Falls in Ontario LTC Settings: Laura M. Wagner, PhD, RN

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Falls in Ontario LTC Settings
Laura M. Wagner, PhD, RN Nursing
Scientist Kunin-Lunenfeld Applied Research Unit
at Baycrest
Kunin-Lunenfeld Applied Research Unit
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Acknowledgments and Funding

• Canadian Patient Safety Institute
• Ontario LTC Association
• Krista Robinson-Holt, RN, MN (Co-I)
• Jennifer Langston
• OLTCA Applied Research Committee
• Family representative Ms. Krystyna Schmidt
• Participating LTC Facilities
• Research Team
• Nina Mafrici, Julie Andrassy, Joanna Dionne,
  Hannah Gao, Xiao Jin Chen, Yannie Aass
• Thecla Damianakis, PhD, MSW

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Background

• Falls are the most frequently reported adverse
  incident in LTC settings
• Approximately 50 of residents fall each year
• Numerous studies have addressed falls in LTC,
  very few have focused on the processes of
  identification, implementation, and communication
  regarding the management of falls

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Research Questions

• What fall risk factors are identified by nursing
  staff and which factors result in associated
  interventions documented on the fall risk care
  plan?
• What fall prevention strategies are listed in the
  fall risk care plan and are these interventions
  correctly implemented into actual practice?
• How is care plan information regarding falls
  communicated and implemented to the health care
  team?

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Methodology

• Descriptive correlational design in 8 randomly
  selected homes in and around central Ontario
  (gt100 beds)
• Range 120-170 avg. monthly census
• Data collection
• Monthly incident report review
• Medical record review
• Quarterly rounds to examine care plan
  interventions
• Focus groups

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Resident Demographics

• N 635
• Average age 82.27years (10.22SD)
• Average Length of stay 28 months
• Female 67
• Risk factors
• Fall history 66 Dizziness 14
• Wandering 26 Anxiolytic 32
• Antidepressants 44 Restraint 6

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Falls

• 1901 Total Reported Falls among the 8 facilities
  over 1 year period
• Average 20 falls per facility/per month
• Range 6 - 37
• Average 3 falls per faller/per year
• Range 1 - 35

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Care Plan/Medical Record Review

• Risk Factor
• Medical Problems
• Mobility Problems
• Footcare Problems
• Urinary/Bowel Incontinence
• Vision Problems
• Unsafe Behaviours
• Psychological condition
• Environmental/external
• hazard
• Medications

• Example
• Stroke/TIA
• Gait dysfunction
• Neuropathy
• Nocturia
• Glaucoma
• Combativeness
• Depression
• Cluttered room
• Antidepressant

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Results Medical Record Review

• Risk Factor
• Medical Problems
• Mobility Problems
• Footcare Problems
• Urinary/Bowel Incontinence
• Vision Problems
• Unsafe Behaviours
• Psychological Condition
• Environmental
• Medications

• Identified / Follow-up
• 86 / 41
• 88 / 73
• 11 / 54
• 74 / 15
• 51 / 14
• 43 / 60
• 76 / 58
• 3 / 21
• 67 / 6

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Quarterly Environmental Rounds

• N 1517 observations
• Observations focused on risk factors
• Mobility, unsafe behaviours, vision, environment,
  incontinence, etc.
• Overall 66 adherence to care plan interventions

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Rounds Adherence

• Mobility (e.g., proper footwear) 64
• Unsafe behaviours (e.g., bed alarm, call bell,
  bed in lowest position) 57
• Vision (e.g., glasses clean and on while out of
  bed) 60
• Environmental (e.g., common items within reach)
  80
• No Falls Risk Care Plan n104

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Facility Policies

• Admission policy (n6 facilities)
• Risk level (e.g., high) (n2)
• Staff education (n3)
• Prevention program reviews (n3)
• Medication reviews (n6)
• Interdisciplinary participation/communication
  (n3)

• Post fall policy (n8)
• Immediate evaluation (n8)
• Contact family member (n7)
• Facility fall committee (n5)
• Explicit QI Program (n2)

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Fall Risk Assessment

• Fall history (n8)
• Secondary diagnosis (n7)
• Ambulatory aid (n4)
• Gait/Balance (n8)
• Mental status (n6)
• Medications (n7)
• Continence (n6)
• Sensory impairment (n5)
• Orthostasis (n1)

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Focus Group Design Selection

• 8 focus groups in 4 randomly selected LTC
  facilities
• 1 RN/RPN and 1 PSW/HCA group per facility
• 21 RNs and RPNs
• 21 PSWs HCAs
• Purposive sampling
• Inclusion criteria
• Informed consent

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Method Focus Group Demographics

• Sex
• 35 female 5 male
• Ages
• 17 26-35 years
• 17 36-45 years
• 24 46-55 years
• 12 gt 56 years
• 30 Preferred not to respond
• Type of Position
• 11 (27) Registered Nurses (RNs)
• 9 (22) Registered Practical Nurses (RPNs)
• 21 (51) Personal Support Workers (PSWs)

• Time Working in Current Job
• 15 lt 1 year
• 34 1 to 5 years
• 20 6 to 10 years
• 10 11 to 15 years
• 5 16 to 20 years
• 16 21 years or gt
• Highest Level of Education
• 20 High school diploma
• 39 Associate degree/diploma in nursing
• 32 Some college or university
• 9 Preferred not to respond

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Method Data Collection

• Semi-Structured Interview Format
• 30 min per focus group
• Audiotaped Transcribed
• Facilitator and Recorder
• Interview Guide
• Falls Risk Identification Assessing High Risk
  Residents
• Post Fall Reporting Procedures
• Communication Processes
• Falls Quality Improvement and Prevention
  Strategies

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Method Data Analysis

• Data Analysis
• Open and hierarchical coding
• Within and cross-case analysis
• Thematic analysis
• Observational recordings
• Interrater reliability of coding and analysis
  with research team triangulation thick
  description

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OVERALL Perceptions

• Falls monitoring and incident reporting good
  overall
• Good communication RNs PSWs
• Teamwork is important
• Staff shortages
• Multiple barriers

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Fall Risk Identification High Risk Resident

• Variation in meaning of High Risk Resident
  across locations and sample groups
• Some falls considered non-preventable
  (inevitable) and others preventable
• Prioritize Seriousness of Falls

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RNs PSWs
Assessing High Risk Residents

• CCAC report
• Visual
• Physiotherapy
• Nurses
• Identifiers
• bracelets bed alarms, signs
• Information from families

• RN Report(s)
• primarily verbal
• Visual
• Physiotherapy
• Identifiers
• bracelets bed alarms, signs

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Falls Risk Identification How do you know
which of your residents are at high risk for
falling?

• RN sometimes we have some information from the
  previous place, but its not always correct and
  we cant rely on that, so the best thing is to
  have our own assessment.
• PSW I believewe have new metal id
  braceletssome of them are colour codedred,
  blue, green, blah, blah, blahbut I cant
  remember the one thats has a history of falls.

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Post Fall Reporting Procedures

• Limitations Noted
• Lack of communication b/w licensed and
  non-licensed staff contributes to poor incident
  reporting
• Lack of knowledge of inexperienced staff

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Post Fall Reporting Procedures How are you
informed that the fall has occurred, and how is
this information communicated to other staff
members working on the following shift?

• RN I do a reporta written report at the end of
  the shift, and that report goes down to
  management.And then we report at the end of the
  shift to the next shift coming on.
• RN Pretty good here. They (PSWs) let us know
  whatever they discover, anythingif there is
  anything new with the resident.anything
  unusualtheir walking patterns, or if they get
  drowsy or somethingthey let us know.

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Post Fall Reporting Procedures How is the
fall incident communicated to family members?

• PSW Whomever is in charge on the floor.
  Automaticallyit doesnt matter what time of day.
• RN Usually the person whose filling out the
  report, or the registered staff.always
  registered staff.
• RN It depends on when they fall tooif its late
  at night they put it on the report for the next
  shift.the day shift to call the family.

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Post Fall Reporting Procedures How are you
informed of any changes in the residents Care
Plan following his/her fall?

• RN Well, they (PSWs) read the care plan.
• - F And how often do they read it?
• - RNC They dont (with a chuckle)
• RN you go to the person right away, the person
  who is taking care of the person, like the PSW
  whose taking care of them, and you let them know
  the changes and its in the daily report as
  well.

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Post Fall Reporting Procedures Do you have
any concerns when it comes to reporting when a
fall occurs on your unit? 

• RN Id like them in a more timely manner not
  three hours after the fall dont tell me at like
  11 oclock when Im trying to close my shift off,
  that oh, so-and-so fell at 7 oclock and I
  wasnt even aware of it to do the incident
  report.(in a mocking voice) oh I forgot to tell
  you three hours ago that the person fell, and
  they might have hit their head even?!
• PSW It comes back to the same thing about the
  knowledgeyou go to report it and the
  nurseuhwhateverthe nurse will turn around and
  say oh well, you know, you should have done
  this, you should have done thatyou should have
  knownBut if the knowledge isnt there, then how
  wouldve know? So shes getting upset because a
  certain person isnt doing something right, but
  they werent taught the right way, so if they
  dont have the knowledge, were still going to
  have falls.
• PSW I think, in general, the staff in this
  facility take a lot to prevent falls from
  happening on the units.

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Communication Processes
Registered Staff
Administrators Directors of Care
Health Care- Interdisciplinary Professionals
Personal Support Workers
Families
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Communication Processes

• At Risk Identification Post Fall Recording
• Direct and indirect
• Verbal and written
• Quality of relationship important non-punitive
  trusting safe

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Communication Gaps

• Post-Fall Reporting
• Not witnessed resident gets up on their own
• Not reported at the time but reported afterwards
  if there are visible signs (e.g., bruising)
• Like if we are washing the residentsthen we
  have to lookif we locate anything or see
  anything, we have toit gets documented right
  away (PSW)
• Near-misses not identified

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Barriers Preventing Falls or Implementing
Interventions

• Staff (RNs and PSWs) acknowledge multiple
  factors which contribute to falls
• Despite lack of both formal and informal
  discussion on falls, seen as important
• Discrepancy in falls quality improvement actions
  among units at the facilities
• Interventions toward fall quality improvement
  tend toward retroactive not preventative
  strategies
• Infrequent in-service training

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What barriers do you face in preventing falls or
carrying out specific interventions on your unit?

• PSW I think knowledgenot to say that we dont
  have the knowledge, but we could always use more
  knowledge. Because falls is not somethingwe talk
  about all the time unless it happens.
• RN the PSW has eight or ten residents to look
  after, and when they are busy with one, of
  course, anything can happen with another, and
  they cant be there every single minute.
• PSW some of the barrier, I think would be the
  family members.
• PSW Its like too longsometimes they need a
  proper wheelchairwaiting for monthsOh months!
  How long?!! Six months already and we never get
  it.

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Do you have meetings to discuss falls on your
unit?

• PSW We have one inservice two times a yearif
  residents are falling.
• PSW SoIve never had one (referring to meeting
  about falls).. And I worked on there for a year,
  and weve never had one.
• RN inservice, we had one last year, regarding
  falls and these similarsituations
• RN If there is an increasein the number of
  falls and if a resident would have fallenwe
  discuss whats going on, and what we can do.

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Barriers to Falls Prevention

• 1. Family Non-Compliance
• Resident footwear
• 2. Lack of Staff
• Staff-resident ratio
• Limited time to monitor
• 3. Lack of Resident Stimulation
• Lack Quality of Planned Activities
• Resident Boredom
• 4. Cognitive Impairment
• Instability Aggression
• 5. Medications
• Agitation, Weakness

Resident Falls
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Barriers to Falls Prevention

• 6. Lack of Education-Staff Training
• Infrequent in-service training
• 7. Restraint Policies
• Pose ethical tensions for staff
• Self-determination vs. safety
• Families lack of understanding
• 8. Proper Equipment
• Delays in getting equipment
• 9. Environmental Conditions
• Physical-on floor obstructions

Resident Falls
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Falls Quality Improvement What is the most
pressing issue that needs to be addressed when it
comes to residents falling?

• RN Well, staffing issues becauseright nowI
  think there is one lady upstairs and shes out of
  the chair six times an hourand Ive got two
  staff members and thats been taking them away
  from their normal duties.and theyre getting
  stressed out.
• PSW or guilt.because, you know, mom used to be
  up and down here and there, and you know,
  ummthey dont want to have mom restrainedthey
  dont accept that mom is not as strong
  anymoremom is weaker and potential for falls is
  there. So, theyre majorI find the major concern
  is the family members and falls
• RN ..when you have to prevent a fall, you have
  to put every nurse in every roomand this is
  twenty or thirty roomswe have nobody. It is very
  difficult, especially at night.

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Deliverables

• Website live in April 2007
• www.fallsinltc.ca
• OLTCA, ALTCA, Manitoba LTC Assn (Spring 2007)
• LTC magazine article June 2007
• Communicating with Families about Falls

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Key Messages

• Implications for
• Practice-
• Education-
• Management-
• Research-
• Policy-

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Implications for Policy, Clinical Practice and
Research

• Policy Administration

• Need for more staff
• Increase in-service training
• Focus on prevention not only incident reporting
• Encourage non-punitive reporting
• Ensure quality programming which facilitates
  resident N
• stimulation and activities decreases boredom
• Establish an interdisciplinary approach with
  families to
• provide education and facilitate understanding
  of care
• procedures
• Environmental impact geriatricproof to
  minimize impact
• of falls provide frequent audits

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Implications for Policy, Clinical Practice and
Research (contd)

• Clinical Training Practice
• Standardized Assessment Tools
• In-service
• Common meanings of high-risk resident
• Restraint procedures, including policies (e.g.,
  least restraint)
• Dealing with ethical challenges
• Standardize knowledge across floors
• Communication frameworks which focus on quality
  of interaction and promote teamwork
• Includes families

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Implications for Policy, Clinical Practice and
Research (contd)

• Future Research
• Develop valid and reliable fall risk assessment
  tools
• Point-of-care approaches to improve communication
  of care plan interventions