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Falls in Nursing and Personal Care Homes. Looking at Culture and Collaboration. Paula A. Bracken, PCHA, MHA Affinity Health Services, Inc. November 30, 2010 PHCA Webinar. Overview. The Elderly and where they live Falls definition and MDS 3.0 Regulations
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Falls in Nursing and Personal Care Homes Looking at Culture and Collaboration Paula A. Bracken, PCHA, MHA Affinity Health Services, Inc. November 30, 2010PHCA Webinar Affinity Health Services, 2010
Overview • The Elderly and where they live • Falls definition and MDS 3.0 • Regulations • Various Risk Factors & Interventions • What difference does a change in culture make? • We need a different approach Affinity Health Services, 2010
Community-Dwelling • Personal Care / Residential The Elderly Nursing Home Affinity Health Services, 2010
Falls • A very broad issue with many factors involved • There is no simple solution • Falls are a result of complexities within a person as well as within the environment in which they dwell Affinity Health Services, 2010
Falls • Definition • An unintentional change in position coming to rest on the ground, floor or onto the next lower surface – MDS 3.0 • Examples - • Coming to rest on the foot rests of a wheelchair • Knees give out and the person has to be lowered to the floor Affinity Health Services, 2010
MDS 3.0 • G0300: Balance During Transitions and Walking • G0400: Functional Limitation in Range of Motion • G0600: Mobility Devices • G0900: Functional Rehabilitation Potential Affinity Health Services, 2010
Impaired Balance -planning for care • Evaluate • Assess to identify all risk factors • Care Plan to Prevent further decline in function and/or return of function • Depends on resident-specific goal(s) Affinity Health Services, 2010
MDS 3.0 • J1700 :Fall History on Admission • J1800: Any Falls Since Admission or Prior Assessment (OBRA or PPS), whichever is more recent • J1900: Number of Falls Since Admission or Prior Assessment (OBRA or PPS), whichever is more recent Affinity Health Services, 2010
Falls – planning for care • Evaluate potential need for further assessment and intervention • Evaluate the environment • Evaluate staffing in relation to residents at risk for falls Affinity Health Services, 2010
Consequences of falling • Injury • 20-30% suffer serious injuries • 2-6% suffer fractures • Fear of falling in daily life activity • Restricted mobility and activity • Loss of independence • Increased social isolation • Admission to residential care/nursing home Affinity Health Services, 2010
Falls are • Most frequent accident in PC/AL and NHs • 40% of all NH residents fall each year • Several fall 1+ times • 35% occur with those who cannot walk • 10-20% cause serious injuries • Fall history / fall injury before admission • Prevalence of falls in NH higher than among community-dwelling elderly Affinity Health Services, 2010
Inadequate supervision • Frequently cited by state in both PC and NHs • Occurs when there is failure to • Recognize signs and symptoms of fall risk • Intervene appropriately • Plan interventions to prevent future falls Affinity Health Services, 2010
Personal Care Homes • Prevalence of falls depends on • Population characteristics • Personal Care Home practices • Staff skills • Systems established Affinity Health Services, 2010
Nursing Home Regulation & Practices Affinity Health Services, 2010
The Nursing Home • Institutional by nature and background • A medical-model that focuses on tasks and routine Affinity Health Services, 2010
The Institutionalized Culture • The underlying “risk factor” • F 252 Environment • “a homelike environment is one that de-emphasizes the institutional character of the setting . . .A personalized homelike environment recognizes the individuality and autonomy of the resident . . . . Affinity Health Services, 2010
Institutionalized Culture • Standardized “treatments” based on medical dx • Schedules and routines designed by and for staff • Task-oriented work and rotation of assignments • “sterile” environment • Activities only available when activity staff are on duty -Pioneer Network, 2008 Affinity Health Services, 2010
Typical Interventions • Investigate incident first • Ideally - details from investigation determine what interventions are put into place • Alarms • Chair • Bed • Motion detect • Padded mattress beside bed • Shoes on, etc. Affinity Health Services, 2010
F 323 Accidents • The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Affinity Health Services, 2010
Accidents and Supervision • Falls related to • Alarm use or misuse • Misuse of Equipment • Improper Supervision and Assistance • Lack of proper Assessment • Lack of new interventions • Poor communication Affinity Health Services, 2010
Why not Alarms? • False sense of security • Residents learn to turn them off • Can malfunction; battery goes out • A Dignity issue • Contributes to institutionalized atmosphere • Survey deficiencies related to alarms Affinity Health Services, 2010
Why not Alarms? • Staff respond to the alarm and not the resident • Creates confusion from startling noise which increases agitation • Everyone can become desensitized • Potentially “immobilizes” resident • Decline in ADLs • Can act as a “restraint” • Interrupts sleep Affinity Health Services, 2010
Why not Alarms? • Wide spread and long-term use • A false-assurance for staff • Startles the resident • Constrains resident from normal re-positioning movements – may contribute to • Pressure sores • Weakened muscles Affinity Health Services, 2010
Examples of deficiencies • Alarm did not sound • Nurse aide forgot to turn alarm on/attach alarm to resident • Resident turned alarm off • Resident removed clothing to which alarm attached • Lack of monitoring alarms Affinity Health Services, 2010
Conclusion • There is a lack of evidence that support the use of alarms to prevent falls • Alarms cannot be used in place of supervision • Institutionalized care demoralizes the individual and contributes to poor clinical outcomes Affinity Health Services, 2010
Therefore Change is Needed “… A “homelike” or homey environment is not achieved simply through enhancements to the physical environment. It concerns with striving for person-centered care that emphasizes individualization, relationships, and a psychosocial environment that welcomes each resident and makes her/him comfortable . . .” - CMS, 2009 Affinity Health Services, 2010
Interventions and approaches Considering Culture and Collaboration Affinity Health Services, 2010
S.e.r.v.i.c.e. - A Leadership model • Service • Education • Respect • Vision • Inclusion • Communication • Enrichment • Leadership is "the art of influencing and engaging colleagues to serve collaboratively toward a shared vision” • -S. Gilster, “Changing Culture, Changing Care”, 2009 Affinity Health Services, 2010
Collaboration • “a team, with each individual contributing unique talents in such a way that all are used to accomplish the goals and vision.” • “people coming together as one . . . To create a culture or outcome consistent with the vision” • -S. Gilster, “Changing Culture, Changing Care”, 2009 Affinity Health Services, 2010
What does “Person-Centered” mean? • The Person is the focus • Build relationships among care-givers • Gain insight to individualize care routines Knowing residents and relating to them as an individual allows for spontaneity and creativity in the approach Affinity Health Services, 2010
Person-Centered Approach • Puts the Resident first, and tasks second • Identify patterns of resident needs • Toileting, walking, stretching, pain treatment • Identify discomfort related to positioning • Change staffing patterns on 3-11 to better meet resident needs Affinity Health Services, 2010
Person-Centered Culture • Resident- Choice is critical • Meeting the personal wishes of the resident helps to create the foundation for care-giving relationships • Direct care staff can have input into the care-planning for a resident Affinity Health Services, 2010
Other Positive Culture-Oriented Approaches • PHI National - • A “Relationship-centered" culture that first and foremost supports Resident choices and all relationships • Supervisor – Staff • Staff- Staff • Staff – Resident • Core skills, particularly those related to communication, problem-solving and relationship building are needed Affinity Health Services, 2010
Results are a far more empowering and satisfying environment for both staff and residents • When you individualize care, you minimize the need for alarms Affinity Health Services, 2010
Changing Care Routines • Mornings – allow to sleep in – individualize care routine per person - this will affect other systems and processes, such as meals, when medications are given, when treatments are done, etc. • Bladder care – individualize- follow patterns • Medication Pass – a nursing task – can change medication policies for administration time from • “8 a.m.” to “upon rising” • BID to “upon rising” and “before dinner” • TID to “upon rising”, “before lunch” and “before bed” Affinity Health Services, 2010
Changing Care Routines • Suppositories – do not awaken early to give – go back to the basics – high fiber & fluids & exercise • Pain management – individualize • MDS 3.0 – tells us characteristics of a resident’s pain and it’s affect on function and mood • Foodservice – Provide a time range • (i.e. ) 8 a.m. – 10 a.m. - personalize service Affinity Health Services, 2010
A Resident “Right” to a Safe Environment • It is the Right of a Resident to live in a safe, structured, and predictable environment: • Designed around the needs of the person • Safe and well lit, • Offer areas for walking or wandering, • Be uncluttered, • Be pleasant • Provide a structured schedule of activities and meals • Stimulating the senses, yet providing a sense of security • Bell & Troxel, 1997 Affinity Health Services, 2010
Environmental Re-design • If it is financially feasible, an internal environment that is re-designed to facilitate the • Supervision of residents • Movement of individuals throughout the area • Creation of a homelike environment that resembles more of a “home” versus an institution – smaller gathering places According to the Pioneer Network, more documented research in this area is needed -Pioneer Network, 2008 Affinity Health Services, 2010
Neighborhoods vs. ‘Units’ • Resembles a town • Rooms are a “home” • Community or “country” kitchen • Creation of a “hearth” – place to gather • Improved intake and nutrition – overall health Affinity Health Services, 2010
Therapy and Activities as an Intervention • Provides supervision • Exercise improves blood circulation • Increase strength and endurance • Improved sense of well-being • Improved sense of self-worth • Improved function Affinity Health Services, 2010
Treatment and Prevention of Osteoporosis in LTC Setting • Based on Clinical Practice Guideline from AMDA • Dx. of Osteoporosis , Osteomalacia or Osteopenia • Order a Vitamin D level (25-OH- D3 or 25-hydroxy D3) • Sufficient is 32 ng/ml or greater 25 –OH-D3 • Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010
Institute measures to improve function • Encourage exercise to increase muscle strength in leg muscles • Use restorative services to improve strength, balance and ambulation • Discontinue or reduce medications that affect balance or level of consciousness • Administer Vitamin D and Calcium supplements Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010
Treatment and Prevention of Osteoporosis in LTC Setting • To Maintain or improve Calcium Balance • Calcium • Calcium Carbonate Calcium Citrate Vitamin D • Cholecalciferol (D3)– best absorbed • Ergocalciferol (D2) • 1,25 di-hydroxyvitamin D • Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010
Treatment and Prevention of Osteoporosis in LTC Setting • Anti-resorptive Medications • Calcitonin • Raloxifene • Bisphosphonates • Anabolic Medications • Parathyroid hormone Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010
When not to treat Osteoporosis • Terminal condition /palliative care • Unable to tolerate pharmacologic tx • Unwilling to accept treatment • Has been tx’d with Biphosphonates for past 5 years • Patient is non-weight bearing and requires maximal care • No evidence of Treatment efficacy Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010
Fall Risk Assessment • Assess characteristics of the resident • Hx. of a fall • Recent illness and multiple co-morbidities • Dx. Osteoporosis and/or Vitamin D deficiency • Medications and drugs that impact balance, cognition, etc • Restorative nursing • Therapy received • MDS 3.0 data and process Affinity Health Services, 2010
Example of an Intervention Program using a Fall Risk Assessment • General /Medical Assessment • Fall Risk Assessment • At Admission • After a Fall Incident • At the request of a health-care professional • On a change in condition • Periodic review • Fall Prevention Meeting – evaluate Medical and Fall Risk Assessment data together From Neyens et al. (2008) Affinity Health Services, 2010
Fall Prevention Team Evaluate • Fall Prevention Activities • General – Facility-related • Specific – Resident-related • Fall Prevention Meeting • Evaluate general and specific fall prevention activities • Minimum twice a year From Neyens et al. (2008) Affinity Health Services, 2010
