Falls Management Tiresa Parker Learning Session 1 October 2008

Risk of Falls 1 in 3 persons in the community fall every year About ½ of residents in nursing homes fall every year – 30-40% of them will fall again – 1 in 10 residents who fall will have a serious injury (about 11%)

Risk of Falls Most falls happen to women in their homes in the afternoon Physical restraints INCREASE the likelihood of a serious injury resulting from a fall

Risk of Falls and Hip Fractures Increases with Age 87% of fractures in those 65 yrs. and older are caused by falls People 85 yrs. and older are times more likely to sustain hip fracture than yr. olds Tall people appear to have an increased risk of hip fracture when they fall

Older- average age at admission is 82.6 yrs More chronic disease- Over 50% of residents have 3 or more admitting diagnoses More frail –48% receive full time skilled nursing care under physician’s orders –98% require help with bathing –45% require help with eating Long Term Care Population

Consequences of Falls Loss of function and independence Increased fear of falling Increased paperwork for staff Higher acuity level and increased care

Consequences of Falls Poor relations with families and community Poor survey results Monetary awards from lawsuits and increased insurance premiums Increased costs for care and staffing

Fall Risk Factors Effects of Aging Visual –Decreased acuity, contrast sensitivity –Decreased peripheral and night vision –Increased sensitivity to glare Gait –Reduced arm swing –Decreased step length and step height –Slowed reaction time –Slower movement

Fall Risk Factors Effects of Aging Urinary Changes –Feelings of urgency –Frequency Chronic Diseases –Diabetes, stroke, hyper/hypotension –Arthritis, osteoarthritis, foot problems –Parkinson’s, Alzheimer’s, other dementias –Depression Acute Diseases –Elder response

Poor Safety Practices –Management of environment & equipment –Toileting, bathing –Transfer and ambulation –Behavior management Environment –Clutter, lighting, flooring, handrails –Bed wheels, side rails, and beds –Hard to reach items Fall Risk Factors Effects of Aging

Fall Risk Factors Medications Antidepressants Antihypertensives Antipsychotics Benzodiazepines Diuretics Digoxin Narcotics Sedative/hypnotics

Residents taking antipsychotics (Risperadol), antidepressants (Zoloft or Elavil) or benzodiazepines (Ativan) are 2-3 times more likely to fall because of side effects: –Drowsiness, over sedation –Agitation, confusion, pacing –Unsteadiness –Gait disturbance –Dizziness, orthostatic hypotension Fall Risk Factors Medications

The more medications a resident takes, the higher the fall risk Residents on 5-9 medications are 4 times more likely to fall Taking over 10 medications was associated with a 6-fold increase in falls Fall Risk Factors Medications

Wheelchairs Poor maintenance and need for repair Incorrect fit Wheelchair seating problems Missing or lost parts Fall Risk Factors Equipment

Falls are a big concern for residents, families, staff, facility administration, regional and corporate offices, state surveyors and the federal government…… By the year 2040 the annual rate of hip fracture in the US will be > 500,000 with an annual cost of $240 billion In Summary

Preventing one fall, you save staff time Preventing one fall with injury, you save even more staff time Preventing one lawsuit related to a fall, you save thousands of dollars in lawyer/settlement cost Business Case for Falls Prevention

Reduce the frequency Utilize a multifaceted approach Implement individualized interventions Document your actions carefully to reduce the likelihood of litigation It is Impossible to Prevent All Falls! It is possible to use an interdisciplinary team to:

Create a blame-free environment for reporting errors/injuries… ….changing your culture Improve your incident reporting systems Changing your Organizational Culture

Leadership Falls are fully reported, investigated and documented All staff, all shifts, all days are trained All staff problem solve All staff are held accountable without blame or shame Changing Your Culture

Create an atmosphere for reporting errors without punishment Make it easy for staff to admit mistakes Focus on the system, not the individual Blame-Free Environment

Complete falls assessment upon admission, annually, and on change in condition (i.e. Morse Scale) Individualized care plan that is evaluated and modified after each assessment or fall Evaluate medical status Evaluate medications Strategies to Reduce Fall Risk

OT/PT evaluation Gait and balance training Evaluate behaviors Increased activity and exercise programs Evaluate equipment/posturing devices Assess toileting schedule Strategies to Reduce Fall Risk

Utilize low beds and mats Individualized wheelchair seating Alarms and sensors Reduce to ¼ or ½ side rails Utilize concave mattresses Hip protectors Strategies to Reduce Fall Risk

Provide safe footwear Promote safe transfers Remove clutter Strategies to Reduce Fall Risk

Assessment and immediate intervention at the time of the fall to determine the cause and prevent future falls Current care plan reviewed and modified within 72 hours of the fall Falls Investigation

Assessment and evaluation Circumstances of fall Causes Staff response Persons notified Injuries Falls Investigation Use a Comprehensive Report Form

Evaluate and monitor hrs. Investigate fall Record circumstances, outcomes, and staff response Communicate to PCP Immediate intervention Complete falls assessment Develop plan of care Monitor interventions and patient response 8 Step Fall Response

Fall definition is clear to all Comprehensive investigative and documentation tool Easy data entry and analysis Trending and feedback to staff Collect and Analyze Falls Data

# of falls # of fallers # of serious injuries # of recurrent fallers (2 or more) Look by unit, shift, day, location Trend your data over time Analyze Falls Monthly

50-80% of residents have some form of cognitive loss (due to dementia) ½ of these residents have behavioral symptoms Residents with dementia have a higher risk of falling, are more likely to have an injury Utilize a behavior log to target behaviors clearly Behavior Management

Increase the number and levels of activities and exercise programs Utilize activities staff Use volunteers, families, students and friends to supervise residents Use activity boxes on units Reminiscence box Activities

Keep something interesting in your pocket to distract or stimulate resident’s interest Talk about things that interest resident Sing or say some lines of a song, hymn or poem Demonstrate safe exercise Use a memory book Promote Positive Behavior

Emory Falls Program is available along with other restraint tools on -click nursing home (top) -click physical restraint (left) -click tools (right) -click falls management program -click print