Making The Number of Falls Fall

Making The Number of Making The Number of Falls FallFalls Fall

Mara AronsonMara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ

Director of Nursing

Spaulding Nursing & Therapy Center, North EndBoston, MA

ObjectivesObjectives::

By the end of this presentations, participants will be able: Identify characteristics that increase fall risk

Describe the value in individualizing care plans to reduce the risk of falls

Compile, analyze, and trend data to determine patterns of falls

Discuss how trending data can be used to reduce risk of future falls

Definition “FALL”Definition “FALL”

“An event which results in a person unintentionally coming to rest

on the ground or another lower level,

not as a result of a major intrinsic event

(such as a stroke) or overwhelming hazard.”Tinetti et al., 1988

Who fallsWho falls??

#1 risk factor

Confused

Medicated

Impaired senses

Incontinent/Urgency

Use of adaptive devices

Elderly

= History of = History of fallsfalls

Falls are often multifactorial.Falls are often multifactorial.

Where do they fallWhere do they fall??

In the Community:

35%-40% all 65+ y fall once or more/yr25% of 70+ years fall/yr

35% of 75+ years fall/yr

20%-30% of falls result in severe injuries

(ex. hip fx, head injuries)

A leading cause of death amg cmty elders

Where do they fallWhere do they fall??

In Hospitals: 0.6-2.9 falls/year per bed

4-12 falls per 1000 pt bed days

Where do they fallWhere do they fall??

In Nursing Homes: A 100-bed SNF typically has 100-200 falls/yr

Bwt 50%-75% all SNF residents fall/yr

Avg is 2.6 falls per person/yr

4-12 falls per 1000 pt bed days

1800 die/yr from falls in nsg homes1800 die/yr from falls in nsg homes

Trend but considerTrend but consider::

Some falls may not be preventable without jeopardizing the elder’s

dignity &/or compromising function.

Trend but Trend but considerconsider::0% fall rate is a problem0% fall rate is a problem

Under reporting? Are residents immobile?

Hey! I think he just moved, add one more!

Who fallsWho falls??

#1 risk factor

Confused

Medicated

Impaired senses

Incontinent/Urgency

Use of adaptive devices

Elderly

= History of = History of fallsfalls

Falls are often multifactorial.Falls are often multifactorial.

Medicalconditions

Impaired vision & hearing

Psychiatricconditions

Environment

Medications

Assistive Devices

Multifactorial FallsMultifactorial Falls

Intrinsic FactorsIntrinsic Factors Extrinsic FactorsExtrinsic Factors

Social Issues

Incident ReportIncident Report::

Keep it: Keep it:

Brief

Easy Relevant

Our formOur form: : Spaulding Nursing & Rehabilitation Center, North End

EVENT REPORT FORM Use this form for all events other than med events

Date: Time: Location of occurrence: Name: If not a resident: Visitor Outside vendor/clinician Employee (If yes, position & dpt):

Resident condition at assessment (Check all that apply): At baseline Oriented x 3 Orient x 2 Orient x 1 Variable Confused Anxious Reliable historian Resisting assist

If not a resident, phone #: If not a resident, address: Describe the event (what happened, how was it discovered, how pt was first observed ): _________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Describe any known contributing factors: ___________________________________________________________________ _________________________________________________________________________________________________ ___________________________________________________________________________________________________

For all falls, complete FALL INVETSTIGATION WORK SHEET, collect WITNESS STATEMENTS, & call a HUDDLE!

At time of event Resident was: Dry/Continent Incontinent of Urine Feces Catheter in use Leg strap

Other environmental issues noted: . . . .

INDICATE ON BODY LOCATION OF INJURY/INJURIES:

Type of injury: Use # or arrows to locate

Laceration

Hematoma

Abrasion

Burn

Swelling

No apparent injury

Complain / Shows signs of pain (with or without visible injury) Pain Rate 1-10 .

Other – specify: .

NURSE’s NOTE with VS written YES & OrthoVS for all falls YES

Fall investigation formFall investigation form: : Spaulding Nursing & Therapy Center, North End

FALL INVESTIGATION WORKSHEET

Resident Name: Date of fall: Time of fall:

Note: If pt unable to stand, sit, or cooperate with VS assmt, document this in the Nurses’ Note. Lying: BP: AP: Resp: Temp / route:

Sitting: BP: AP: Resp: Temp / route:

VS when found: (temp x 1 only)

Standing: BP: AP: Resp: Temp / route:

Pt’s statement: .. .

PRIOR TO THE FALL:

Where last seen? How long since last seen: Activity prior to fall:

Lighting: Dark Light Floor: Dry Wet

Shoes: Barefoot Regular socks Non-skid socks

Slippers Shoes/sneakers Tied Untied

Continence: Dry Incont of urine Incont of feces

Time since last void/toileting .

Catheter Leg Bag

Mental Status (MS) Prior to Fall:

Oriented X 3 Oriented X 2 Oriented X 1

Forgetful Poor Safety Awareness Impulsive

Lethargic Restless/Agitated MS varies

Other (describe): .

Describe MS after Fall): No change

Change: : .

Alarm: In-place Connected Sounding

If not sounding: . Turned ‘off’ Low/dead battery Type of alarm: .

Call bell: Within reach Call bell functioning: Ringing Hall light on Not working

Equipment in Care Plan:

Cane

Walker

Wheelchair

Seat belt

Brace (type): .

Gait belt

Side rail(s)-how many .

Mechanical lift Other: .

Equip. in use at time of Fall:

Cane

Walker

Wheelchair

Seat belt

Brace (type): .

Gait belt

Side rail(s)-how many .

Mechanical lift Other: .

Fall investigation Fall investigation formform: :

Check all that apply:

Change in med, dose or schedule in past 72 hrs Acute change of condition: .

Fall within the last 30 days Recent change of function: .

This event was witnessed:

No

Yes – Have staff witness(es) complete WITNESS STATEMENT FORM

Yes – If witnessed by another resident or visitor, document their observations on WITNESS STATEMENT FORM Evaluation: This fall is thought to be due to:

Cardiovascular condition

Neuromuscular condition

Orthopedic condition

Vision impairment

Cognitive condition

Environmental condition

Other (describe): ___________________ ___________________________________

Notes & Care Plan: The care plan is updated based on this assessment. Nurse’s note written about this fall. Nurse initials Nurse initials

Signature of person completing this worksheet: Date: _______________________

2nd half of page

HUDDLE HUDDLE ::Spaulding Nursing & Therapy Center, North End

Huddle Worksheet

Patient’s name: . Time of fall: .

Location of fall: . Time Huddle was called: .

Report of what happened: .

Report of intervention: .

Rehab Screen needed: Yes No

Type of service needed: PT OT SLP Members Present at Huddle:

1. 2. 3. 4.

Join the HUDDLE!Help prevent the next fall!

Huddle in ProgressHuddle in Progress

How are we doing?

Let’s do even better in September.

Join the HUDDLE on your unit.

Help us prevent the next fall.

Thank you for all your hard work & care! Posted. 9/7/10

FALLS May ‘10 19 falls 15 residents June ‘10 24 falls 15 residents –

1 resident fell 5 times! July ‘10 25 falls 13 residents –

1 resident fell 5 times!

August ‘10 11 falls 8 residents

Mr SS fell twice. Mr EM fell three times.

We did a terrific job in preventing falls

in August!

Trend but Trend but considerconsider::

Fall numbers will rise while

“frequent fallers” are in the house

& fall when they leave.

Our fall dataOur fall data::

0

5

10

15

20

25

30

2010 2011

0

5

10

15

20

25

30

Falls with injuries

All Falls

Our fall dataOur fall data::

2010 2011

Trending all Trending all eventsevents:: FALL / RELATED INJURIES EVENT BY TYPE See log* Rpt DPH

Date

Unit Time Resident Fall

No Yes If yes,injury type Rsdt-

Rsdt

Bruis

e

Othe

r Skin

Othe

r

Alleg

ation

Elop

emen

t

Emplo

yee

Notes & Other Events

Med event if yes, date

1-May 2 Anne See Med Event log 1

2-May 4 7:35a Bernard 1 1leaned forward from WC and fell to floor; laceration on eyebrow sent to ER; wound sutured 3-May

2-May 3 10:10a Carolyn 1 Bruise found on posterior hand; phlebotomy draw yesterday

4-May 4 11:30a Dora 1 1 Fall from toiled during BM

4-May 4 2:00p Edward 1 Skin tear noted on LLE; rsdt says bumped on leg rest of WC

5-May Frost, Frank 1 See Employee Event Log5-May 2 5:15p Geraldine 1 1 Spilled hot soup in lap; denies pain; area pinkened immediately post event

5-May 3 12noon Howard 1 1 abrasion In main DR; tried to help peer to her seat; witnessed fall to knees

6-May 3 3:15p Imogen 1 1Roommate summoned staff; rsdt found on floor beside bed; rsdt report tried to go back to bed w/o help

6-May 4 2:00p Joyce 1 missing hearing aide

7-May 4 6:20p Kate 1 1 found on floor outside of room; said going to work; no injury; restless

7-May 4 7:10p Kate 1 1 c/o hip pain

seated in corridor for observation; witnessed evt: pt rose from chair & fell to left rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb

8-May 3 2:30a Louise 1 1 See Med Event log 1

TOTALS 7 4 3 0 1 2 2 0 0 1 2

STAFF:

Resident-to-Resident

Bruise

Other Skin

Other/Misc

Allegation

Elopement

Employee

Trending all eventsTrending all events:: FALL / RELATED INJURIES EVENT BY TYPE See log* Rpt DPH

Date

Unit Time Resident Fall

No Yes If yes,injury type Rsdt-

Rsdt

Bruis

e

Othe

r Skin

Othe

r

Alleg

ation

Elop

emen

t

Emplo

yee

Notes & Other Events

Med event if yes, date

1-May 2 Anne See Med Event log 1

2-May 4 7:35a Bernard 1 1leaned forward from WC and fell to floor; laceration on eyebrow sent to ER; wound sutured 3-May

2-May 3 10:10a Carolyn 1 Bruise found on posterior hand; phlebotomy draw yesterday

4-May 4 11:30a Dora 1 1 Fall from toiled during BM

4-May 4 2:00p Edward 1 Skin tear noted on LLE; rsdt says bumped on leg rest of WC

5-May Frost, Frank 1 See Employee Event Log5-May 2 5:15p Geraldine 1 1 Spilled hot soup in lap; denies pain; area pinkened immediately post event

5-May 3 12noon Howard 1 1 abrasion In main DR; tried to help peer to her seat; witnessed fall to knees

6-May 3 3:15p Imogen 1 1Roommate summoned staff; rsdt found on floor beside bed; rsdt report tried to go back to bed w/o help

6-May 4 2:00p Joyce 1 missing hearing aide

7-May 4 6:20p Kate 1 1 found on floor outside of room; said going to work; no injury; restless

7-May 4 7:10p Kate 1 1 c/o hip pain

seated in corridor for observation; witnessed evt: pt rose from chair & fell to left rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb

8-May 3 2:30a Louise 1 1 See Med Event log 1

TOTALS 7 4 3 0 1 2 2 0 0 1 2

STAFF:

All fallsAll falls With or w/o injury

Fall Risk Assessment Fall Risk Assessment ToolsTools::

Valid? For what population? In what setting?

But if every one is at risk. . . . .nearly

is it useful???

What’s been triedWhat’s been tried??

Staff education

Reprimands for high fall rates

Rewards for low fall rates

Falling Stars & Falling Leaves

Colored bracelets or socks

Bed & chair alarms

Restraints

Falling Stars/LeavesFalling Stars/Leaves

On door jams, foot boards, bracelets, care cards

Be realistic

Policies

Forms & Documentation

Interventions

What’s been tried? Staff education

Reprimands for high fall ratesRewards for low fall ratesFalling Stars & Falling Leaves Colored braceletsColored slippers Bed & chair alarms Restraints

What else?

Lots strategies workMost do work

To sustain results, best ==

QI principlesTrending Sharing trends with staffVaried reminders & education

In the SHORT TERMIn the SHORT TERM

“Borrow ideas” from other SNFs

For example:

Prevent the next fall.

Mind your ‘P’s! PAIN

POTTY

POSITION

PERSONAL ITEMS

PLUGS

Tend to the pain.

Toilet the patient.

Reposition for safety

& comfort. Place within

reach. Things plugged into

pts.

Reasons to limit restraint use

#1:#1: RESTRAINTS DO NOT REDUCE FALL RATES

#2:#2: RESTRAINTS MAY INJURE

OR KILL PATIENTS

Reasons to limit restraint use

Reasons to limit restraint use

#3:#3: RESTRAINTS JEOPARDIZE

SURVEY RESULTS

Reasons to limit restraint use Increase risk of complications

Skin breakdownDecrease mobilityDisorientFrighten

Isolate Injure Risk death Liability F-Tags

Remember when?

1980’sAdmission orders:

PRN Tylenol PRN MOM PRN Haldol PRN Vest restraint

Miles & Irvine, 1992

S Miles,

S Miles,

S Miles, 1996

When falls occurred pre-OBRA:

Nurse assessed for gross injuriesNurse put bandage on boo-booNurse tied Mrs B to her chairNurse tied chair to the handrail

When falls occurred post-OBRA:

MDS prompts consideration:MDS prompts consideration:

Infection?

Medication?

Glasses/vision?

etc.

Facility QI trending:Facility QI trending:

Location?

Time?

Equipment?

Personnel

Respond to trends:

Staff education

Address “not-my-patient” syndrome

Toileting schedules

Activities

EVERY one involved?

Nurses & Nsg MgtNursing AssistantsRestorative AidesPTs & OTsResident Resident’s family

Maintenance staffHousekeepersDietitiansDietary aidesStaff DevelopmentPharm ConsultantAdministrator Medical Director

Facility-wide interventions

All staff involved

Remove clutter

Assess staff competence w/ transfers

Assess staff competence w/ equipment

Assess, address & reassess individuals

Individualize interventions

Consider the falls:Clinically?From what position? Where? When? Circumstances?

Falls from what position?

Falls fromBEDBED

↓↓

Falls fromCHAIRCHAIR

↓↓

Falls fromSTANDINGSTANDING

↓↓

Benefit from PT?Need assistive devices?

Develop menu of possible interventions

Falls where?

Bedroom?

En route toilet?

Toilet?

Outside?

Activities?

Falls when?

During night? Early AM? Late afternoon? Bwt dinner & bed? After certain activity?

Change of shift?

Summary: For individual:

AssessEducate Address ReassessRe-address

For population:Assess/trendEducate Address Continue to monitorRe-address

Summary:

“Falling itself is not a diagnosis but a symptom of multiple underlying diseases,

the effects of certain medications …, and /or environmental hazards or obstacles

that interfere with safe mobility”(Tideiksarr, 1993)

Summary:

Therefore, individual assessments must be frequent and interdisicplinary.

And each rsdt’s care plan must also be frequently reviewed and interdisicplinary.

Summary:

And…And… Trending must be continuous, thoughtful,

& interdisciplinary. Facility-wide interventions must be thoughtful,

interdisciplinary, & continuously reviewed, reinforced, and changed as trending indicates.

Summary of Summary of strategiesstrategies::

Include ‘front line’ staff in developing care plans

Include ‘front line’ staff in changing practice

Trend falls

Share fall trends with staff

Periodic and varied in-services

Fliers (in staff-access areas)

Be creative

Share/adopt strategies from other facilities

DiscussionDiscussion. . .. . . To reach Mara:

Mara Aronson, Director of Nursing Spaulding Nursing & Therapy Center, North End 70 Fulton Street Boston, MA 02109 (617) 726-9702 MEAronson@partners.org