 1997 JAMA – RCT - targeted four specific areas, interdisciplinary approach. Reduced proportion of recurrent fallers by 19%; injurious falls by 31% (not statistically significant). Extended to 112 homes by phase IV in concert with CDC, to see if program could be applied to a large scale intervention So what we can tell you today, in terms of information you can take back with you to your facility, is that comprehensive risk assessment programs such as the Vanderbilt falls prevention program can work. Certain facility characteristics need to be in place. No studies on nursing home interventions describe cost-effectiveness of the program. Need to examine what the costs are to facilities, and where the reduced costs are to insurers, as well as the quality of life benefits Conclusions: Need a champion - that’s you!

81. Successful Fall Prevention and Restraint Reduction Strategies Sensory stimulation room or activity drop in center for sundowners or those with behaviors at certain times Staffing analysis with reallocation of staff to activities or 3-11 or other pattern Weekly walk rounds with medical director Weekly environmental rounds with rehab Ruby slippers (for hospital and subacute)

82. Person-centered Approaches to Fall Prevention Consistent staffing is the most critical element!!!

83. Effective Communication Avoid ambiguity Avoid work around culture Avoid working in silos Encourage shift to shift communication and interdepartmental communication

84. Involving Residents and Families Identify high risk residents on admission Discuss with resident and family Educate! Get their input Set REALISTIC goals

85. Preventing Litigation Care plan should be comprehensive and interdisciplinary Involve primary care providers (MD/NP/PA) Set realistic goals Insure consistent documentation Know the high risk categories and the high risk residents Make sure risks are incorporated into the care plan Make sure that practice follows policy!

86. Patient/Family Education Materials The National Center for Injury Prevention and Control Division of Unintentional Injury Prevention 4770 Buford Highway, NE, Mailstop K-63 Atlanta, GA 30341 http://www.cdc.gov/ncipc

87. Patient/Family Education Materials www.healthinaging.org/agingintheknow   http://www.niapublications.org/engagepages/Preventing_Falls_and_Fractures.pdf

88. National QIO Falls Management Program Has many downloadable forms, including policies and procedures Can be easily adapted or customized to your facility www.medqic.org  Enter falls management program as a search term

89. Summary Fall-related injury prevention and restraint reduction are both important goals Management and leadership need to be committed to reducing both falls and restraints Begin with an assessment of where your facility is now, where the gaps are, and how you will implement the first phase of your program

90. What are Residents, Family and Staff Seeking? Quality of life, not just quality of care Staff who are respectful and 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 and have time for me.” National Citizens' Coalition for Nursing Home Reform (NCCNHR), 1985 Tellis-Nayak and Tellis-Nayak, 2005

91. Summary Who will be on the fall/restraint team? Who will be the falls champion? How will this fit with the culture of safety and resident-centered care at your facility? How will the message be communicated to frontline staff, families, residents? How will new staff be oriented and how will annual competencies be determined?

92. Summary Ongoing monitoring and re-evaluation of your results Manage with your DATA Unit level falls and injury reports Report on near misses and talk them up! Communication!!!! Teamwork!!!!!!!!!! Documentation!!!!

93. Thank you for being a falls champion!

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