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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 10-15 times more likely to sustain hip fracture than 60-65 yr. olds • Tall people appear to have an increased risk of hip fracture when they fall Long Term Care Population • 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 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 Fall Risk Factors Effects of Aging • 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 Medications • Antidepressants • Antihypertensives • Antipsychotics • Benzodiazepines • Diuretics • Digoxin • Narcotics • Sedative/hypnotics Fall Risk Factors Medications • 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 Equipment Wheelchairs • Poor maintenance and need for repair • Incorrect fit • Wheelchair seating problems • Missing or lost parts In Summary • 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 Business Case for Falls Prevention • 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 It is Impossible to Prevent All Falls! It is possible to use an interdisciplinary team to: • Reduce the frequency • Utilize a multifaceted approach • Implement individualized interventions • Document your actions carefully to reduce the likelihood of litigation Changing your Organizational Culture • Create a blame-free environment for reporting errors/injuries… ….changing your culture • Improve your incident reporting systems Changing Your 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 Blame-Free Environment • Create an atmosphere for reporting errors without punishment • Make it easy for staff to admit mistakes • Focus on the system, not the individual Strategies to Reduce Fall Risk • 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 Falls Investigation • 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 Use a Comprehensive Report Form • • • • • • Assessment and evaluation Circumstances of fall Causes Staff response Persons notified Injuries 8 Step Fall Response • Evaluate and monitor 24-72 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 Collect and Analyze Falls Data • Fall definition is clear to all • Comprehensive investigative and documentation tool • Easy data entry and analysis • Trending and feedback to staff Analyze Falls Monthly • • • • • • # of falls # of fallers # of serious injuries # of recurrent fallers (2 or more) Look by unit, shift, day, location Trend your data over time Behavior Management • 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 Activities • 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 Promote Positive Behavior • 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 Emory Falls Program is available along with other restraint tools on www.medqic.org -click nursing home (top) -click physical restraint (left) -click tools (right) -click falls management program -click print