Fall Management and Restraint Reduction in Long Term Care

1
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

2
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

3
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)

4
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)
5
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?

6
(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
  injury.
• 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
  floor.
• Here are the answers

7
CMSs Answer

• All of those scenarios should be reported as a
  fall

8
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
  assessment?
• Is all staff aware of the policies?
• Are the policies followed?

9
From A Program Perspective...

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

10
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.

11
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?

12
Now lets look at some statistics that can help
you convince other staff, residents and families
why falls prevention is so important
13
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

14
Statistics

• 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

15
Statistics

• 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
  n
• 40 of nursing home admissions are at least in
  part related to falls

16
Fall prevention is a priority for nursing home
residents. Why is the identification of risk
factors important in this effort?
17
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

18
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

19
In addition to looking at overall risk factors,
it is also useful to break down risk factors into
intrinsic and extrinsic components
20
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

21
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

22
Potential Intrinsic Risk Factors

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

23
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)

24
Potential Intrinsic Risk Factors

• Syncope/dysrhythmias
• Fear of falling
• Dizziness
• Incontinence
• Depression
• Generalized weakness, deconditioning
• Any acute illness often infection, delirium,
  dehydration.

25
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

26
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
  footwear

27
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)

28
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,
  2003)

29
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

30
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?

31
What is a root cause analysis?
32
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34
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

35
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
  resident
• 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)

36
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
  accidents

37
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.

38
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?

39
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
  plan?
• Do you think some falls are not avoidable?

40
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

41
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?????

42
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?

43
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?

44
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

45
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

46
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.)

47
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?

48
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
  information?
• Is there detailed documentation of what was
  discussed with resident and/or family and is this
  revised as needed?

49
Comprehensive Risk AssessmentTargeted
InterventionsIndividualized Plan of Care
50
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,
  activity)
• follow up before the trail is cold

51
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
  report)

52
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

53
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
  appropriate
• Witness (if available)
• Family(?)

54
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

55
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

56
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

57
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
  think?
• ASK THE CNAs WHAT THEY THINK!!!

58
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
59
Checklist for Assessing Fall Risk and Post-fall
ReviewAMDA Clinical Practice Guideline Falls
Fall Risk 2003
60
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)

61
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

62
Comprehensive Risk Assessment Includes

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

63
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.
64
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!
65
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

66
Comprehensive Risk Assessment

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

67
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)

68
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

69
Targeted InterventionsIndividualized Plan of Care

• Do you think these issues could be related to
  falls?
• Interactions with staff
• Pain
• Comfort
• Contentment
• Anger, guilt
• Urgency, incontinence
• Sleep
• Constipation

70
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
  confusion
• see restraint reduction guidelines and tables
  (Medqic)

71
Targeted InterventionsIndividualized Plan of Care

• Reduce/eliminate/alter medications whenever
  possible
• Follow these general guidelines

72
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

73
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

74
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
  assessment
• Transfer, gait, balance training strengthening,
  ROM exercises habituation exercises for
  vestibular problems
• Exercise, exercise, exercise!

75
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

76
Alarms

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

77
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

78
Activities

• 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?

79
The Hospital Bed Safety Workgroup www.fda.gov/cdr
h/beds/ And http//ute.kendaloutreach.org/learning
/HospitalBedSafetyWorkgroupHBSW.aspx
80
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,
  pain)
• Continuous efforts are required to sustain
  benefit of interventions (Taylor, 2002)

81
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)

82
Person-centered Approaches to Fall Prevention

• Consistent staffing is the most critical
  element!!!

83
Effective Communication

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

84
Involving Residents and Families

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

85
Preventing Litigation

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

86
Patient/Family Education Materials

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

87
Patient/Family Education Materials

• www.healthinaging.org/agingintheknow
•  
• http//www.niapublications.org/engagepages/Prevent
  ing_Falls_and_Fractures.pdf

88
National QIO Falls Management Program

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

89
Summary

• 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

90
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

91
Summary

• 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?

92
Summary

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

93
Thank you for being a falls champion!
Alice Bonner, APRN-BC, GNP Abonner_at_mecf.org