1. Falls Reduction Betsy Willy MA, PT, CWS Pathway Health Services January 2012

2. Falls Management Goal Eliminate Restraints and alarms without increasing falls or injuries from falls

3. We all know: Alarms Do Not Prevent Falls Alarms are scary Alarms are scary Alarms are humiliating Alarms are humiliating Alarms annoy roommates Alarms annoy roommates Folks with alarms are afraid to move Folks with alarms are afraid to move Staff become immune to alarms Staff become immune to alarms Alarms add to auditory clutter and chaos Alarms add to auditory clutter and chaos Alarms create agitation which leads to poor safety judgment Alarms create agitation which leads to poor safety judgment Why do we use them?? Why do we use them??

4. No one wants to be restrained MDS: Coding Definition A restraint is any device that prevents you from doing something you could do without the device or from accessing your body parts

5. Examples for Correct Coding Deciding if a device is a restraint depends on the effect it has on this individual Deciding if a device is a restraint depends on the effect it has on this individual A dependent resident with a seat belt or lap buddy is not restrained A dependent resident with a seat belt or lap buddy is not restrained A seat belt is a restraint when used on a resident who rises unsupervised from the wheelchair - if he cannot open it independently A seat belt is a restraint when used on a resident who rises unsupervised from the wheelchair - if he cannot open it independently A lap tray is a restraint if it prevents a capable resident from scratching their thigh. A lap tray is a restraint if it prevents a capable resident from scratching their thigh.

6. Hierarchy of Restraints From least to most safe: From least to most safe: –Seat belt loosely applied –Lap Tray –Lap Buddy –Snug seat belt –Tilt in space seat From least to most dignified: From least to most dignified: –Lap Buddy –Lap Tray –Seat Belt –Tilt in space seat

7. Death by Entrapment: Seat Belt, Side rail, U Bar Fireman’s Pole

8. Recent Colorado Deaths Eliminate side rails Eliminate side rails –Lower bed –Fall mat Eliminate seat belts except for individuals with severe extension tone Eliminate seat belts except for individuals with severe extension tone Recommendations: Recommendations: –Fireman’s pole and U Bar placement No further then 4 inches from mattress OR no further then half the width of the thorax –Tie down Mattress to prevent slippage

9. When reducing or eliminating restraint use First - put effective alternatives in place First - put effective alternatives in place –Gravity assisted seating –Visual supervision –Opportunities Alternative positioning –Fix root cause UTI UTI Medication issues etc Medication issues etc Second – progressive reduction with family participation, care plan, & documentation of results Second – progressive reduction with family participation, care plan, & documentation of results –Off when visually supervised Meals and activity –Off during most coherent time of day Not when “sun-downing” –Increase off time till device is eliminated

10. Managing Family Resistance Are you treating the family’s needs or the resident’s needs? Are you treating the family’s needs or the resident’s needs? On admission – provide pamphlet and explain policy “We are a restraint free facility” On admission – provide pamphlet and explain policy “We are a restraint free facility” –Don’t wait for the issue to become urgent Explore their fear with them Explore their fear with them Create a safe plan Create a safe plan Explain safe plan to family showing them how it can work Explain safe plan to family showing them how it can work When eliminating a restraint - Do not take restraint off until safe plan is in place and working When eliminating a restraint - Do not take restraint off until safe plan is in place and working Do a gradual progression with good family feedback Do a gradual progression with good family feedback When all else fails, do 30 day notification, so family can find a facility which agrees with their philosophy When all else fails, do 30 day notification, so family can find a facility which agrees with their philosophy

11. Prevention of Falls Stable staffing Stable staffing –Units –Neighborhoods Relationships Relationships –Knowing them so well, you can predict behaviors Ownership of resident’s safety Ownership of resident’s safety –Caring for your own

12. Overwhelming Sense of Responsibility for Resident’s safety Awareness of where they are and what they are doing Awareness of where they are and what they are doing Visual supervision Visual supervision –Mobile work stations –Common areas Engaged in relationships and activity – in life! Engaged in relationships and activity – in life! Auditory monitors Auditory monitors

13. Hand off - Communication –Admission –Shift changes –Transfer unit to unit –Transfer to ED –Discharge to home

14. Physical Fitness Use it or Lose it Muscle strength – –Sit to Stand – –Transfers to dining chair Balance – obstacles and reaching – –Over, Under, around and through Endurance – –Walk across America Integrated in all activity Integrated in all activity

15. How are we Supporting Hydration?

16. Preventing Injury: Helmets Ambulatory anti-coagulated residents with poor balance

17. Hip Protectors Prevent Impact that fractures osteoporotic hip Prevent Impact that fractures osteoporotic hip VISN8: Hip protection implementation tool kit VISN8: Hip protection implementation tool kit

18. Falls from Beds Sitting on edge of bed and reaching –Slippery incontinence pads or bed spreads –Overinflated low air loss mattresses –Bed higher then knee height

19. Falls Related to Seating Unlocked Brakes Unlocked Brakes Over reaching Over reaching Sliding Sliding Tipping chair Tipping chair Unassisted transfers Unassisted transfers

20. Failure to lock brakes: Anti-rollback brakes Advantages: Advantages: –prevents roll back during attempts to independently transfer Disadvantages: Disadvantages: –Must be carefully adjusted to prevent excess pressure on ischial tuberosity

21. Over Reaching Over Reaching Center of gravity must remain within the base of support Center of gravity must remain within the base of support Leaning forward will tip this guy Leaning forward will tip this guy Increase seat depth and length of wheel base Increase seat depth and length of wheel base

22. Why DO folks attempt to get out of their chairs? Uncomfortable – –Pain – –Fatigue Boredom – –Lack of engagement with others – –Left for long periods in front of TV or in their rooms Confusion – –Agitation/anxiety Need to move !!

23. Provide Alternative Options – YOU don’t sit in one chair all day long!

24. Fit The Chair to Resident and keep it well maintained

25. CNA’s and Nurses must be able to identify poor W/C fit Correct Fit Correct Fit –Thighs level –Feet flat on floor –Back of chair comes up to mid shoulder bone –Elbows rest on armrests without leaning and without tucking them inside armrests

26. Two Finger Rule Width: Width: –Two fingers of space between hip and side arm Seat depth: Seat depth: –Two fingers of space behind back of calf and edge of seat

27. Most common causes of falls from chairs Due to knees lower then hips putting resident on a sliding board to the floor Due to knees lower then hips putting resident on a sliding board to the floor –Lower seat Seat not deep enough causing chair to tip when resident leans forward Seat not deep enough causing chair to tip when resident leans forward Rises unsafely from chair Rises unsafely from chair –Tip seat using dual axel adjustment –Meet need to move with frequent position changes –Keep engaged in activity and visually supervised

28. Sliding from chair Pulls self from chair propelling down the hall Pulls self from chair propelling down the hall Slumped sitting - oozes from chair Slumped sitting - oozes from chair Effect is worse if seat is too high and knees are lower then hips Effect is worse if seat is too high and knees are lower then hips

29. Gravity Assisted Seating – Eliminate Restraint Need Let gravity help keep the individual in the chair - not slide them out of the chair Let gravity help keep the individual in the chair - not slide them out of the chair Tip chair using dual axel placement Tip chair using dual axel placement –Lower back of seat and raise front –May need to start with lower chair frame

30. What’s wrong with this picture?

31. Tall lean folks: deeper seat, higher off ground, taller back

32. Seat or Cushion Depth Cushion or seat too short – folding forward Cushion or seat Too long – slides into sacral sitting

33. Bariatric Seating Large buttocks push pelvis forward in chair Large buttocks push pelvis forward in chair –Extra depth wheelchair seat –Support low back above buttocks –Tip chair by lowering back of seat and raising front (dual axel chairs) Extra width Extra width Heavy duty chair Heavy duty chair

34. Sacral sitting – high pressure points and pain

35. Kyphotic Back – molded back, extra depth seat and tipped seat

36. Moldable back – Total Contact

37. Recessed deep surround back

38. Exhaustion: COPD or CHF Use Lightweight Chair Average Wheelchair weighs 35-50 pounds plus weight of oxygen tank Average Wheelchair weighs 35-50 pounds plus weight of oxygen tank Rugs create resistance Rugs create resistance Wheels don’t turn equally pulling wc to side Wheels don’t turn equally pulling wc to side

39. Habitual Rocking Elder with Dementia Pacing in a sitting position Pacing in a sitting position Self Stimulation through movement Self Stimulation through movement Solutions: Provide opportunity for movement Stationery glider Stationery glider Frequent opportunities to walk with staff Frequent opportunities to walk with staff Stimulation class Stimulation class Anti-tipping devices - front and rear Anti-tipping devices - front and rear

40. Sounds good but how do we pay for it?? Federal Regulations require facilities to meet the needs of residents it admits Federal Regulations require facilities to meet the needs of residents it admits Reshuffle current wheelchairs Reshuffle current wheelchairs –Wheelchair Rodeo Utilize dual axel component on chairs already owned by facility Utilize dual axel component on chairs already owned by facility Prioritize - meet needs of frequent fallers first Prioritize - meet needs of frequent fallers first Prioritize - acquire chairs with deeper seats Prioritize - acquire chairs with deeper seats Therapy assessments and reassessments are reimbursable Therapy assessments and reassessments are reimbursable Delegate: Tracking orders – purchasing Delegate: Tracking orders – purchasing Delegate: Maintenance of chairs – maintenance Delegate: Maintenance of chairs – maintenance

41. Resources - Google Joann Rader Joann Rader –Rethinking Personal Alarms –Individualized Wheelchair Seating for Older Adults CMS – MDS 3.0 Resident Assessment Instrument (RAI) manual for examples of Restraint coding CMS – MDS 3.0 Resident Assessment Instrument (RAI) manual for examples of Restraint coding Mountain Pacific QIO web site: Seating ideas Mountain Pacific QIO web site: Seating ideas –Falls tool box: Betsy Willy PT, MA VISN – 8 Hip protector implementation tool kit VISN – 8 Hip protector implementation tool kit VISN – 8 Falls conference - May 2012, Tampa Florida VISN – 8 Falls conference - May 2012, Tampa Florida Family Pamphlet - Reducing Restraint Use in Nursing homes: A guide for Residents and Families – Colorado Foundation for Medical Care web site Family Pamphlet - Reducing Restraint Use in Nursing homes: A guide for Residents and Families – Colorado Foundation for Medical Care web site Email Betsy Willy: Betsy.willy@pathwayhealth.com Email Betsy Willy: Betsy.willy@pathwayhealth.com