Quality Improvement in Long Term Care Program Falls Prevention

Falls Management Program The purpose of a falls management program is to assess each resident fall risk. To assess each resident’s fall risk, ensure the resident’s immediate safety and to ensure further safety and fall prevention through a multidisciplinary approach.

FIRST STEPS We determined the need for an initiative by reviewing and analyzing the Quality Assurance data collected each month. Review current resident falls assessment from pre-admission information to current data.

SCREENING Review resident applications, many are high-lighted for fall risk. On admission (and quarterly) a FALL RISK ASSESSMENT is completed: Identifies history of falls Medication used Diagnosis and vital signs Memory and orientation Vision and hearing ability Continence level Mobility status, including gait analysis Related behaviours

RESIDENT CARE PLAN When a resident is high/medium risk a care plan is developed to identify the risk. FOCUS Potential/ high risk for Falls related to ….. GOAL Prevention of falls. INTERVENTIONS Place wheelchair in tilted back position to prevent exit from chair and improve positioning. Check q1h to ensure safety. Have commonly used articles within easy reach.(papers, pen, Kleenx) Transfer and Change positions slowly. Reinforce need to call for assistance, check with resident every 1/2 hour to see if she needs assitance Put 2 siderails up at all times / when in bed for safety. Seat belt is for safety purposes only. Resident is able to remove Call bell with in reach when in bed

POST FALL ASSESSMENT Date, time, location Head to toe assessment, ROM ROM, changes to extremities Skin condition: abrasions, redness (location, size and colour of injury) Pain Head injury Vital signs Blood pressure : lying and standing (if possible) Pulse, respirations Notify physician and family

ENVIRONMENTAL FACTORS Lighting Call bell within reach Flooring: wet or cluttered, carpeting Footwear Restrictive clothing Glasses/hearing aide within reach Use of assistive devices

THREE TEARED DOCUMENT 1 st Fall 2nd Fall 3rd Fall Reminders to use call bell Physio. assessment requested Toileting routine reviewed Initiate q1/2 hour safety check Floor pad placed at bedside Safety alarm in use when in bed Medical assessment Hip protectors Upgraded footwear Installed night light

DOCUMENTATION Incident report / line listing Incidental charting (each shift x 3 days or 9 shifts) Present a clear account of incident Factual, precise, descriptive language recording observations Action taken, MD directive Vital signs Family member / SDM: who was notified Document on shift report

REFERRALS Pharmacist Physiotherapist Pharmacological review Makes recommendations to MD Education Physiotherapist Assess balance (gait) and mobility Strength and balance training Needs for physio. / rehab / restorative / assistive devices Transfer advice education

PREVENTION Care Plans will be reviewed and updated, review toileting routines, transferring needs and mobility Prevention strategies will also identify safety equipment such as mattresses on the floor, safety monitors/alarms for chair and bed, hip protectors. A multidisciplinary team meeting including the resident (if appropriate) and their family will be held following the assessment process to problem solve and draw an action plan for falls prevention.

Falls Drills On the scheduled date, a staff member will be assigned the role of “fallen person”. A case study scenario will be given to this staff member outlining their diagnosis, any injuries and the circumstances surrounding the “fall”. Once the team discovers the “fallen person”, they will proceed to care for them according to policy and procedure for falls management. The Falls Drill Report is completed by care team and submitted to the Director of Care. A debriefing meeting will be held following the drill to review the procedure and education as needed.

EVALUATION OF PROGRAM 2005 = total falls 799 2006 = total falls 526 2008 to present, focus on sustainability

Setting up a Falls Prevention Program Start small – set goals Introduce the initiative to the Leadership team, then departmental teams (get buy-in) Select one unit (the most interested team) to trial the program Get input and evaluate the program as you go, be open to new ideas Embrace challenges Celebrate successes Maintain the commitment to be Resident Focused

Falls Committee In September 2009 we resumed our falls committee Consisting of RN’s, RPN’s, PSW’s, a Restorative Care Assistant, our Dietician, the Physiotherapist and the Safety & Wellness Co-ordinator Each discipline brings a unique perspective on how to prevent falls A “Frequent Fall Assessment” was created and are reviewed at meetings

Frequent Fall Assessment Age Device (transfer pole, trapeze) Aide (wheelchair, walker or cane) Medical Conditions Dementia Pain

Physiotherapy Assessment Tenetti and/or Berg Score Identified Gait Balance Range of Motion Weakness Transfers

Medications Antianxiety Antidepressants Treatment of Osteoporosis (specifically Vitamin D) Analgesics Was there a medication change?

Restraints Review the use of restraint with the staff, the resident, the family or SDM and the Occupational Therapist Did the restraint contribute to the fall? Can the restraint be removed?

Post Fall Assessment Review the Post Fall Assessment Environment Time Location Behaviour Footwear Vital Signs

Documentation Review the Chart What were they doing before the fall? Laboratory Results? Infections? Bath day? Were they ill? Any behaviours?

What interventions have already been tried? Were they effective? Pattern and Cause Consider all factors and opinions to identify any pattern and probable cause! What interventions have already been tried? Were they effective?

Suggestions Referrals Actions Pharmacist Review OT Referral Physician Review PT Referral Responsive Behaviour Team Dietician Review Safety Checks Increase Activities Increase Exercise Restraint Alternatives Modify Environment New footwear Other……

Review with The Resident and Their Family Discuss the Fall(s) and Review findings Present Suggestions Listen Respect their views Establish a common goal!

Evaluate Evaluate effectiveness of individual cases at Falls Committee Monitor Falls Prevention Program with Quality and Risk Management Committee

‘Frequent Faller’ case review Mr. and Mrs. W. are a very pleasant couple who have been married for 60 years. Each have their own room in a nursing home but have chosen to push both beds together in one room and use the other room down the hall, as a sitting area. Both residents have moderate dementia. Mr. W has noticeable weakness, walks stooped over, has difficulties balancing while standing and refuses to use his walker or even to grasp hand rails in hall.

Case Review Continued Mr. W. has had 3 falls at different times of day, all in his room while his wife was assisting him to stand to go to the washroom. Both have call bells within reach, neither remember to use them. Mr. W. has a diagnosis of Osteoporosis and during his last fall, he obtained a compression fracture. The physician has prescribed Fentanyl Patch and Tylenol #3 prn.

Mr. And Mrs. W One daughter, wants the residents separated, the other three children want their parents to remain together. Mr. and Mrs. W. don’t want to be separated. All agree to adjoining rooms which are not available at this time.

Pattern Interventions The pattern is easy in this case. For the past 60 years, Mrs. W. has cared for her husband. It would be unrealistic to expect that to change. Safety checks were initiated Both resident were reminded to call for assistance Mr W. has been co-operative with exercises suggested by PT

Some Suggestions Pharmacist review of treatment of Osteoporosis and Pain Control OT referral for transferring device (if a pole is there he might use it) PT referral for strengthening exercise and safe transfers Adjoining room when available Review and modify toileting schedule Continue Safety Checks

Looking to the Future The committee will Identify those at risk using the “Falls RAP Key” Increase exercise through restorative care initiatives Explore risks and treatment of Osteoporosis

Questions?