Falls in Ontario LTC Settings:

1. Falls in Ontario LTC Settings: Laura M. Wagner, PhD, RN Nursing Scientist Kunin-Lunenfeld Applied Research Unit at Baycrest Kunin-Lunenfeld Applied Research Unit

2. Acknowledgments and Funding • Canadian Patient Safety Institute • Ontario LTC Association: • Krista Robinson-Holt, RN, MN (Co-I) • Jennifer Langston • OLTCA Applied Research Committee Family representative: Ms. Krystyna Schmidt • Participating LTC Facilities • Research Team: • Nina Mafrici, Julie Andrassy, Joanna Dionne, Hannah Gao, Xiao Jin Chen, Yannie Aass • Thecla Damianakis, PhD, MSW

3. Background • Falls are the most frequently reported adverse incident in LTC settings • Approximately 50% of residents fall each year • Numerous studies have addressed falls in LTC, very few have focused on the processes of identification, implementation, and communication regarding the management of falls

4. Research Questions • What fall risk factors are identified by nursing staff and which factors result in associated interventions documented on the fall risk care plan? • What fall prevention strategies are listed in the fall risk care plan and are these interventions correctly implemented into actual practice? • How is care plan information regarding falls communicated and implemented to the health care team?

5. Methodology • Descriptive correlational design in 8 randomly selected homes in and around central Ontario (>100 beds) • Range 120-170 avg. monthly census • Data collection: • Monthly incident report review • Medical record review • Quarterly rounds to examine care plan interventions • Focus groups

6. Resident Demographics • N= 635 • Average age: 82.27years (10.22SD) • Average Length of stay: 28 months • Female: 67% • Risk factors: • Fall history 66% Dizziness 14% • Wandering 26% Anxiolytic 32% • Antidepressants 44% Restraint 6%

7. Falls • 1901 Total Reported Falls among the 8 facilities over 1 year period • Average 20 falls per facility/per month • Range 6 - 37 • Average 3 falls per faller/per year • Range 1 - 35

8. Risk Factor Medical Problems Mobility Problems Footcare Problems Urinary/Bowel Incontinence Vision Problems Unsafe Behaviours Psychological condition Environmental/external hazard Medications Example Stroke/TIA Gait dysfunction Neuropathy Nocturia Glaucoma Combativeness Depression Cluttered room Antidepressant Care Plan/Medical Record Review

9. Risk Factor Medical Problems Mobility Problems Footcare Problems Urinary/Bowel Incontinence Vision Problems Unsafe Behaviours Psychological Condition Environmental Medications % Identified / % Follow-up 86% / 41% 88% / 73% 11% / 54% 74% / 15% 51% / 14% 43% / 60% 76% / 58% 3% / 21% 67% / 6% Results: Medical Record Review

10. Quarterly Environmental Rounds • N= 1517 observations • Observations focused on risk factors • Mobility, unsafe behaviours, vision, environment, incontinence, etc. • Overall: 66% adherence to care plan interventions

11. Rounds Adherence • Mobility (e.g., proper footwear): 64% • Unsafe behaviours (e.g., bed alarm, call bell, bed in lowest position): 57% • Vision (e.g., glasses clean and on while out of bed): 60% • Environmental (e.g., common items within reach): 80% • No Falls Risk Care Plan: n=104

12. Admission policy (n=6 facilities) Risk level (e.g., high) (n=2) Staff education (n=3) Prevention program reviews (n=3) Medication reviews (n=6) Interdisciplinary participation/communication (n=3) Post fall policy (n=8) Immediate evaluation (n=8) Contact family member (n=7) Facility fall committee (n=5) Explicit QI Program (n=2) Facility Policies

13. Fall Risk Assessment • Fall history (n=8) • Secondary diagnosis (n=7) • Ambulatory aid (n=4) • Gait/Balance (n=8) • Mental status (n=6) • Medications (n=7) • Continence (n=6) • Sensory impairment (n=5) • Orthostasis (n=1)

14. Focus Group: Design & Selection • 8 focus groups in 4 randomly selected LTC facilities • 1 RN/RPN and 1 PSW/HCA group per facility • 21 RN’s and RPN’s • 21 PSW’s & HCA’s • Purposive sampling • Inclusion criteria • Informed consent

15. Method: Focus Group Demographics • Time Working in Current Job: • 15% < 1 year • 34% 1 to 5 years • 20% 6 to 10 years • 10% 11 to 15 years • 5% 16 to 20 years • 16% 21 years or > • Highest Level of Education: • 20% High school diploma • 39% Associate degree/diploma in nursing • 32% Some college or university • 9% Preferred not to respond • Sex: • 35 female; 5 male • Ages: • 17% 26-35 years • 17% 36-45 years • 24% 46-55 years • 12% > 56 years • 30% Preferred not to respond • Type of Position: • 11 (27%) Registered Nurses (RNs) • 9 (22%) Registered Practical Nurses (RPNs) • 21 (51%) Personal Support Workers (PSWs)

16. Method: Data Collection • Semi-Structured Interview Format: • 30 min per focus group • Audiotaped; Transcribed • Facilitator and Recorder • Interview Guide: • Falls Risk Identification: Assessing “High Risk” Residents • Post Fall Reporting Procedures • Communication Processes • Falls Quality Improvement and Prevention Strategies

17. Method: Data Analysis • Data Analysis: • Open and hierarchical coding • Within and cross-case analysis • Thematic analysis • Observational recordings • Interrater reliability of coding and analysis with research team; triangulation; thick description

18. OVERALL Perceptions • Falls monitoring and incident reporting good overall • Good communication: RN’s & PSW’s • Teamwork is important • Staff shortages • Multiple barriers

19. Fall Risk Identification: “High Risk Resident” • Variation in meaning of “High Risk Resident” across locations and sample groups • Some falls considered non-preventable (inevitable) and others preventable • Prioritize: Seriousness of Falls

20. CCAC report Visual Physiotherapy Nurses Identifiers: bracelets; bed alarms, signs Information from families RN Report(s) primarily verbal Visual Physiotherapy Identifiers: bracelets; bed alarms, signs Assessing “High Risk” Residents RN’sPSW’s

21. Falls Risk Identification: How do you know which of your residents are at high risk for falling? • RN: sometimes we have some information from the previous place, but it’s not always correct and we can’t rely on that, so the best thing is to have our own assessment. • PSW: I believe…we have new metal id bracelets…some of them are colour coded…red, blue, green, blah, blah, blah…but I can’t remember the one that’s “has a history of falls”.

22. Post Fall Reporting Procedures • Limitations Noted: • Lack of communication b/w licensed and non-licensed staff contributes to poor incident reporting • Lack of knowledge of inexperienced staff

23. Post Fall Reporting Procedures:How are you informed that the fall has occurred, and how is this information communicated to other staff members working on the following shift? • RN: I do a report…a written report at the end of the shift, and that report goes down to management….And then we report at the end of the shift to the next shift coming on. • RN: Pretty good here. They (PSW’s) let us know whatever they discover, anything…if there is anything new with the resident….anything unusual…their walking patterns, or if they get drowsy or something…they let us know.

24. Post Fall Reporting Procedures:How is the fall incident communicated to family members? • PSW: Whomever is in charge on the floor. Automatically…it doesn’t matter what time of day. • RN: Usually the person whose filling out the report, or the registered staff….always registered staff. • RN: It depends on when they fall too…if it’s late at night they put it on the report for the next shift….the day shift to call the family.

25. Post Fall Reporting Procedures:How are you informed of any changes in the resident’s Care Plan following his/her fall? • RN: Well, they (PSW’s) read the care plan. - F: And how often do they read it? - RNC: They don’t (with a chuckle) • RN: … you go to the person right away, the person who is taking care of the person, like the PSW whose taking care of them, and you let them know the changes; and it’s in the daily report as well.

26. Post Fall Reporting Procedures:Do you have any concerns when it comes to reporting when a fall occurs on your unit? • RN: I’d like them in a more timely manner not three hours after the fall… don’t tell me at like 11 o’clock when I’m trying to close my shift off, that “oh, so-and-so fell at 7 o’clock” and I wasn’t even aware of it to do the incident report.(in a mocking voice): “oh I forgot to tell you three hours ago that the person fell, and they might have hit their head even?!” • PSW: It comes back to the same thing about the knowledge…you go to report it and the nurse…uh…whatever…the nurse will turn around and say: “oh well, you know, you should have done this, you should have done that…you should have known”…But if the knowledge isn’t there, then how would’ve know? So she’s getting upset because a certain person isn’t doing something right, but they weren’t taught the right way, so if they don’t have the knowledge, we’re still going to have falls. • PSW: I think, [in] general, the staff in this facility take a lot to prevent falls from happening on the units.

27. Communication Processes Registered Staff Administrators Directors of Care Health Care- Interdisciplinary Professionals Personal Support Workers Families

28. Communication Processes • At Risk Identification & Post Fall Recording: • Direct and indirect • Verbal and written • Quality of relationship important: non-punitive; trusting; safe

29. Communication Gaps • Post-Fall Reporting • Not witnessed; resident gets up on their own • Not reported at the time; but reported afterwards if there are visible signs (e.g., bruising) • “Like if we are washing [the residents]…then we have to look…if we locate anything or see anything, we have to…it gets documented right away” (PSW) • Near-misses: not identified

30. Barriers: Preventing Falls or Implementing Interventions • Staff (RN’s and PSW’s) acknowledge multiple factors which contribute to falls • Despite lack of both formal and informal discussion on falls, seen as important • Discrepancy in falls quality improvement actions among units at the facilities • Interventions toward fall quality improvement tend toward retroactive not preventative strategies • Infrequent in-service training

31. What barriers do you face in preventing falls or carrying out specific interventions on your unit? • PSW: …I think knowledge…not to say that we don’t have the knowledge, but we could always use more knowledge. Because falls is not something…we talk about all the time unless it happens. • RN: …the PSW has eight or ten residents to look after, and when they are busy with one, of course, anything can happen with another, and they can’t be there every single minute. • PSW: …some of the barrier, I think would be the family members. • PSW: It’s like too long…sometimes they need [a] proper wheelchair…waiting for months…Oh months! How long?!! Six months already and we never get it….

32. Do you have meetings to discuss falls on your unit? • PSW: We have one inservice two times a year…if residents are falling. PSW: So…I’ve never had one (referring to meeting about falls).. And I worked on there for a year, and we’ve never had one. RN: …inservice, we had one last year, regarding falls and these similar…situations RN: If there is an increase…in the number of falls [and] if a resident would have fallen…[we] discuss what’s going on, and what we can do.

33. Barriers to Falls Prevention • 1. Family Non-Compliance • Resident footwear • 2. Lack of Staff • Staff-resident ratio • Limited time to monitor • 3. Lack of Resident Stimulation • Lack & Quality of Planned Activities • Resident Boredom • 4. Cognitive Impairment • Instability; Aggression • 5. Medications • Agitation, Weakness Resident Falls

34. Barriers to Falls Prevention • 6. Lack of Education-Staff Training • Infrequent in-service training • 7. Restraint Policies • Pose ethical tensions for staff • Self-determination vs. safety • Families lack of understanding • 8. Proper Equipment • Delays in getting equipment • 9. Environmental Conditions • Physical-on floor obstructions Resident Falls

35. Falls Quality Improvement: What is the most pressing issue that needs to be addressed when it comes to residents falling? • RN: Well, staffing issues because…right now…I think there is one lady upstairs and she’s out of the chair six times an hour…and I’ve got two staff members and that’s been taking them away from their normal duties….and they’re getting stressed out. • PSW: …or guilt….because, you know, mom used to be up and down here and there, and you know, umm…they don’t want to have mom restrained…they don’t accept that mom is not as strong anymore…mom is weaker and potential for falls is there. So, they’re major…I find the major concern is the family members and falls • RN: ..when you have to prevent a fall, you have to put every nurse in every room…and this is twenty or thirty rooms…we have nobody. It is very difficult, especially at night.

36. Deliverables • Website live in April 2007: • www.fallsinltc.ca • OLTCA, ALTCA, Manitoba LTC Assn (Spring 2007) • LTC magazine article: June 2007 • “Communicating with Families about Falls”

37. Key Messages • Implications for: • Practice- • Education- • Management- • Research- • Policy-

38. Implications for Policy, Clinical Practice and Research • Policy & Administration • Need for more staff • Increase in-service training • Focus on prevention not only incident reporting • Encourage non-punitive reporting • Ensure quality programming which facilitates resident N stimulation and activities; decreases boredom • Establish an interdisciplinary approach with families to provide education and facilitate understanding of care procedures • Environmental impact: “geriatricproof” to minimize impact of falls; provide frequent audits

39. Implications for Policy, Clinical Practice and Research (cont’d) • Clinical Training & Practice • Standardized Assessment Tools • In-service: • Common meanings of ‘high-risk’ resident; • Restraint procedures, including policies (e.g., least restraint) • Dealing with ethical challenges • Standardize knowledge across floors • Communication frameworks which focus on quality of interaction and promote teamwork • Includes families

40. Implications for Policy, Clinical Practice and Research (cont’d) • Future Research • Develop valid and reliable fall risk assessment tools • Point-of-care approaches to improve communication of care plan interventions