Session 2

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

Limiting Falls that Cause Injury

Residents in long-term care settings are likely to fall. Often, the price of too much caution is lost quality of life; a resident may want to dance, or garden, or go on an outing, and taking the risk of falling may be worth it to the resident. In the past, we thought that using restraints to keep a resident tied to his or her bed or chair would protect them. Mostly, it so deprived them of their quality of life that residents often got into dangerous situations trying to get out of the restraints. So, now we accept that some falls are inevitable, even in an optimal care environment. However, what we can do is eliminate needless falls and limit the injuries from falls that do occur. Communication and teamwork are a necessary part of achieving these goals, but restraints are not.

Communicate

There are many things that the care team can do routinely to limit injurious falls. First and foremost is to have clear and consistent communication between nursing assistants and licensed nurses about which residents are at risk for falls. Any resident who has a pattern of falls is at risk of falling again. After the licensed nurse has assessed a resident for fall risk it is important to communicate the results of the assessment to the nurse's front-line coworkers. Nursing assistants are better equipped to guard against falls when they know which residents—especially new residents or those in transition back from hospital stays—are going to need a special "fall watch."

Many care teams have found it useful to place a symbol on the resident's chart or in his or her room to alert the entire team that that person is at risk for falls. These are all care routines that only work well when there also is good communication.

Work as a Team

Teamwork between nursing assistants is also essential to falls prevention. Nursing assistants should know which residents need assistance in ambulating, transferring, or simply standing. Any of these can result in a fall. To help prevent falls, never leave a resident alone during a transfer (bed to chair, wheelchair to toilet, etc.). When nursing assistants work in a two-person team to provide more support for a resident during the transfer (“the two-person assist”), safety is further improved. All this requires team work. Team members need to know when another team member needs help.

Avoid Restraints

Although in some cases it may seem that restraints could help keep a resident safe, the research shows that exactly the opposite is true. Using restraints does not help to prevent falls. In fact, restraints can actually cause falls when residents attempt to get out of them or slide down through them.10 Posey vests, pelvic restraints, and lap trays on geri-chairs all contribute to falls and to injuries that occur with falls.

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Assessing and Decreasing Fall Risk

An important job for licensed nurses is to assess residents' risk of falling. This is best done using a protocol or instrument that asks the licensed nurse to look at or test several features about the resident.

The Hartford Institute for Geriatric Nursing recommends the Hendrich II Fall Risk Model.11,12 Other instruments include the Comprehensive Falls Risk Screening Instrument,13 the Falls Assessment portion of The Falls Management Program,14 the Vanderbilt Fall Prevention Program for Long-Term Care,15 and the Timed Up and Go Test.16 These and other resources are shown in the Appendix.

To help prevent falls, check on your residents frequently and be alert for any furniture, equipment, or other items that might make a fall likely—fixing risks as you see them. Ask yourself: "Is this resident getting enough of the right exercises and ambulating enough?" If not, consider what else could be done to help the patient avoid a fall.

Review a Checklist—HEAR ME

Often, it is useful to have a mechanism to help you remember all of the things you need to think about. Here is a list of things to remember that fit into a handy memory aide: "HEAR ME." Remembering these "HEAR ME" tips can help you prevent falls in your nursing center.

  • Hazards in the environment should be noticed and eliminated.
  • Educate residents about how to accomplish their activities in a safe way.
  • Anticipate the needs of residents. As you get to know your residents, you will learn their routines and habits and the times they will need your help. You can use that knowledge to "be there" almost before the residents know they need help.
  • Round frequently to learn residents' needs. Rounding—going from patient to patient to see how they are doing—is the activity that lets you "keep an eye" on each of the residents and accommodate his or her needs in a timely way.
  • Materials and equipment should be in working order, and they should be used correctly.
  • Exercise and ambulation with residents is vital to maintaining their fitness and preventing falls. Occupational and physical therapy, if available, can be very helpful.

HEAR ME

  • Hazards in the environment.
  • Educate residents.
  • Anticipate residents' needs.
  • Round frequently.
  • Materials and equipment.
  • Exercises and ambulation.

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Responding to a Near Fall or Fall

Everyone on the care team has a role to play in responding to a nursing center resident's near fall or fall. There are four steps to responding effectively.

1. Observe and evaluate.

When you see that a resident has fallen, what do you observe? Is first aid or other additional care required? If so, your first priority is to make sure the resident gets that care as quickly as possible. You should always alert the attending professional (whether a licensed nurse, nurse practitioner, or doctor) according to the guidelines for notification that are the policy of your nursing center.

2. Investigate and document.

Once the resident's condition has been addressed, it is important to investigate the circumstances in which the fall took place. Try to notice and list everything that may have contributed to the fall, including the resident's individual risk factors, environmental factors, and factors in care or equipment. Then you need to document what you have found. In most nursing centers, this involves completing an incident report.

3. Implement an individualized care plan.

Once the team reaches a conclusion about the causes of the resident's fall, nursing should add an individualized approach for falls to the resident's care plan. This approach may call for one or many interventions. If the falls continue, a group involving several disciplines beyond nursing, such as physical therapy and the doctor, may need to meet with the nursing staff to address the problem.

An individualized care plan for falls is not a one-time solution. Licensed nurses and other staff must revisit the plan to make sure it is effective in preventing additional falls and injuries from falls. If the plan is not effective, a new one should be devised.

4. Develop a falls management program.

Beyond individualized care plans, nursing centers can develop a falls management program aimed at falls prevention across the nursing center. Staff must be able to document how many falls are occurring in a given time period and why those falls are occurring. With this information at hand, the team can design a menu of interventions and a process for individualizing interventions. In one nursing center, for example, lack of easy access to call buttons may be a major issue in falls; in another, falls may result from insufficient ambulation and exercise. When such trends come to light, nursing centers can make organization-wide changes in services or care processes that will help prevent falls.17

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After a Fall

There are many interventions that can be tried to limit the risk of future falls. Here are some things that staff should think about and discuss with the nurse practitioner or doctor.

Examples of Fall Prevention Interventions

To reduce fall risk consider:

  • Things about the environment (e.g., rearrange the resident's furniture).
  • Things about the resident (e.g., review medications).
  • Things about the equipment or care plan (e.g., monitor blood pressure frequently).
  • Things about the nursing center (e.g., provide education on falls prevention).

Things about the environment, including:

  • Keep frequently needed items (glasses, water, blankets, call lights, telephone) close to a resident where they can be reached safely.
  • Rearrange residents' room furniture to reduce hazards.
  • Add safety equipment.

Things about the resident, including:

  • Take the resident to the bathroom often.
  • Review medications.
  • Consider which balance exercise programs are best for the resident.
  • Evaluate and, if needed, adjust assistive devices.
  • Assess the resident's gait and consider gait training.

Things about equipment or the care plan, including:

  • More frequent blood pressure monitoring.
  • More frequent toileting.
  • Safer footwear.
  • Lower beds.
  • Use of bedrails.

Things about how the nursing center operates, including:

  • Falls surveillance.
  • Multidisciplinary falls assessment.
  • Changing staffing schedules to provide increased monitoring.
  • Providing education on falls prevention to staff and/or residents.

A comprehensive facility assessment may be necessary to make all the needed changes.

Usually, more than one intervention is tried, perhaps by adding one at a time or perhaps several all together. Each plan should be tailored to the individual. That is, each change should be made to address a reason that this particular resident may be falling. So, knowledge of the resident's history, and observations about how this particular resident came to fall, are critical in selecting the appropriate intervention.


10 Capezuti E, Strumpf N, Evans LK, et al. Relationship between physical restraint removal and falls and injuries among nursing home residents. J Gerontol A Biol Sci Med Sci 1998; 53A(1):M47-M52.
11 Gray-Micelli D. Falls: Nursing Standard of Practice Protocol: Fall Prevention. New York, NY: New York University College of Nursing, Hartford Institute for Geriatric Nursing; 2008. Available at http://consultgerirn.org/topics/falls/want_to_know_more. Accessed January 30, 2012.
12 Hendrich AL, Bender PS, Nyhuis A. validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients. Appl Nurs Res 2003; 16(1):9-21.
13 Fabre JM, Ellis R, Kosma M, et al. Development and validation of the Comprehensive Falls Risk Screening Instrument. Phys Occup Ther Geriatr 2010; 28(2):181-194.
14 The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Available at http://www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm. Accessed January 30, 2012.
15 Taylor JA. The Vanderbilt Fall Prevention program for long-term care: Eight years of field experience with nursing home staff. J Am Med Dir Assoc 2002; 3(3):180-185.
16 The Timed Up and Go Test for Fall Assessment. Available at http://www.patientsafety.gov/SafetyTopics/fallstoolkit/media/timed_up_and_go_test-07-15-04.pdf [Plugin Software Help]. Accessed January 30, 2012.
17 Taylor JA, Parmelee P, Brown H, et al. Model quality improvement program for the management of falls in nursing homes. J Am Med Dir Assoc 2007; 8(3, Suppl 1):S26-S36.

Page last reviewed June 2012
Internet Citation: Session 2: 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/ltcmod3sess2.html