The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 5. Information and Training for Staff, Primary Care Providers, and Residents and their Families
This chapter contains three modules for orienting staff, primary care providers and residents and their families to the FMP. Staff materials are more structured and include a train-the-trainer module.
Module One: Staff Training
This module provides all of the information necessary for the Falls Nurse Coordinator or staff development coordinator to deliver two 30-minute training sessions for all facility staff and one additional 30-minute session with licensed nursing staff.
People have many different learning styles, however, the following principles apply to all adult learners and will enhance their ability to learn:
- Provide adult learners the opportunity to talk about their own life experiences.
- Provide adult learners with content based on real-life situations that can be applied in a practical way.
- Provide adult learners the opportunity to participate in the classroom in an active way.
Adults learn best when the teaching situation encourages them to contribute their ideas and opinions. This principle is especially applicable to nursing assistants who have valuable knowledge and experience but may have limited classroom experience. It is important to ask nursing assistants for their ideas about changes in care and to acknowledge their central role in any plan. This is accomplished by asking for their opinions, listening to their responses, acknowledging the value of their opinions and then incorporating their suggestions into care routines. The classes are designed so that after the video, the participants discuss the content and how to apply it while caring for their residents.
In a culture of safety, it is the role of the Falls Nurse Coordinator to encourage full reporting by staff of all fall incidents and to emphasize there is no blame or shame attached to mistakes that may result in a resident's fall. This message must also come from the administration through reassurance that those reporting a fall will not be punished.
Emphasis should be on examining the system rather than blaming individuals. During the inservices, the instructor should communicate this message and encourage staff to report falls accurately and to participate in group problem solving to develop new interventions.
Section One: Inservices for All Facility Staff
Goals and objectives of class
The goals of Inservice #1, "Why Falls Happen," are to explain the importance of reducing falls in long-term care and common causes of falls. This inservice should include a description of the FMP, introduction of the team members, and a review of the culture of safety.
Program Objectives for Inservice #1
Upon completion of Inservice #1, each staff member will be able to name:
- Common safety problems in the resident's room and bathroom.
- Safety problems during transfer and ambulation.
- Unsafe behaviors that increase fall risk.
- Safety problems related to wheelchair use.
- Side effects of psychotropic drugs that increase fall risk.
The goals of Inservice #2, "How to Reduce Falls," are to explain specific strategies to reduce fall risk and to discuss their application to individual residents in the program.
Program Objectives for Inservice #2
Upon completion of Inservice #2, each staff member will be able to name:
- Strategies to improve safety in the resident's room and bathroom.
- Strategies to improve safety during transfer and ambulation.
- Strategies to manage unsafe behaviors.
- Strategies to improve safety during wheelchair use.
The materials for both inservices include a variety of instructional methods. Participants will hear the content delivered by the instructor, see the content on video and read it in a handout. In this way the material is reinforced and individual preferences for learning may be met. Pre and posttests for each inservice are provided in Appendix B. However, they should be used in a manner that encourages staff to see their progress instead of noting failure. For staff members who do not understand English well or have other learning barriers, the instructor may need to provide an additional review of the program. Handouts 1 and 2 as well as the pre and posttests are provided in Spanish and English.
It is helpful to use examples and case histories during the group discussion. This can be easily accomplished by naming a specific room or bathroom, wheelchair, or resident with risk factors. A sample case study with discussion points for both inservices is provided in Appendix C.
Resources and materials
There is one videotape, The Fall Reduction Program, that contains two 15 minute sessions. The first program, Part I, is for inservice #1 and the second program, Part II, is for inservice #2. Information for the purchase of this video is provided in Appendix A, item #6. There is one handout for inservice #1, Why Falls Happen, and one handout for inservice #2, How to Reduce Falls).
The following items are needed for both Inservice #1 and #2:
- Reserved Room.
- Videotape, The Fall Reduction Program, Part I and II.
- Videotape player and monitor.
- Attendance sheet.
- Handout for inservice #1, Why Falls Happen, a copy for each participant.
- Handout for inservice #2, How to Reduce Falls, a copy for each participant.
Section Two: Education For Registered Nurses and Licensed Practical Nurses
Goals and Objectives of Class
The goal of this inservice is to provide the information and training that nurses need in order to coordinate the Fall Response when a resident on their unit falls. Training should include nurses on all three shifts and those who work on weekends.
Upon completion of this session, the participants will be able to:
- Name the components of the Fall Response.
- Correctly complete the Tracking Record for Improving Patient Safety.
- List all of the information that should be included in their nurses notes during the period of increased monitoring.
- Name the five areas of falls risk on the Falls Assessment.
- Recognize the Primary Care Provider FAX Report and Orders.
- Name at least ten interventions that can be implemented during the first 24 hours after a fall.
Training for licensed staff should emphasize each of the eight elements of the Fall Response as described in Chapter 2. In reviewing this material, the trainer should emphasize the importance of prompt and thorough resident evaluation and investigation of the circumstances. Nurses on all three shifts and those who work the weekend are expected to respond immediately. The nurse should rely upon direct care staff's knowledge and experience with the resident to completely fill out the TRIPS form.
Licensed personnel may need follow-up after the inservice to ensure correct completion of the form. Licensed staff should rely on direct care staff's input but remember that they are ultimately accountable for the investigation and documentation of a fall as well as implementing an immediate response on their shift.
Licensed staff should be reminded of the crucial role of documentation during state surveys, litigation or other formal investigations so that their notes during the first 72 hours after the fall are comprehensive and always reference the fall. Information on the TRIPS form should be used as the basis for their first note.
All licensed staff should understand the processes related to assessment, care plan development and monitoring as outlined in the FMP. While the Falls Nurse Coordinator is responsible for completion of the Falls Assessment and Falls Intervention Monitor, various aspects may be delegated to direct care staff.
The following items are needed for this inservice:
- Reserved room.
- Attendance sheet.
- Tracking Record for Improving Patient Safety, a copy for each participant.
- Falls Assessment, a copy for each participant.
- Mobility and Transfer Assessment, a copy for each participant.
- Unsafe Behavior Worksheet, a copy for each participant.
- Primary Care Provider FAX Report and Orders, a copy for each participant.
- Fall Interventions Plan, a copy for each participant.
- Fall Interventions Monitor, a copy for each participant.
Module Two: Information for Primary Care Providers
All primary care providers should be kept informed of their residents' fall risk and be active during the assessment process and treatment. To ensure that this communication occurs, the FMP provides two formal methods for correspondence between the nursing staff and the resident's primary care provider.
Once a resident has been entered into the FMP as a result of screening or during the Fall Response, the Falls Nurse Coordinator conducts a Falls Assessment. The results of this assessment are communicated to the primary care provider using a 3-page fax called the Primary Care Provider Fax Report and Orders. The first page is a Cover Sheet; the second page is the falls assessment report; and the third page is the Fax Back Orders.
Once this fax is received, the primary care provider should review the results of the Falls Assessment and use the Fax Back Orders to order referrals and any further evaluations. It is important that the primary care provider return the Fax Back Orders on the next business day to ensure appropriate safety measures and interventions are implemented in a timely manner.
- When a resident who has already been entered into the FMP falls, a FAX Alert will be sent to the primary care provider communicating the total number of falls for this resident during the past 180 days and asking the primary care provider for further evaluation.
The Falls Nurse Coordinator is the point of contact for the primary care physician in monitoring residents' status. The Falls Nurse Coordinator will continue to work collaboratively with the primary care physician to ensure appropriate interventions and care plan changes occur as necessary.
Primary care providers should also be kept informed of relevant monthly data including the key indicators (number of falls, number of fallers, number of residents with 2 or more falls and number of serious injuries) during quality improvement or utilization review meetings.
It is the medical director's responsibility to inform all primary care providers of their role in the program. This includes explaining the program; providing a background on falls in long-term care; reviewing suggestions for further assessment and intervention; and answering questions. The handouts intended for distribution to the primary care providers are designed to aid the medical director in this process. They include:
- Basic facts about falls and the FMP flow chart.
- Suggestions for further assessment and/or interventions.
Copies of the Primary Care Provider FAX Report and Orders, FAX Alert, Falls Assessment and TRIPS form should also be given to the primary care providers to familiarize them with the correspondence and documentation tools used during the FMP. All of the handouts and forms for the primary care providers are in Appendix B. A letter that may be used by the medical director to introduce primary care providers to the program is also provided in Appendix B.
Module Three: Information for Residents and Their Families
The purpose of the educational session for families and residents is to present information about falls in the elderly and to describe the facility's program to reduce the fall risk of their residents. Some family members may want to talk about other aspects of a resident's care. It is best to stay on the topic of fall reduction. Acknowledge concerns and ask families to write questions down for later discussion with the appropriate staff.
Goal and Objectives of Class
The goal of this class is to inform families of the high risk of falls in the elderly, common causes of falls in a nursing facility, consequences of falls, and basic strategies to reduce them. Residents who can understand and follow the discussion should be encouraged to attend and to participate in whatever manner they can.
After attending the presentation, each family member will be able to:
- Improve the safety of resident's room by removing clutter and unused items.
- Distinguish between safe and unsafe footwear for the resident.
- Understand the need to call for help from staff during transfer and mobility when the resident is unsafe.
- Remind and encourage the resident to follow precautions for postural hypotension when appropriate.
Some facilities may choose to conduct the class during regularly scheduled family meetings. A second option is to have a "De-clutter Luncheon". For this, families would be invited to a lunch at the facility. The class could be conducted either before or after the lunch. At the conclusion of the presentation, families are asked to evaluate the resident's room with the resident and then take home items that are no longer used. Content for the presentation, which can be used for other presentations as well, follows at the end of the chapter. The following items are needed for the session.
- Reserved room.
- Attendance sheet or a form of check-in.
- Name tags.
- Handout, Ways Families Can Help Reduce Fall Risk.
- Brochure, Reducing Falls: A Safety Checklist for the Home.
- Samples of safe and unsafe footwear
The handout and brochure are in Appendix B.
- Slide 1. Facts About Falls
- Slide 2. Facts About Falls (continued)
- Slide 3. Facts About Falls (continued)
- Slide 4. Intrinsic Fall Risk Factors
- Slide 5. Intrinsic Fall Risk Factors (continued)
- Slide 6. Intrinsic Fall Risk Factors (continued)
- Slide 7. Extrinsic Fall Risk Factors
- Slide 8. Extrinsic Fall Risk Factors (continued)
- Slide 9. Extrinsic Fall Risk Factors (continued)
- Slide 10. Physical Restraints
- Slide 11. Consequences of Falls
- Slide 12a. Staff Strategies to Reduce Fall Risk
- Slide 12b. Staff Strategies to Reduce Fall Risk (continued)
- Slide 13. How You Can Help
- Slide 14. Remove Clutter
- Slide 15. Provide Safe Footwear
- Slide 16. Promote Safety During Transfer
- Slide 17. Use Low Blood Pressure Precautions