Conclusion

Improving Patient Safety in Long-Term Care Facilities, Module 3

In Summary

Falls prevention aims to balance patient safety and personal freedom to do things. The goal is to maintain and maximize quality of life, while minimizing each individual resident's risk of having a fall resulting in an injury. This is best done in an environment where it is easy to report, and everyone supports discussions about what happens and how to make things better.

Things to Remember

  • Not every fall is just a fall.
  • There are many risk factors for falls.
  • Using the HEAR ME tips can help reduce falls.
  • Appropriate interventions can minimize future falls.

Not every fall is just a fall. All falls need to be investigated. But, some falls are due to a stroke or a seizure or dizziness. The licensed nurse needs to make an assessment and talk it over with the nurse practitioner or doctor. A falls assessment may be relevant only after the medical cause has been taken care of, perhaps in a hospital or at another care level.

There are many risk factors for falls. If a fall occurs, after taking care of the resident, assessing the resident again for risk factors is an important way of reducing the chance of another fall. The risk factors for falls are many, and they relate to individual residents and their environment. Important risk factors about the individual include a history of previous falls, diminished lower limb strength, gait or balance impairments, and use of certain medications. Important environmental risk factors include design problems, lack of space, obstacles, equipment misuse or malfunction, and inadequate staffing and organization of care.

HEAR ME. The HEAR ME tips can help staff remember to: address hazards in the environment, educate residents about safety, anticipate the needs of residents, engage in the practice of rounding to stay aware of residents' needs as they arise, and make sure needed materials are available and equipment is in working order. You will want to be sure that you know how to operate all available equipment, and that you encourage and assist residents to exercise so that their fitness and strength can be maintained.

Minimizing further falls. Interventions to minimize further falls usually involve several changes, and they should be tailored to the individual resident's reasons for falling. Nursing assistants and licensed nurses must cooperate to observe and evaluate the specific fall event, investigate and document the circumstances of the fall, implement and monitor an individualized care plan, and wherever possible, develop a falls management program.

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Pearls and Pitfalls

Pearls

  1. Awareness is a watchword in falls prevention. Only by carefully observing residents from our various trained viewpoints can we prevent falls. Only by remaining alert to the needs of residents, and meeting those needs in as timely a way as possible, can we contribute to the prevention of falls.
  2. Teamwork is necessary to prevent falls. It is not the job of nursing assistants or licensed nurses alone to prevent falls. Each member of the nursing team, along with staff from other disciplines, must play a role in preventing falls and intervening in falls. Every fall presents an opportunity for the team to work together to improve care.
  3. Risk factors are always present. We all have risk factors for falls. Older people in general, and nursing center residents in particular, are less able to compensate for those risk factors. This means that fall prevention requires active thought about each resident's risk factors and interventions tailored to those risk factors. Falls hardly ever have one single cause, but rather they require adjustments in multiple areas to prevent future falls.
  4. Go beyond incident reports to help establish a revised care plan for falls that corresponds to the individual resident's needs and circumstances. Using nursing skills at all levels to develop a collaborative plan helps to prevent a particular resident's falls. Use the interdisciplinary team—rehabilitation, pharmacy, medicine, and dietary—to address issues that would benefit from their working together.

Pearls

  • Awareness is a watchword in falls prevention.
  • Teamwork is necessary to prevent falls.
  • Fall prevention requires active engagement.
  • You must go beyond an incident report to develop a revised care plan.

Pitfalls

  1. Not having a falls assessment for a resident is like allowing an "accident waiting to happen" to occur.
  2. Failing to make a new falls assessment and care plan for a resident who has fallen misses an opportunity to reduce that resident's risk of falling again in the future.

Pitfalls

  • Forgetting to do a falls assessment for a resident.
  • Failing to make a new falls assessment and care plan for a resident who has fallen.
Current as of June 2012
Internet Citation: Conclusion: Improving Patient Safety in Long-Term Care Facilities, Module 3. June 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcmod3concl.html