All residents in nursing homes have some degree of fall risk; however, the FMP includes various approaches to address different levels of risk. (Figure 1)
Three classes of residents should be entered into the FMP:
- Those who fall while in the facility.
- Those with a history of falls.
- Those who have not fallen but trigger the Falls RAP during Minimum Data Set (MDS) assessment.
The FMP Progression illustrated in Table 4 describes the suggested immediate and long-term management for residents in each of these three classes. Immediate response for those who fall in the facility is described in Chapter 2. The other two groups, those with a history of falls or who are at high risk of falls, must be identified through the screening process.
Table 4. FMP Progression
1. Screening Process
The basic criteria for screening are those used in the Minimum Data Set (MDS) that trigger the Falls Resident Assessment Protocol (RAP). These are listed in Table 5. The criteria used to trigger the Falls RAP and their corresponding MDS section in parentheses are highlighted in bold.
When examining the risk of residents who have not fallen but have one of the other risk factors, it is helpful to determine how long the factor has been present. For example, a resident who has been taking a benzodiazepine for longer than 90 days and has not fallen during the past 6 months is considered to have less risk than a resident with a new prescription.
A resident with a new trigger that occurred during the previous three months or since the last quarterly MDS is considered at higher risk of falling and may benefit from the Falls Assessment, Interventions Plan and Monitor. Staff may enter any resident they believe to be at high risk into the full FMP.
The total number of residents who are entered into the FMP varies widely according to resident and facility characteristics. Between 25-50% of all residents is common. The only exception to entering a resident who has known risk factors is when that person has become bedridden without any ability to stand or get out of bed.
The Falls Nurse Coordinator may use the FMP Entry Log to record the names of all residents who are entered into the program. The date each was entered as well as dates of any subsequent falls should be recorded.
2. Falls Assessment
The Falls Assessment is a two step process.
Step 1: Identify which of the five risk areas contribute to resident's fall risk.
Step 2: Send a Primary Care Provider Report, receive the Order Sheet and make appropriate referrals.
Once the Falls Assessment is complete, it should be placed in the resident's medical record. Refer to Appendix C for a sample of a completed Falls Assessment.
Step 1: Identify which of the five risk areas contribute to the resident's fall risk.
The five areas of fall risk are:
- Orthostatic hypotension
- Unsafe behavior
The Falls Assessment Cue Sheet provides instructions for all of the procedures used to assess risk in each of the areas and should be used by the nurse for quick reference during assessment. A given resident may have one, several or all of these types of risks. Thus, thorough assessment is needed to identify all appropriate interventions. When a resident does not have risk in one of the listed areas, check NA.
While all medications should be reviewed for their potential impact on fall risk, the following classes of drugs are reported in the literature as most important.
If the resident received a drug in any of these classes on 4 or more of the past 7 days, the nurse should put a check by the specific drug class. Please go to the Falls Assessment Cue Sheet for a list of the drugs in each class.
Postural vital signs are taken for ambulatory residents and should be taken in the right arm unless indicated otherwise. The resident should be seated for at least five minutes prior to measurement. The resident's blood pressure and apical heart rate are taken while sitting and at 1 minute after standing. If there is a drop of 20 mm Hg or more in the resident's systolic pressure 1 minute after standing, the nurse should put a check by Orthostatic Hypotension and write in values for the two BP measurements. Sometimes it may be difficult to determine if the resident is hypotensive when checking only one point in time. If the resident does not show evidence of orthostatic hypotension during the Falls Assessment but complains of light headedness or dizziness, the nurse should perform the measurements when the resident complains or after meals.
The nurse should observe the resident during activities of daily living while in the bedroom, bathroom, hallway and dining room. If the resident stumbles or trips, has difficulty finding objects or detecting changes in floor surfaces, or shows other signs of poor vision, the nurse should put a check by Vision.
The nurse should complete the Mobility and Transfer Assessment to screen residents for safety problems related to gait, balance, transfer and wheelchair seating. This is a 3 step process to determine
- the level of assistance needed by the resident,
- any environmental adjustments needed for safe transfer and
- wheelchair changes needed for safe position and use.
The nurse uses the Get Up and Go Test to determine safety during rising and ambulation. The resident should be instructed to sit in a standard chair with armrests, rise, walk 10 feet, turn, walk back to the chair and sit down. The resident should use a cane or walker if she normally does so. Any unsteadiness, loss of balance or problems with gait should be noted. In addition, the nurse should ask the resident to transfer in and out of bed, on and off the toilet and in and out of the lounge chair if one is used. Any difficulty the resident has rising, turning, managing clothing or lowering during the transfers should be noted.
Step 1: Determine the level of assistance needed by the resident to be safe during the Get Up and Go Test and during each of the transfers. Record as safe independent, safe with 1 person assist or safe with 2 person assist.
Step 2: Determine if adjustments to the bed height, toilet height, lounge chair and handrail support are necessary and record findings. Determine if further evaluation of the resident's assistive device is needed and record findings.
Step 3: Perform a Wheelchair Screen for all residents who use a wheelchair other than for transport only. Locate all missing equipment and check for correct personal labeling. Using the diagrams on the Falls Assessment Cue Sheet, check the size and ?t of the wheelchair as well as the resident's position. Record findings.
If the resident is unsafe during the Get Up and Go Test or during transfer, the nurse should put a check by Mobility on the Falls Assessment. When the resident's wheelchair does not fit or if the resident is positioned incorrectly, the nurse should put a check by Mobility as well. In both cases, the resident should be referred to a physical or occupational therapist for evaluation. The Wheelchair Seating Assessment provided in Appendix B may be used by a therapist to evaluate the resident's seating. It is a detailed assessment that includes recommendations for seating changes.
The nurse should talk with staff to determine if the resident had any of the following unsafe behaviors on 2 or more occasions during the past month:
- Tried to stand, transfer or walk alone unsafely.
- Tried to get out of the bed alone unsafely or climbed over bed rails.
- Walked or paced when too tired to be safe.
- Propelled wheelchair or walked alone in unsafe areas such as outdoors on rough pavement or in parking lot.
If the resident has one or more of these unsafe behaviors, the nurse should put a check by Unsafe Behavior and identify the specific behavior(s).
Step 2. Send a Primary Care Provider Report, receive orders and make appropriate referrals.
Once the Falls Assessment is complete, the nurse should use the 3-page Primary Care Provider FAX Report and Orders to inform the physician, nurse practitioner or physician's assistant of the results of the Falls Assessment. On the first page, the FAX Cover Sheet, the nurse should add the name of the primary care provider, resident's name, unit/room number, date, and fax number of the primary care provider. The second page, Falls Assessment Report, is a list of the safety problems found by the nurse during the Falls Assessment and a list of suggestions for further assessment and/or interventions. The nurse should write in the resident's name and date and put a check by each identified risk area. If Medications is checked, the specific medications should be added as well. The third page is the Fax Back Orders for the primary care provider to complete. Before sending the FAX, the nurse should fill in the FAX number of the facility, resident name, date, and unit/room at the top of this page. Providers who are in the facility multiple times per week may prefer to receive these forms in person, rather than by fax.
The primary care provider is asked to respond to the FAX by the next business day. It is recommended that the nurse wait two business days for a reply and contact them again if a reply is not received. Once the Fax Back Orders are received, the nurse should carry out all of those requested. This may include referrals to an OT/PT, optometrist or ophthalmologist as well as medication changes, laboratory tests or other procedures. While the Falls Assessment and care planning are in process, an interim care plan to reduce fall risk should be used.
3. Fall Interventions Plan
Care plans that incorporate input from medicine, therapy and other health care professionals are more likely to address the multiple risk factors common in this population. Input from direct care staff can provide the personal details necessary to target specific behaviors and personal situations of increased risk.
The continuum of care to manage fall risk includes three areas of focus which need special consideration:
- Interim plan of care for new admissions
- Comprehensive care plan development driven by the Falls Assessment
- Intensive care planning for residents with recurrent falls
A. Interim Plan of Care for New Admissions
Most residents are at a higher risk of falling in the first 2-3 weeks following admission to a facility. However, it may take staff a significant portion of this period to develop a comprehensive care plan based on a multidisciplinary approach. Also, it may be difficult to determine the resident's risk this early in their stay. Other residents may have increased fall risk after admission that will decrease once adjustment to the facility is made.
For these reasons, an interim plan of care should be implemented for all new admissions regardless of risk level. During this time, close observation to collect information about the resident's risk factors and individual behaviors can be used to develop a more comprehensive plan once a Falls Assessment is complete. If a resident is found not to be at high risk during screening or this observation period, some measures may be stopped.
Interim Plan of Care
- Close observation and increased supervision.
- Frequent orientation to room, bathroom and facility.
- Medication review.
- Use of safe footwear.
- Staff assistance to toilet or bedside commode.
- Use of monitoring or sensor devices.
- Use of pressure, position, seat belt or other alarm.
- Use of protective clothing/devices: helmet, wrist guards or hip protectors.
B. Comprehensive Care Plan Development Driven by the Falls Assessment
A comprehensive falls care plan is developed using two steps.
- Complete the Falls Assessment.
- Select and individualize interventions on the Fall Interventions Plan.
1. Complete the Falls Assessment
Once the nurse completes an assessment in each of the five areas (Column 1) and sends the Primary Care Provider FAX Report and Orders, the next step is to complete all of the recommendations and orders from the primary care provider, therapist and any other healthcare professionals (Column 2). Examples include medication changes, lab tests, new assistive devices and seating modifications. This step ensures multidisciplinary involvement. Because some referrals and further evaluations will take longer, the Falls Nurse Coordinator should proceed with the care plan and add later recommendations at the time they are received.
2. Select and individualize interventions on Fall Interventions Plan
For most residents who trigger a Falls RAP but have not actually fallen in the past 180 days, do not complete the Falls Intervention Plan. Rather, incorporate results of the assessment into the regular care plan. Exceptions may include residents felt to be high-risk due to risk factors not included on the current MDS or those residents with a new MDS trigger occurring in the last 90 days.
Development of the Fall Interventions Plan is based on results of the Falls Assessment as well as investigation of all circumstances and related resident outcomes. In order to be specific during care plan development, the nurse must have the following information:
- Input from direct care staff about effective and ineffective strategies tried in the past.
- Input from direct care staff about resident's individual behaviors and needs.
- Past fall history including TRIPS data.
- Input from family and resident.
Based on this information, the nurse checks those interventions listed in each of the risk categories checked on the resident's Falls Assessment that are appropriate. Additional tasks can be added beside "other" and to the back of the form when needed. An example of a completed Fall Interventions Plan is provided in Appendix C. A copy of the Fall Interventions Plan should be kept on the unit with other CNA guidelines and revised as needed. Once it is revised several times, it may be necessary to complete a new updated one to ensure readability.
If the nurse has difficulty selecting interventions for the management of identified unsafe behaviors, he or she should complete the Unsafe Behavior Worksheet. This 2-page worksheet will help staff identify the circumstances of the behavior, review the resident's personal and medical history and analyze staff/resident interactions so that staff can problem solve and develop new management strategies. Detailed instructions are provided on the form. A copy is provided in Appendix B and a sample of a completed Unsafe Behavior Worksheet is provided in Appendix C.
C. Intensive Care Planning for Residents With Recurrent Falls
Often in nursing facilities there are recurrent fallers, that is, residents who fall two or more times. Developing care plans for these residents is challenging, not only because of their high fall risk but also because staff may become discouraged and feel nothing will work. However, careful assessment and care planning can reduce risk of additional falls in most residents. Risk factors that are common in recurrent fallers are described in Figure 10.
To be effective, management of falls in this group of residents must include multidisciplinary assessment, creative team problem solving with direct care staff and weekly monitoring of staff implementation and resident response. Adjustments to the care plan and a willingness to try both new and old interventions is needed. This is time consuming and labor intensive for staff. However, residents in this group require and can benefit from ongoing team efforts. General guidelines for managing recurrent falls include careful investigation in the following areas:
- Toileting. Often for recurrent fallers, toileting by staff must be individualized and more frequent. If it is determined that urgency, frequency or incontinence are reasons for unsafe transfer or ambulation, staff must develop a toileting plan that will minimize these symptoms. Strategies may include medication review, an individualized toileting plan and restorative care measures.
- Monitoring. Recurrent fallers need more supervision than other residents either by staff, family, volunteers or through the use of equipment. Room sensors to detect resident movement; position or pressure alarms on the bed, chair or wheelchair; and alarms to prevent unsafe wandering can be helpful. Recurrent fallers should be placed in structured activities and exercise programs whenever possible so that observation by other residents and the activities staff occurs. As new models of care develop within the long-term care industry, new living space and staffing structures will enable increased interaction between residents and staff and therefore may improve observation.
- Bed safety. Residents who try to get out of the bed unsafely when alone should be evaluated for a low bed and floor mat. Full side rails should not be used as a means to keep a resident in the bed when they are trying to exit. Trying to climb over bedrails may well result in a serious fall related injury. Cradle mattresses or perimeters are useful options.
- Individualized seating. For residents who exhibit unsafe behavior while in a wheelchair, individualized seating modifications and equipment prescribed by an OT/PT experienced in functional seating can reduce fall risk. The Wheelchair Seating Assessment outlines specific solutions to seating problems and can be used by a qualified therapist to perform a detailed assessment.
- Environment. Staff should work with residents and their families to eliminate all possible hazards in the resident's room and bathroom. Adequate lighting at night and safe footwear are crucial. (Go to Living Space Inspection, Chapter 6.)
- Underlying medical conditions. Every effort should be made to determine what health conditions may be increasing the resident's fall risk. Infections, uncontrolled blood sugar, stroke and other acute conditions should be treated promptly.
- Chronic conditions. Ongoing management of risk for residents with chronic degenerative diseases is difficult. Staff must have a good picture of the resident's baseline function such as known periods of weakness during the day and side effects of the medications used to treat the disease. From this staff can determine routine measures and respond appropriately when the resident's condition worsens.
- Pain management. Appropriate pain assessment and treatment may reduce unsafe behaviors stemming from pain or discomfort.
- Protective clothing. For residents who are in danger of head injury, a helmet can provide protection. Wrist guards may also be used to protect the resident's wrists and forearms during a fall. Hip protectors should be used for all frail, ambulatory residents. Newer brands are easier to use during toileting and residents should be encouraged to wear them on a daily basis.
- Behavior management. All direct care staff should be skilled in responding to behavioral symptoms in a way to minimize the resident's anxiety and agitation rather than fuel it through inappropriate staff attitudes and responses. Basic behavior management skills are illustrated in Table 6.
Since falls management for this group of residents can be frustrating, it is important for the Falls Nurse Coordinator to provide leadership and make all possible resources available to staff. Articles, books and Web sites are referenced in Appendix A. Lists of companies that sell adaptive equipment, alarms, low beds and other items that may be used to reduce risk are also provided.
Know the Resident. Know what the resident likes and does not like, past behaviors, family history, habits and customs, past interests, and at least three things that bring the resident comfort.
Be sure to depersonalize the resident's behavior. Remember that the behavioral symptom is caused by the resident's condition. Don't let the behavior be a trigger for you.
Use good communication skills to approach the resident and give a clear message.
Match the Demands of Caregiving to the Patient's Abilities. Watch for signs of increasing anxiety. When resident's anxiety increases, slow down, re-explain, reassure, or return later.
Use environmental management to keep the resident safe, to help control the resident's behavior and to reduce the effects of other residents' behaviors.
4. Falls Intervention Monitor
In a nursing home, routine supervision of front line staff may not provide enough consistent information about specific care processes such as the interventions listed on a resident's Fall Interventions Plan. This can be the result of many factors including heavy workloads, competing priorities and staff turnover. As a result, individualized care plans may be implemented inconsistently. As the leader of the FMP, the Falls Nurse Coordinator uses the Fall Interventions Monitor to evaluate implementation of the program by direct care staff.
The Falls Nurse Coordinator records on the Fall Interventions Monitor whether the selected interventions are being done by staff and their effectiveness. Many of the tasks listed on the Fall Interventions Plan can be observed directly by the nurse-for example, locked or unlocked bed wheels and safe footwear. For other tasks, such as the level of assistance provided, the nurse should ask direct care staff. Comments and changes to the Fall Interventions Plan should be noted on the form each week.
The following guidelines (refer to Table 4) provide suggestions for how often to monitor different categories of residents in the FMP.
For residents who fall in the facility and those with a history of falls, monitor weekly X4 and then every 2 weeks X4. After 3 months with no fall, monitor monthly. Update Fall Interventions Plan as needed.
For residents who trigger the Falls RAP but have not fallen in the past 180 days, review quarterly.
When a resident falls, return to Step 2 of the FMP Progression and revise the Falls Assessment as needed. Then continue with Steps 3 and 4.