Quality Quality Improvement in Improvement in Long Term Care Long Term Care

Program Program FallsFalls PreventionPrevention

Falls Management Falls Management ProgramProgram

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

FIRST STEPSFIRST STEPS

We determined the We determined the need for an initiative need for an initiative by reviewing and by reviewing and analyzing the Quality analyzing the Quality Assurance data Assurance data collected each month. collected each month.

Review current Review current resident falls resident falls assessment from pre-assessment from pre-admission information admission information to current data.to current data.

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SCREENINGSCREENING Review resident applications, many are high-Review resident applications, many are high-

lighted for fall risk.lighted for fall risk. On admission (and quarterly) a FALL RISK On admission (and quarterly) a FALL RISK

ASSESSMENT is completed:ASSESSMENT is completed: Identifies history of fallsIdentifies history of falls Medication usedMedication used Diagnosis and vital signsDiagnosis and vital signs Memory and orientationMemory and orientation Vision and hearing abilityVision and hearing ability Continence levelContinence level Mobility status, including gait analysisMobility status, including gait analysis Related behavioursRelated behaviours

RESIDENT CARE PLANRESIDENT CARE PLANWhen a resident is high/medium risk a care plan is When a resident is high/medium risk a care plan is

developed to identify the risk.developed to identify the risk. FOCUSFOCUS

Potential/ high risk for Falls related to ….. Potential/ high risk for Falls related to ….. GOALGOAL

Prevention of falls.Prevention of falls. INTERVENTIONSINTERVENTIONS

Place wheelchair in tilted back position to prevent exit Place wheelchair in tilted back position to prevent exit from chair and improve positioning.from chair and improve positioning.

Check q1h to ensure safety.Check q1h to ensure safety. Have commonly used articles within easy reach.(papers, Have commonly used articles within easy reach.(papers,

pen, Kleenx)pen, Kleenx) Transfer and Change positions slowly.Transfer and Change positions slowly. Reinforce need to call for assistance, check with resident Reinforce need to call for assistance, check with resident

every 1/2 hour to see if she needs assitanceevery 1/2 hour to see if she needs assitance Put 2 siderails up at all times / when in bed for safety.Put 2 siderails up at all times / when in bed for safety. Seat belt is for safety purposes only. Resident is able to Seat belt is for safety purposes only. Resident is able to

removeremove Call bell with in reach when in bedCall bell with in reach when in bed

POST FALL POST FALL ASSESSMENTASSESSMENT Date, time, locationDate, time, location Head to toe assessment, ROMHead to toe assessment, ROM

ROM, changes to extremitiesROM, changes to extremities Skin condition: abrasions, redness (location, Skin condition: abrasions, redness (location,

size and colour of injury)size and colour of injury) PainPain Head injuryHead injury

Vital signsVital signs Blood pressure : lying and standing (if Blood pressure : lying and standing (if

possible)possible) Pulse, respirationsPulse, respirations

Notify physician and familyNotify physician and family

ENVIRONMENTAL ENVIRONMENTAL FACTORSFACTORS

LightingLighting Call bell within reachCall bell within reach Flooring: wet or cluttered, carpetingFlooring: wet or cluttered, carpeting FootwearFootwear Restrictive clothingRestrictive clothing Glasses/hearing aide within reachGlasses/hearing aide within reach Use of assistive devicesUse of assistive devices

THREE TEARED THREE TEARED DOCUMENTDOCUMENT

1 st 1 st FallFall

2nd 2nd FallFall

3rd 3rd FallFall

Reminders to use call bell Reminders to use call bell

Physio. assessment requested Physio. assessment requested

Toileting routine reviewed Toileting routine reviewed

Initiate q1/2 hour safety Initiate q1/2 hour safety check check

Floor pad placed at bedside Floor pad placed at bedside

Safety alarm in use when in Safety alarm in use when in bed bed

Medical assessment Medical assessment

Hip protectors Hip protectors

Upgraded footwear Upgraded footwear

Installed night light Installed night light

DOCUMENTATIONDOCUMENTATION

Incident report / line listingIncident report / line listing Incidental charting (each shift x 3 days Incidental charting (each shift x 3 days

or 9 shifts)or 9 shifts) Present a clear account of incidentPresent a clear account of incident Factual, precise, descriptive language Factual, precise, descriptive language

recording observationsrecording observations Action taken, MD directiveAction taken, MD directive Vital signsVital signs Family member / SDM: who was notified Family member / SDM: who was notified

Document on shift reportDocument on shift report

REFERRALSREFERRALS PharmacistPharmacist

Pharmacological reviewPharmacological review Makes recommendations to MDMakes recommendations to MD EducationEducation

PhysiotherapistPhysiotherapist Assess balance (gait) and mobilityAssess balance (gait) and mobility Strength and balance trainingStrength and balance training Needs for physio. / rehab / restorative / assistive Needs for physio. / rehab / restorative / assistive

devicesdevices Transfer adviceTransfer advice educationeducation

PREVENTIONPREVENTION Care Plans will be reviewed and updated, Care Plans will be reviewed and updated,

review toileting routines, transferring needs review toileting routines, transferring needs and mobilityand mobility

Prevention strategies will also identify safety Prevention strategies will also identify safety equipment such as mattresses on the floor, equipment such as mattresses on the floor, safety monitors/alarms for chair and bed, hip safety monitors/alarms for chair and bed, hip protectors.protectors.

A multidisciplinary team meeting including the A multidisciplinary team meeting including the resident (if resident (if appropriate) and their family appropriate) and their family will be held will be held following the assessment following the assessment process to problem solve and draw an process to problem solve and draw an

action plan for falls prevention.action plan for falls prevention.

Falls DrillsFalls Drills

On the scheduled date, a staff member will be On the scheduled date, a staff member will be assigned the role of “fallen person”. A case assigned the role of “fallen person”. A case study scenario will be given to this staff study scenario will be given to this staff member outlining their diagnosis, any injuries member outlining their diagnosis, any injuries and the circumstances surrounding the “fall”.and the circumstances surrounding the “fall”.

Once the team discovers the “fallen person”, Once the team discovers the “fallen person”, they will proceed to care for them according they will proceed to care for them according to policy and procedure for falls management.to policy and procedure for falls management.

The Falls Drill Report is completed by care The Falls Drill Report is completed by care team and submitted to the Director of Care. A team and submitted to the Director of Care. A debriefing meeting will be held following the debriefing meeting will be held following the drill to review the procedure and education as drill to review the procedure and education as needed.needed.

EVALUATION OF EVALUATION OF PROGRAMPROGRAM

2005 = total falls 7992005 = total falls 799 2006 = total falls 5262006 = total falls 526 2007 = total falls 4502007 = total falls 450 2008 to present, focus on 2008 to present, focus on

sustainabilitysustainability

Setting up a Falls Prevention Setting up a Falls Prevention ProgramProgram

Start small – set goalsStart small – set goals Introduce the initiative to the Leadership Introduce the initiative to the Leadership

team, then departmental teams (get buy-in)team, then departmental teams (get buy-in) Select one unit (the most interested team) to Select one unit (the most interested team) to

trial the program trial the program Get input and evaluate the program as you Get input and evaluate the program as you

go, be open to new ideasgo, be open to new ideas Embrace challengesEmbrace challenges Celebrate successesCelebrate successes Maintain the commitment to be Maintain the commitment to be Resident Resident

FocusedFocused

Falls CommitteeFalls Committee In September 2009 we resumed our falls In September 2009 we resumed our falls

committeecommittee Consisting of RN’s, RPN’s, PSW’s, a Consisting of RN’s, RPN’s, PSW’s, a

Restorative Care Assistant, our Dietician, Restorative Care Assistant, our Dietician, the Physiotherapist and the Safety & the Physiotherapist and the Safety & Wellness Wellness

Co-ordinatorCo-ordinator Each discipline brings a unique Each discipline brings a unique

perspective on how to prevent fallsperspective on how to prevent falls A “Frequent Fall Assessment” was created A “Frequent Fall Assessment” was created

and are reviewed at meetingsand are reviewed at meetings

Frequent Fall Frequent Fall AssessmentAssessment

AgeAge Device (transfer pole, trapeze)Device (transfer pole, trapeze) Aide (wheelchair, walker or Aide (wheelchair, walker or

cane)cane) Medical ConditionsMedical Conditions DementiaDementia PainPain

Physiotherapy Physiotherapy AssessmentAssessment

Tenetti and/or Berg ScoreTenetti and/or Berg Score Identified GaitIdentified Gait BalanceBalance Range of MotionRange of Motion WeaknessWeakness TransfersTransfers

MedicationsMedications

Antianxiety Antianxiety AntidepressantsAntidepressants Treatment of Osteoporosis Treatment of Osteoporosis

(specifically Vitamin D)(specifically Vitamin D) AnalgesicsAnalgesics Was there a medication Was there a medication

change?change?

RestraintsRestraints

Review the use of restraint Review the use of restraint with the staff, the resident, the with the staff, the resident, the family or SDM and the family or SDM and the Occupational TherapistOccupational Therapist

Did the restraint contribute to Did the restraint contribute to the fall?the fall?

Can the restraint be removed?Can the restraint be removed?

Post Fall AssessmentPost Fall Assessment

Review the Post Fall AssessmentReview the Post Fall Assessment EnvironmentEnvironment TimeTime LocationLocation BehaviourBehaviour FootwearFootwear Vital SignsVital Signs

DocumentationDocumentationReview the ChartReview the Chart What were they doing before the What were they doing before the

fall?fall? Laboratory Results?Laboratory Results? Infections?Infections? Bath day?Bath day? Were they ill?Were they ill? Any behaviours?Any behaviours?

Pattern and CausePattern and Cause

Consider all factors and Consider all factors and opinions to opinions to identify any identify any pattern and probable cause!pattern and probable cause!

What interventions have What interventions have already been tried? Were already been tried? Were they effective?they effective?

SuggestionsSuggestions

ReferralsReferrals Pharmacist ReviewPharmacist Review OT ReferralOT Referral Physician ReviewPhysician Review PT ReferralPT Referral Responsive Responsive

Behaviour TeamBehaviour Team Dietician ReviewDietician Review

ActionsActions Safety ChecksSafety Checks Increase ActivitiesIncrease Activities Increase ExerciseIncrease Exercise Restraint Restraint

AlternativesAlternatives Modify EnvironmentModify Environment New footwearNew footwear Other……Other……

Review with The Review with The Resident Resident

and Their Familyand Their Family Discuss the Fall(s) and Review Discuss the Fall(s) and Review

findingsfindings Present SuggestionsPresent Suggestions ListenListen Respect their viewsRespect their views Establish a common goal!Establish a common goal!

EvaluateEvaluate

Evaluate effectiveness of Evaluate effectiveness of individual cases at Falls individual cases at Falls CommitteeCommittee

Monitor Falls Prevention Monitor Falls Prevention Program with Quality and Program with Quality and Risk Management CommitteeRisk Management Committee

‘‘Frequent Faller’ case Frequent Faller’ case reviewreview 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 ContinuedCase Review Continued

Mr. W. has had 3 falls at different times Mr. W. has had 3 falls at different times of day, all in his room while his wife was of day, all in his room while his wife was assisting him to stand to go to the assisting him to stand to go to the washroom. Both have call bells within washroom. Both have call bells within reach, neither remember to use them.reach, neither remember to use them.

Mr. W. has a diagnosis of Osteoporosis Mr. W. has a diagnosis of Osteoporosis and during his last fall, he obtained a and during his last fall, he obtained a compression fracture. The physician has compression fracture. The physician has prescribed Fentanyl Patch and Tylenol prescribed Fentanyl Patch and Tylenol #3 prn.#3 prn.

Mr. And Mrs. WMr. And Mrs. W

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

Pattern Pattern InterventionsInterventions The pattern is easy The pattern is easy

in this case.in this case. For the past 60 For the past 60

years, Mrs. W. has years, Mrs. W. has cared for her cared for her husband.husband.

It would be It would be unrealistic to unrealistic to expect that to expect that to change.change.

Safety checks Safety checks were initiatedwere initiated

Both resident Both resident were reminded to were reminded to call for assistancecall for assistance

Mr W. has been Mr W. has been co-operative co-operative with exercises with exercises suggested by PTsuggested by PT

Some SuggestionsSome Suggestions Pharmacist review of treatment of Pharmacist review of treatment of

Osteoporosis and Pain ControlOsteoporosis and Pain Control OT referral for transferring device (if a OT referral for transferring device (if a

pole is there he might use it)pole is there he might use it) PT referral for strengthening exercise PT referral for strengthening exercise

and safe transfersand safe transfers Adjoining room when availableAdjoining room when available Review and modify toileting scheduleReview and modify toileting schedule Continue Safety ChecksContinue Safety Checks

Looking to the FutureLooking to the Future The committee will The committee will

Identify those at Identify those at risk using the risk using the “Falls RAP Key” “Falls RAP Key”

Increase exercise Increase exercise through restorative through restorative care initiativescare initiatives

Explore risks and Explore risks and treatment of treatment of OsteoporosisOsteoporosis

Questions?