Case Study: Mr. P
Mr. P is an 84-year-old man who has been a resident at the nursing center for the last 2 years. He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. Until recently he shared a room at the nursing center with his wife, but she passed away earlier this year. Since that time, he has been more depressed and has had difficulty sleeping. On admission to the nursing center, he used a walker to get around, but now he mostly uses a wheelchair, and he is less able to do his own toileting and grooming. His safety awareness is poor, and he has had many falls. Most of the falls have happened at night after his private duty caregiver has gone home.
What are his risk factors for falling? How might you, as his nursing assistant, help protect him from having an injurious fall during the night?
We all try to provide the highest possible level of care to our residents. Their safety is a priority for us. Safety means avoiding, preventing, and lessening the effects of harm and injury while residents are in a health care setting.1 Within nursing centers, one of the biggest safety challenges is preventing falls. Research shows that three of every four nursing center residents fall each year, and the average resident has two to three falls per year. Most nursing centers have more than 100 falls per year.2, 3, 4
At the same time, another priority is the resident's quality of life. We try to respect a resident's right to make choices that make him or her happy, to have respect, and to have privacy.5 In settings in which older people both live and receive health care, it can be difficult for care providers to meet both of these goals of safety and quality of life at the same time. This is particularly true in nursing centers, where residents' ability to make choices may be affected by dementia, and their ability to keep themselves safe may be affected by frailty (being in a weakened condition).
According to the National Center for Injury Prevention and Control, "fall prevention takes a combination of medical treatment, rehabilitation, and environmental changes."6 The Center found that the most effective interventions—things care providers can do—include:
- Educating staff members about risk factors and prevention strategies for falls.
- Making environmental changes designed to prevent falls.
- Reviewing medicines to see which have side effects that might cause falls.
- Assessing patients after a fall to identify and treat their risk factors for the future.
To prevent injury from falls, all nursing staff need knowledge and skills. Licensed nurses have assessment skills and knowledge about medications that make them key to this process. Nursing assistants and other front-line workers spend more time with the residents and also have skills that they contribute to the nursing team. Front-line workers deliver most of the hands-on care that residents receive, so their insight on how to prevent falls in the context of residents' daily activities is unique and valuable.
Facts About Falls
A Safe and Enjoyable Environment
Care providers can help keep residents safe by helping to create and maintain a safe environment. That means:
- Being aware. Being aware means that we are alert to the needs of our residents. We are "tuned in" and tend to their needs. To do this, we need to learn to watch residents, noticing and thinking clearly about what is going on with them.
- Responsiveness. When we notice something that might affect a resident's safety, it is our job to respond and do what is needed to protect the resident. A response is not complete until there has been followup. In other words, response is not a one-time thing. It may have several steps, or it may need to be repeated, until the issue is resolved.
- Sharing and teamwork. Being alert and responding to our residents' needs is only possible when we work as a team. We should understand the jobs of our coworkers and create teams that include workers with other jobs and skills. We should be available to assist our coworkers at any time. We can respond more completely to our residents' needs together than by ourselves.
- Reporting and supporting. We all feel terrible when a resident falls. We might wonder if we could have done something different, or worry that we let the resident and the team down. Also, we might feel frustrated that the environment was not safer.
Often, when a change occurs that might signal illness in a resident, that change has nothing to do with a mistake or a problem in the care system; it is simply that the resident is frail and unsteady. But even if you think a mistake may have happened, you must report the change. The resident can't be helped if no one knows there might be a problem.
- Learning by talking with team members. Reporting changes helps keep residents as safe as possible. Residents are most protected from harm or injury when providers openly report anything that might affect a resident's well-being.
We need to see how things work, notice when they aren't working right, learn how to fix problems, and learn how to recover when things do go wrong. An experienced care team has seen things go wrong in the care system. They have learned how to avoid those situations and, when they do happen, to fix them as well as they can.
Perhaps most importantly, they have learned to communicate openly with each other when something might affect a resident's well-being. This may not be easy. When things go wrong (adverse events) or look as if they are about to (near-misses), we may feel embarrassed and worry that if we report the problem our job performance could be questioned or we might get punished. Also, we don't want to get anyone else in trouble. This is particularly true if a supervisor needs to be involved. As a result, things that might affect a resident's safety may go unreported or not be discussed.
We learn best when we talk about how things might or did go wrong. Learning is much harder if we can't see what happens when things go wrong for others or can't get feedback when it happens to us. Everyone—residents and staff—does better when people support discussion and learn from near misses and adverse events.
- Avoiding blame helps. We all care about the residents in our nursing center. To make sure they stay safe, we have to openly share experiences—good and bad. Blame prevents open communication. A situation in which a care provider's actions are not well-intended may happen; that person may have to be identified and possibly removed from the setting. But that is very unusual. Usually, when things go wrong it is because a provider was too tired, distracted, didn't know how things work, or the teamwork was not smooth. Sometimes, there is a situation that can be called "an accident waiting to happen." This kind of problem can be fixed best if discussion is encouraged, and the care team works together to find a solution.
- Fixing "accidents waiting to happen." Hazards in the environment can—by themselves or in combination with other factors—cause falls. To prevent falls, we have to be aware of our environment. We have to notice hazards in the environment and eliminate those hazards ourselves. We should take action to eliminate the hazards if we can, or if not, we should work with the person who can eliminate them.
- Expect teamwork. Caring means speaking up. But you also need your team to hear you in a helpful way. Residents expect and deserve a safe environment and often cannot speak or do for themselves, so it is up to members of their care team to speak for them and to be a team that hears and responds positively. While that's sometimes easier said than done—especially on sensitive matters that we think might cause blame—it's something we all have to learn to do together. Often it helps just to expect that kind of teamwork. Thinking beyond blame to expecting teamwork and problem solving makes it much easier to speak up, be heard, and respond positively together.
As we do this work, we can also keep in mind that residents want to do things that give them happiness, respect, and independence. Most people like to be able to move around and take care of themselves. For people who are weak, confused, and fall easily, it can be hard to be happy and safe. So watching and helping to make sure that people are as safe as they can be without making them unhappy is our goal.
Knowing When a Fall Has Occurred
A person can end up on the ground for many reasons. Experts have defined a fall as an "unintentional change in position, coming to rest on the ground or onto the next lower surface (e.g., onto a bed, chair, or bedside mat)." That is, a person falls down, is not pushed down, and does not collapse from a sudden medical condition like a stroke.
It is important to determine whether the resident has fallen down because of another medical problem that caused a loss of consciousness like a stroke or a seizure. Falls are more likely to be part of another problem when the person has no history of falling and few risk factors for falling. If the person has many risk factors for falling, it may be that the fall is the main problem.
Is it a fall?
Risk Factors for Falls
A risk factor for falling is one that, in clinical studies, has been found to present frequently in people who fall. Research shows that there are several key risk factors for falls among nursing center residents. Many residents have more than one risk factor. The more risk factors a person has, the more likely he or she is to fall.7
There are two main groups of risk factors. The first group has to do with the person who falls; maybe the person has poor vision or dizziness when he or she gets up too fast. The second group of risk factors has to do with the environment.
Risk Factors Related to the Resident
The most important risk factors for falls having to do with the resident are:
- Previous falls. If residents have fallen in the past, or if they have a pattern of falling, they are much more likely to fall in the future.
- Diminished strength. Residents may not be strong enough to counter the tendency to fall. Strength is measured by the ability to stand and walk unaided, commonly called the “Get Up and Go Test.” Loss of strength in the lower limbs is especially common in residents who fall. Anyone who walks with a cane or a walker has diminished strength in the lower limbs and is at risk for falling.
- Gait and balance impairments. Even if residents can walk unaided, they may have abnormal patterns of steps, or they may have difficulty in maintaining their balance. Such gait and balance problems are always suspect in a resident who falls and are an important risk factor for falling.
- Medications. Taking certain medications has been shown to result in an increased risk of falls.8 In particular, the use of sedatives and hypnotics, antidepressants, and benzodiazepines has been found to be associated with falls. Often, however, eliminating such medications is not an option.
- Alzheimer's disease or dementia. Many nursing center residents suffer from Alzheimer's disease or dementia, which may put them at additional risk. In general, people who have dementia are more likely to fall than people who don't, and they are more likely to be injured in a fall. When people with dementia move about when they are not being watched and do not have help, they are at greater risk for falling. Also, when their behavior is agitated or disruptive, they are more likely to fall. People with dementia are also more likely to fall in the late afternoon or during the night.
- Vision impairment. Problems with vision are common in nursing center residents, and vision problems make residents more likely to fall.
Resident Risk Factors for Falls
Risk Factors in the Environment
Things like poor lighting or a cluttered room can make it more likely that a person will fall. Factors related to equipment that is being used may increase a resident's fall risk. For example, the walker may not be stable, or the wheelchair lock may be hard to use. Falling risk also can be related to how care is organized. For example, perhaps not all members of the team are aware that the resident tends to wander at night. This may be because they do not read one another's notes or talk much at change of shift.
Nursing center residents often fall for reasons that have little to do with their health or behaviors. Nursing assistants and licensed nurses know that factors in the environment are extremely important causes of falls. Risk factors for falls having to do with the environment include:9
- Design problems. Inaccessible call buttons, inadequate lighting, and uneven, wet, or slippery floors.
- Lack of space. Small or overcrowded rooms that can be difficult to navigate.
- Obstacles. Wheelchairs, linen carts, medicine carts, and cleaning equipment left in crowded rooms or hallways.
- Equipment misuse or malfunction. Examples include wheelchairs that do not lock or Hoyer lifts that are not properly operated.
- Staffing and organization of care. Inadequate staffing may leave residents who are likely to fall without proper supervision.
Environmental Risk Factors for Falls
1. Key Facts About Patient Safety. Boston, MA: National Patient Safety Foundation; 1997. Available at http://www.npsf.org/for-patients-consumers/patients-and-consumers-key-facts-about-patient-safety/. Accessed January 30, 2012.
2. Rubenstein LZ, Robbins AS, Josephson KR, et al. The value of assessing falls in an elderly population: A randomized clinical trial. Ann Intern Med 1990; 113(4):308-316.
3. Rubenstein LZ. Preventing falls in the nursing home [comment]. JAMA 1997; 278(7):595-596.
4. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994; 121:442-451.
5. Slater L. Person-centeredness: A concept analysis. Contemp Nurse 2006; 23(1):135; 2006.
6. Injury Prevention and Control: Home and Recreational Safety; Falls in Nursing Homes. Centers for Disease Control and Prevention; 2011. Available at http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html. Accessed January 25, 2012.
7. Tinetti ME, Kumar C. The patient who falls. JAMA 2010; 303(3):258-266.
8. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of nine medication classes on falls in elderly persons. Arch Intern Med 2009; 169(21):1952-1960.
9. Hill EE, Nguyen TM, Shaha M, et al. Person-environment interactions contrbuting to nursing home resident falls. Res Gerontol Nurs 2009; 2(4):287-296.