Courage to Improve III Becoming a Restraint Appropriate Facility

1
Courage to Improve III Becoming a Restraint
Appropriate Facility

• Carroll Manor Nursing
• and
• Rehabilitation Center
• Eileen Mulaney VP/Admin
• Denise Gaston RN /DON

2
Identification

• Team Players
• Ellen Diggs RN ADON Chair
• Falls Prevention Committee
• Janice Johnson RN NM Mark
  Boothe LICSW SW Manager
• Jackie Batcha RN NM Jeff
  Wright Dir PT (Consult)
• Rosemary Tyner RN NM Cathy Akers
  RN CNSC
• Ivory Bradford RN NM Claudia
  Smith RN NM

3
Identification

• Carroll Manor Nursing and Rehabilitation
  Center is a hospital based 250 bed JCAHO
  accredited Nursing Home.
• Located in the District of Columbia.
• Nursing ,Rehabilitation, and Sub-Acute .
• Carroll Manor is a member of member of the
  Ascension Healthcare System and the American
  Health Care Association in Washington DC.

4
Project Aim

• The goal of the project was to decrease the use
  of restraints at Carroll Manor.
• The role and impact of leadership was to
  motivate and lead associates thru the difficult
  process involved in cultural change.
• Provide education and support to associates
  ,residents and families.

5
Project Description

• Strategies Educated associates residents and
  family members in regulations and laws which now
  mandated restraint use.
• Consultants used to assist in development of
  strategies
• Interventions Facility wide Blitz Buttons
  Balloons poster boards signs with message side
  rails down for safety.
• Fall prevention program developed

6
Project Description

• Closely monitored compliance walking rounds
  re-instructed on site team effort
• Care Planned
• Side rails came down.

7
Keys to Success

• Education, Focus ,Consistency, Associate
  involvement.
• Barriers Perceptions of associates residents
  would fall
• Old practice habits are sometimes hard to break
  Learning to allow them to fall was difficult
• Accepted increased falls in number .

8
Results Data Restraints

• That project took place 6 years ago Carroll Manor
  currently has a 0 restraint use rate.
• Data located CMS Nursing Home Compare
• Side rail is only use as an enabler and coded
  accordingly on MDS

9
Results Data Falls

• lt 1 of falls at Carroll Manor are are from the
  bed or chair.
• We follow strict federal guidelines when
  recording falls.
• Development of strong Fall prevention program.
  With use of low beds , bed chair alarms , walking
  programs , education of associates ,families ,Q 1
  hr Safety checks.

10
Results DataFalls

• Falls Committee meets monthly Report is analyzed
  and interventions are determined.
• Post monthly graphs on units for staff to review
  and as measure of communication. (where do you
  hope to go next with changes you have implemented)

11
Data Falls Graphs
12
Data Falls Graphs
13
Data Falls Graphs
14
Data Falls Graphs
15
Data Falls Graphs
16
Conclusion

• Continue on present course
• Fall injury rate is very low
• Decrease use of restraints will increase number
  of falls this must be factored into education
  process.
• Culture change must take place at all levels in
  facility in order to be successful