Fall Management and Restraint Reduction in Long Term Care - PowerPoint PPT Presentation


PPT – Fall Management and Restraint Reduction in Long Term Care PowerPoint presentation | free to view - id: 51fab-ZDc1Z


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Fall Management and Restraint Reduction in Long Term Care


40% of nursing home admissions are at least in part related to falls ... Checklist for Assessing Fall Risk and Post-fall Review ... – PowerPoint PPT presentation

Number of Views:397
Avg rating:3.0/5.0
Slides: 94
Provided by: quali2


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Fall Management and Restraint Reduction in Long Term Care

Fall Management and Restraint Reduction in Long
Term Care
  • Alice Bonner, APRN-BC, GNP, FAANP
  • Director of Clinical Quality
  • Massachusetts Extended Care Federation
  • Abonner_at_mecf.org

Definition of a Fall
  • Unintentional coming to rest on the floor, ground
    or other lower level
  • Or unintentional change in position, occurring
    where a fit person could have resisted the
    external hazard

But Beyond that Definition
  • Falling is a clinical entity in its own right,
    most commonly due to the accumulated effect of
    multiple chronic disabilities and potentially is
    preventable if the causative factors are
    recognized in individual patients (Tinetti, 1986)

One Problem with Falls is under-reporting, some
of which may come from failure to recognize when
a fall has actually occurred. Test your knowledge
with the following questions from the Centers for
Medicare and Medicaid Services (CMS)
Definition of a Fall CMS RAI Version 2.0 Q
AS March 2001
  • Question 2-22
  • Should the following situations be recorded as
  • falls in items J4 Fell in the past 30 days
    or J5 fell in the past 31-180 days?

(Question 2-22 continued)
  • a) resident lost their balance, and was lowered
    to the floor by staff.
  • b) resident fell to the floor, but there was no
  • c) resident was found on the floor, but the means
    by which he/she got to the floor was unwitnessed.
  • d) resident rolled off a mattress that was on the
  • Here are the answers

CMSs Answer
  • All of those scenarios should be reported as a

From A Program Perspective...
  • Do you have corporate/executive/administrator
    support for a falls prevention program?
  • Has your organization looked at what is in place
    right now, and where the gaps are in falls
    prevention in your building?
  • Are there policies in place for fall risk
  • Is all staff aware of the policies?
  • Are the policies followed?

From A Program Perspective...
  • Are residents assessed immediately (on, or even
    prior to, admission), and reassessed when
  • Are you using a standardized fall risk assessment
  • Is the risk assessment reflected in the care
  • Do you know how the risk assessment is
    communicated to direct care staff?
  • Is someone on staff accountable for collecting
    data and monitoring systems?

Case Study
  • Friday night was busy. There were four new
    admissions to the subacute unit. One of the new
    admissions was an 84 year old man, s/p CVA
    history of DM, CHF, COPD, Dementia. The nurse did
    not have time to complete all of the assessments
    on her 3-11 shift. The falls assessment was only
    partially done. One of the nurses wanted to
    restrain the resident because we just dont have
    the staff to watch him and hes unsafe.

Case Study
  • What is the most important individual action that
    the nurse on the next shift can take?
  • What is the most important aspect of the nursing
    homes policy to insure that this situation does
    not result in resident injury?
  • How can nursing leadership and administration
    insure that problems come to their attention so
    that they can be addressed?
  • Would you physically restrain this resident? Why
    or why not?

Now lets look at some statistics that can help
you convince other staff, residents and families
why falls prevention is so important
Some Statistics
  • 35-40 of community-dwelling, generally healthy
    adults over age 65 fall annually
  • Rates are higher after age 75
  • In nursing homes and hospitals, rates are almost
    three times higher (1.5 falls per bed)
  • 50 of fallers do so repeatedly

  • Injury is the 5th leading cause of death over age
    65 and most fatalities are related to falls
  • 2-5 of falls result in fractures 1 are hip
    fractures in the over 65 population
  • In nursing homes, 10-25 of falls result in
    fracture, laceration, or hospitalization

  • Fall-related injuries recently accounted for 6
    of all medical expenditures for persons age 65
    and older
  • Fall-related injuries may cost up to 20 billion
    dollars/year in acute care and institutionalizatio
  • 40 of nursing home admissions are at least in
    part related to falls

Fall prevention is a priority for nursing home
residents. Why is the identification of risk
factors important in this effort?
Risk Factors for Fallsin Nursing Home Residents
  • In studies on nursing home residents, the risk
    factors most commonly associated with falls were
  • Muscle weakness
  • History of falls
  • Gait or balance deficit
  • Use of assistive devices
  • Visual deficit

Risk Factors for Fallsin Nursing Home Residents
  • Additional risk factors for falls in nursing home
    residents were
  • Arthritis
  • Impaired ADL
  • Depression
  • Cognitive impairment
  • Age over 80 years

In addition to looking at overall risk factors,
it is also useful to break down risk factors into
intrinsic and extrinsic components
Intrinsic and Extrinsic Risk Factors
  • Intrinsic factors (physiological changes with
    age, disease processes, iatrogenesis, medications
    or a combination)
  • Extrinsic factors (types of activity, hazards and
    demands of the environment)
  • At least 50 of falls are multifactorial

Potential Intrinsic Risk Factors
  • Disorders of gait and/or balance
  • Most common predictors of balance problems
  • difficulty rising from a chair and sitting down
  • instability on first standing
  • staggering on turning
  • short, discontinuous steps
  • step to step variability

Potential Intrinsic Risk Factors
  • Knee, hip, foot deformities and/or associated
    pain arthritis, myopathy
  • Sensory impairment (decreased vision, hearing)
  • Neuromuscular diseases (CVA, dementia,
  • Cognitive impairment (poor judgment, safety
    awareness) doubles the risk of falls in some

Potential Intrinsic Risk Factors
  • Peripheral neuropathy
  • Orthostatic hypotension
  • Postprandial hypotension (Aranow 1997)
  • Total number of chronic diseases/conditions
  • Total number of medications (gt3 or 4)
  • types of medications (class IA antiarrhythmics,
    digoxin, diuretics psychoactive medications,
    anticholinergics). Alcohol use
  • (Leipzig, JAGS, January, 1999)

Potential Intrinsic Risk Factors
  • Syncope/dysrhythmias
  • Fear of falling
  • Dizziness
  • Incontinence
  • Depression
  • Generalized weakness, deconditioning
  • Any acute illness often infection, delirium,

Potential Intrinsic Risk Factors
  • Age over 80 years
  • History of falls
  • Use of an assistive device
  • Dependent in two or more ADLs
  • Total number of risk factors for falls

Potential Extrinsic Risk Factors
  • Lack of, inappropriate or ill-fitting footwear
  • fit
  • heel height and width
  • type of sole
  • Low heel, firm sole (Tinetti, 2003)
  • collar height
  • High collar increases balance (Lord, 1999)
  • 2004 and 2005 studies confirm earlier results
  • Risk is highest is for patients who wear NO

Potential Extrinsic Risk Factors
  • Lack of, inappropriate or ill-fitting clothing
    (no belt, pants too long, cant get clothes off
    fast enough for toileting)
  • Room too far from caregivers/nurses station
  • Type of setting not appropriate or cannot meet
    needs for adequate assessment and supervision of
    a particular resident (e.g., subacute caregivers
    not trained in how to redirect or intervene with
    dementia residents)

Potential Extrinsic Risk Factors
  • Adaptive equipment lacking or used
    inappropriately (e.g., walker too low)
  • Lack of restorative program lack of exercise and
    routine ambulation to maintain function
  • Use of restraints (physical, chemical) resulting
    in decreased activity, deconditioning (Dimant,

What makes staff think about using restraints?
  • Fear of being cited by surveyors for failure to
    protect resident from harm/falls
  • They think they will work to protect the resident
    from harm
  • They think it is better than not using them
  • They think it might prevent other problems
    (wandering, residents getting into altercations)
  • They think it will help them to better care for
    other residents

What should staff be thinking about?
  • Root cause why was the resident trying to get
    up, walk, lean over, engage in an activity in
    the first place????
  • What kinds of behaviors did they engage in prior
    to coming to the nursing home? Any patterns?
  • What pushes their buttons?
  • What makes them tick?
  • Have we gotten all the possible information from
    family or other informants?

What is a root cause analysis?
(No Transcript)
(No Transcript)
Guidance to Surveyors on Restraint Use
  • May not be used for discipline or convenience
  • A device may constitute a restraint for one
    resident and not for another
  • May be used in medical or psychiatric
    urgent/emergent situations (short-term)
  • Full explanation to resident/family on risks and
    benefits of restraints
  • Facility may not use restraints just because
    health care proxy or guardian requests it, or
    because physician writes an order

Guidance to Surveyors on Restraint Use
  • Least restrictive form of restraint must be used
  • Other alternatives that were tried and the
    outcomes must be documented, sometimes multiple
    times. There is no magic answer on this question,
    nor is there consensus or best practice or
    guideline, except to individualize to each
  • Systematic plan for care planning and evaluation
    of restraints, including restraint reduction plan
    must be documented in policies and procedures
    (facility-wide) and in individual care plans (see
    www.medqic.org for some ideas)

Federal F tags on Restraint Use
  • Ftag Each resident will receive, and the
    facility provide, the necessary care and services
    to attain or maintain the highest practicable
    physical, mental and psychosocial well-being, in
    accordance with the comprehensive assessment and
    plan of care
  • Ftag The facility must ensure that the resident
    environment remains as free of accident hazards
    as is possible and each resident receive adequate
    supervision and assistive devices to prevent

Another Case Study
  • Mrs. Lopez is an 89 year old resident of a
    special care (dementia) unit. She has Lewy body
    dementia, CHF, COPD, DJD, GERD. Prominent
    features of her dementia are psychomotor
    agitation, unsteadiness and stiffness. She
    repeatedly self-rises, has no safety awareness,
    does not remember any attempts to redirect her.
    She has had 9 falls in the past month, mostly in
    self-attempted transfers.

Another Case Study
  • On 3-11 on Friday night, Mrs. Lopez is found on
    the floor in her room, next to her bed. The nurse
    finds her while conducting her med pass. The
    nurse establishes that the resident has no
    injuries and proceeds to complete a post-fall
    assessment form. How should the nurse begin a
    root cause analysis on this case?

Another Case Study
  • How would you care plan for falls in this
    resident? Who should be at the table?
  • If this resident has had 10 falls now, should she
    be restrained? Why? Is there any evidence that
    restraining her will make her safer? How will you
    make this decision?
  • Would you use alarms on this resident?
  • What interventions would you use in the care
  • Do you think some falls are not avoidable?

Environmental Factors Associated with Falling
  • Dim lighting
  • Poor or weak seating
  • Glare
  • Use of full-length side rails
  • Uneven flooring
  • Bed height
  • Loose carpet or throw rugs
  • Inadequate assistive devices
  • -AMDA Clinical Practice Guideline Falls and Fall
    Risk, 2003
  • Wet or slippery floor
  • Inappropriate footwear
  • Lack of safety railings in room or hallway
  • Malfunctioning emergency call systems
  • Lack of grab bars in bathrooms
  • Poorly fitting or incorrect eye wear
  • Poorly positioned storage areas

Self-determination, freedom and safety
  • The resident wants their fuzzy slippers, even
    though they have fallen 3 times in them because
    they do not fit correctly. Her favorite niece
    gave them to her.
  • The resident is only mildly demented, but does
    not clearly understand the risk of a hip fracture
    and what the consequences might be
  • What should the facility do?????

From A Program Perspective...
  • Is equipment available, even on the off shifts?
    Is it well maintained?
  • Are forms for documenting fall risk and
    interventions available?
  • Does every staff member feel accountable for
    preventing falls?
  • Is there a culture of safety and not of blame, so
    that people feel comfortable reporting falls and
    fall related problems?
  • Is there a champion and a falls prevention team?

From A Program Perspective...
  • Are CNAs involved? Do they have CNA care plans or
    fall assessment tools for ADL safety?
  • Quick Tips Badge
  • Is feedback provided on successful strategies?
  • Hospitality Aids (Rhode Island)
  • Is data shared with staff? (post in shower room!)
  • When the CNAs reassess residents if the
    residents status/condition changes, how is this
    communicated to the nurse and provider (NP/MD),
    and CNAs on the next shift?
  • Regular (weekly) review of all high risk
    residents for potential changes
  • Do nurses listen attentively to CNAs?
  • Do all providers read each others notes or share
    information with other departments?

From A Program Perspective...
  • Are non-nursing staff involved?
  • Are non-nursing staff encouraged to prevent falls
    and communicate risks?
  • Are non-nursing staff valued for what they bring
    to fall prevention?
  • Do people work in silos, or do they collaborate
    and communicate openly?
  • Adopt-a-resident program facility-wide

What might surveyors be looking for in fall
prevention care plan?
  • Is the plan individualized? Does it make sense
    for that resident?
  • Is it realistic?
  • Dont say q15 minute checks if you dont have
    the staff to do it!
  • Be careful about how specific you make your care
    plan if it is written in the care plan, it must
    be done

What might surveyors be looking for in fall
prevention care plan?
  • Words or phrases to watch out for
  • resident will be supervised at all times
  • monitor resident for falls
  • What does that mean? How often? By whom?
  • Better choice just list specifically the things
    that you WILL do (toileting every 2 hours,
    provide drink and snack in between meals,
    ambulate resident between meals/care, etc.)

What might surveyors be looking for in fall
prevention care plan?
  • Is the care plan communicated to frontline staff?
    Is it simply on paper, or is it really being
    communicated and being done consistently?
  • What happens if someone unfamiliar with the
    resident has to care for that resident for one
    shift? What is the back up system or safety net
    to communicate what that resident needs during
    that shift?

What might surveyors be looking for in fall
prevention care plan?
  • Are all departments involved?
  • Is the family involved?
  • Are staff reading each others notes and sharing
  • Is there detailed documentation of what was
    discussed with resident and/or family and is this
    revised as needed?

Comprehensive Risk AssessmentTargeted
InterventionsIndividualized Plan of Care
Comprehensive Risk Assessment Includes
  • A complete falls history
  • any recent falls whether any associated injury,
    fracture, etc.
  • estimate of frequency of falls
  • qualitative information from patient/family/caregi
    vers on nature of falls, any identifiable
    patterns or triggers (location, time of day,
  • follow up before the trail is cold

Comprehensive Risk Assessment Includes
  • Identification of all potential intrinsic and
    extrinsic risk factors
  • Screening tool for
  • New admission
  • Post-fall assessment form (beyond the incident

Post Fall Review Process
  • Immediate Investigation
  • Root Cause Analysis
  • Falls Committee
  • System of Communication
  • Medical Assessments/Rehabilitation Screens
  • Care Plan Modification
  • Implement Changes
  • Follow Up

Falls Committee
  • Multidisciplinary Team
  • Administrator
  • DON
  • ADON
  • Unit Manager designates staff (nurse, CNA)
  • Rehabilitation Director/Assistant (team leader)
  • MDS Coordinators
  • Social Service, activities, other departments as
  • Witness (if available)
  • Family(?)

Falls Committee Meeting
  • Initiated within 24 hours of fall
  • Consistent meeting time (830AM)
  • Mandatory attendance
  • Keep it short!
  • Follow up from previous meeting
  • Current incident report reviewed
  • Classify Fall (nine categories) and collect other
    relevant data
  • Set up plan and implement necessary changes

Falls Classification
  • Environmental
  • Resident non adherence
  • Staff non adherence
  • Acute medical decompensation
  • UTI
  • Pneumonia
  • Medication related
  • Progressive functional decline
  • Dementia
  • Parkinsons
  • Equipment malfunction
  • Isolated incident
  • Not classified

Falls Classification (some ideas)
  • Location (unit)
  • Location within the unit (bathroom, dining room)
  • Time, day of week
  • Predisposing event
  • Other antecedents
  • Footwear, clothing, assistive devices
  • Staffing issues
  • Family issues
  • Psychosocial issues

Post Fall Follow Up
  • Root cause analysis
  • Ongoing education and reeducation of all staff
  • Ongoing communication on the problem of falls in
    this individual resident
  • Ask the resident, family and staff, what do you

Dont leave the provider out! The NP, PA or MD
can use a guideline or template to document
his/her workup of falls. A sample page of the
American Medical Directors Association (AMDA)
guideline follows
Checklist for Assessing Fall Risk and Post-fall
ReviewAMDA Clinical Practice Guideline Falls
Fall Risk 2003
How is the PCP notified of a fall?
  • Use the post-fall assessment tool as a guide
  • Always consider change from baseline
  • Always relay family or staff concerns
  • Always mention if the resident is on warfarin or
    other anticoagulant
  • Mention other recent changes (medication changes,
    recent illness, other falls)

Comprehensive Risk Assessment Includes
  • Complete medication review, including
  • new medications
  • dosage adjustments
  • recently discontinued medications
  • attention to medications requiring levels
    (digoxin, phenytoin, etc.)
  • eyedrops, topicals
  • alternative/homeopathic remedies

Comprehensive Risk Assessment Includes
  • Comprehensive examination targeted areas to
  • orthostatic vital signs
  • neurological exam (gait)
  • MMSE
  • vision exam
  • musculoskeletal exam (lower extremity joint
  • cardiovascular exam
  • careful exam of affected/injured area

Some nurses, NPs, physicians and CNAs may not
know how to correctly take orthostatic vital
signs. Each facility should have a policy on
this, and it should be included in orientation
materials and annual competencies.
Functional Assessment and Tests of Gait and
Balance are Generally Performed by Rehabilitation
Staff (PT, OT). It is critical that findings are
shared with nursing, activities and direct care
staff as soon as they are known!
Comprehensive Risk Assessment Diagnostic Testing
  • Highly individualized
  • Laboratory tests
  • usually want to rule out infection, dehydration,
    drug toxicity
  • CBC, CP7, drug levels, u/a cs
  • TSH
  • Cardiology workup may include EKG, holter monitor
  • Radiology

Comprehensive Risk Assessment
  • Final assessment should list all possible causes
    of falls in this particular patient.

Targeting Interventions Based on Specific Problems
  • http//www.medqic.org
  • Go to Physical Restraints
  • Go to Tools
  • To to Restraint Reduction Assessment and
    Alternatives Help Guide
  • -or-
  • Falls Management Program (FMP)

Targeted InterventionsIndividualized Plan of Care
  • First, determine if risk is high and immediate
    action needs to be taken
  • 11 with staff, family or sitter
  • Team conference for brainstorming
  • Consider speaking with PCP
  • Obtain input from family on what has worked in
    the past
  • Listen, listen, listen

Targeted InterventionsIndividualized Plan of Care
  • Do you think these issues could be related to
  • Interactions with staff
  • Pain
  • Comfort
  • Contentment
  • Anger, guilt
  • Urgency, incontinence
  • Sleep
  • Constipation

Targeted InterventionsIndividualized Plan of Care
  • Address specific intrinsic risk factors
    identified in the work up
  • consider causes of behaviors
  • treat or manage orthostatic hypotension
  • correct metabolic imbalances
  • treat infection or dehydration
  • treat pain
  • consider nutritional issues
  • determine underlying cause for delirium or
  • see restraint reduction guidelines and tables

Targeted InterventionsIndividualized Plan of Care
  • Reduce/eliminate/alter medications whenever
  • Follow these general guidelines

Medication Principles to Reduce Fall Risk
  • Reduce the total number of medications given
  • Asses the risks and benefits of each medication
  • Select medications least associated with
    orthostatic hypotension
  • Prescribe lowest effective doses
  • Reassess risks and benefits at each regulatory
    visit and as needed
  • AMDA Clinical Practice Guideline Fall and Fall
    Risk 2003

Medication Categories More Commonly Associated
with Injury from Falling
  • Anticoagulants
  • Antidepressants
  • Anti-epileptics
  • Anti-hypertensives
  • Anti-Parkinsonian agents
  • Benzodiazepines
  • Diuretics
  • Narcotic analgesics
  • Non-steroidal anti-inflammatory agents NSAIDS
  • Psychotropics
  • Vasodilators
  • -AMDA Clinical Practice Guideline Falls and Fall
    Risk, 2003

Targeted InterventionsIndividualized Plan of Care
  • Consider PT/OT screens or evaluations for
    problems with gait or balance, need for muscle
    strengthening program, seating systems or
    assistive/adaptive equipment or environmental
  • Transfer, gait, balance training strengthening,
    ROM exercises habituation exercises for
    vestibular problems
  • Exercise, exercise, exercise!

Targeted InterventionsIndividualized Plan of Care
  • Environmental adaptations might include
  • low bed
  • AFO, brace, splint, walker,cane
  • different seating system
  • specialized floor mats
  • raised toilet seats

  • Chair alarm
  • Personal alarm
  • Bed alarm
  • No studies prove value
  • Must weigh risks and benefits
  • May be helpful for some residents and harmful for
  • Consider for short, but not for long term use
  • How do you reduce alarms in the facility?

Targeted InterventionsIndividualized Plan of Care
  • Environmental adaptations might include
  • siderails for positioning
  • different bedroom
  • nightlight at night, keeping BR door ajar
  • non-skid strips for floor
  • rearranging room (Hofman, 2003)
  • external hip protectors

  • How are activities related to falls?
  • Knowing previous patterns of behavior
  • What is the role of the activities staff in fall
    prevention? Do other staff read activities notes,
    especially admission info?
  • Maintenance? Housekeeping? Dietary?
  • Family?
  • What is the All Hands on Deck program?
  • What is the Walk to Dine program?

The Hospital Bed Safety Workgroup www.fda.gov/cdr
h/beds/ And http//ute.kendaloutreach.org/learning
Targeted InterventionsIndividualized Plan of Care
  • Create an individualized care plan on admission,
    using the MDS, developed by interdisciplinary
    team to address all risk factors
  • Design and implement interventions, monitor and
    evaluate outcomes. Update MDS with increase,
    decrease in falls. Update care plan if risk
    factors or condition changes
  • Consider the inter-relatedness of other MDS items
    and fall prevention (incontinence, depression,
  • Continuous efforts are required to sustain
    benefit of interventions (Taylor, 2002)

Successful Fall Prevention and Restraint
Reduction Strategies
  • Sensory stimulation room or activity drop in
    center for sundowners or those with behaviors at
    certain times
  • Staffing analysis with reallocation of staff to
    activities or 3-11 or other pattern
  • Weekly walk rounds with medical director
  • Weekly environmental rounds with rehab
  • Ruby slippers (for hospital and subacute)

Person-centered Approaches to Fall Prevention
  • Consistent staffing is the most critical

Effective Communication
  • Avoid ambiguity
  • Avoid work around culture
  • Avoid working in silos
  • Encourage shift to shift communication and
    interdepartmental communication

Involving Residents and Families
  • Identify high risk residents on admission
  • Discuss with resident and family
  • Educate!
  • Get their input
  • Set REALISTIC goals

Preventing Litigation
  • Care plan should be comprehensive and
  • Involve primary care providers (MD/NP/PA)
  • Set realistic goals
  • Insure consistent documentation
  • Know the high risk categories and the high risk
  • Make sure risks are incorporated into the care
  • Make sure that practice follows policy!

Patient/Family Education Materials
  • The National Center for Injury Prevention and
    Control Division of Unintentional Injury
  • 4770 Buford Highway, NE, Mailstop K-63
  • Atlanta, GA 30341
  • http//www.cdc.gov/ncipc

Patient/Family Education Materials
  • www.healthinaging.org/agingintheknow
  • http//www.niapublications.org/engagepages/Prevent

National QIO Falls Management Program
  • Has many downloadable forms, including policies
    and procedures
  • Can be easily adapted or customized to your
  • www.medqic.org
  •  Enter falls management program as a search term

  • Fall-related injury prevention and restraint
    reduction are both important goals
  • Management and leadership need to be committed to
    reducing both falls and restraints
  • Begin with an assessment of where your facility
    is now, where the gaps are, and how you will
    implement the first phase of your program

What are Residents, Family and Staff Seeking?
  • Quality of life, not just quality of care
  • Staff who are respectful and well trained
  • Most of all Staff who care
  • They want to help.
  • They are kind and good to me.
  • There are enough of them.
  • They are friendly and cheerful.
  • They are patient and have time for me.
  • National Citizens' Coalition for Nursing Home
    Reform (NCCNHR), 1985
  • Tellis-Nayak and Tellis-Nayak, 2005

  • Who will be on the fall/restraint team?
  • Who will be the falls champion?
  • How will this fit with the culture of safety and
    resident-centered care at your facility?
  • How will the message be communicated to frontline
    staff, families, residents?
  • How will new staff be oriented and how will
    annual competencies be determined?

  • Ongoing monitoring and re-evaluation of your
  • Manage with your DATA
  • Unit level falls and injury reports
  • Report on near misses and talk them up!
  • Communication!!!!
  • Teamwork!!!!!!!!!!
  • Documentation!!!!

Thank you for being a falls champion!
Alice Bonner, APRN-BC, GNP Abonner_at_mecf.org
About PowerShow.com