AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Facilitator Training Slide Presentation
Slide 1: Introduction to Falls Reports
AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training
Introduction to Falls Reports
Slide 2: Falls Prevention Electronic Reports
- Electronic Reports
- Falls High-Risk Report
- Summary of Fall Risk Factors (by Unit or Facility)
- Contextual Factors Report (by Unit or Facility)
- Postfall Assessment Report (by Resident)
Slide 3: Teaching the Falls Prevention Electronic Reports
- The teaching sessions for each report should include the following content:
- Purpose of the report
- Content of the report
- Calculation details
- Quizzes and exercises
Slide 4: Postfall Assessment Data Elements
- Required data elements include:
- The date and time of the fall.
- The name of the person who witnessed the fall, OR the name of the person who found the resident (if the fall was not witnessed).
- The location where the resident fell.
- The position the resident was found in.
- The activity the person was engaged in when he or she fell, if the fall was witnessed.
Slide 5: Postfall Assessment Data Elements
- Additional data elements include:
- Suspected cause of the fall.
- Description of any injury and treatment.
- Physician notification and examination.
- Family notification.
- Physical therapy evaluation, if indicated.
Slide 6: Postfall Assessment Data Elements
- These data are typically collected and documented in a facility’s EMR by staff immediately after a resident’s fall.
- Facilities should work with their EMR vendors to determine how and when these data are currently documented.
Slide 7: Falls High-Risk Report
- Provides a weekly snapshot summary of facility residents at highest risk of falling
- Enables staff to be more proactive, consistent, and accurate when identifying residents at risk
- Helps clinicians see changes in resident status earlier, and identify residents at risk before they fall
Slide 8: Falls High-Risk Report
- How many residents triggered for highest risk of falling?
- What are the most common risk factors?
- Which acute change was seen most often? Least often?
- How many residents at highest risk are cognitively impaired? Have no cognitive impairment?
- How many residents at highest risk had a change in status during the report week?
Slide 9: Falls High-Risk Report: High-Risk Criteria
- Risk criteria identified based on:
- A review of the literature
- Fall elements and scoring from existing instruments
- Input from an advisory panel of leading experts and nursing home users
Slide 10: Falls High-Risk Report: High-Risk Criteria
- Risk determined based on a combination of the following elements:
- Presence of existing conditions considered high risk
- A change of condition of one or more risk elements
- New contributing risk factors
Slide 11: Rules for Determining High Risk
- Rule #1: High Risk Based on an Existing Condition Within 90 Days:
- Residents will be flagged as “high risk” using this criterion if they have at least 3 of the 4 following conditions:
- Severe cognitive impairment or unsafe behaviors
- Gait and balance instability
- A history of falls within the last 180 days
- Use of psychoactive medications
- Residents will be flagged as “high risk” using this criterion if they have at least 3 of the 4 following conditions:
Slide 12: Rules for Determining High Risk
- Rule #2: High Risk Based on a Change of Status Within 7 Days:
- Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition and one of the following changes in status:
- Acute mental status change
- New unsafe behaviors
- New gait/balance problem or mobility device
- New fall
- New medication or dosage change
- Orthostatic hypotension/dehydration
- Vertigo/dizziness
- Syncope fainting
- Hypoglycemia
- Possible infection
- New seizure activity
- New admission
- Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition and one of the following changes in status:
Slide 13: Rules for Determining High Risk
- Rule #3: High Risk Based on New Contributing Risk Factor Within 7 Days:
- Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition and one of the following new contributing factors:
- New or uncontrolled pain
- New or increased urinary incontinence
- Increased independence in mobility
- Room change
- Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition and one of the following new contributing factors:
Slide 14: ADL Changes and Additional Info
- Supplementary information about activities of daily living
- Included in the Falls High-Risk Report but not used in calculations of high risk
Slide 15: ADL Changes and Additional Info
- Includes changes in last 7 days:
- Decline in bed mobility, transfer, or toileting
- Symptoms of depression
- Low body mass index
- Significant weight change
- An active physician’s order for vitamin D
- Osteoporosis
- Diabetes
- Visual impairment
Slide 16: Sample Falls High-Risk Report
Slide 17: Falls High-Risk Report Calculation Details
- Displays the following data for Existing Conditions:
- Mental: Unsafe Behaviors
- Mental: Cognitive Impairment
- Gait and Balance Instability
- Fall Within 30 Days
- Fall Within 31-180 Days
- Psychoactive Medications
- Other High-Risk Medications
Slide 18: Falls High-Risk Report Calculation Details
- Displays the following Change in Condition data:
- Acute Mental Status Change
- Behavior: New Unsafe
- New Gait/Balance or Device Order
- New Fall
- Medication: New Medication or Dose Change
- Orthostatic Hypotension/Dehydration
- Vertigo/Dizziness
- Syncope/Fainting
- Hypoglycemia
- Possible Infection
- New Seizure Activity
- New Admission
Slide 19: Falls High-Risk Report Calculation Details
- Displays the following New Contributing Risk Factors:
- Pain: New or Uncontrolled Chronic
- Urinary Incontinence
- Mobility: More Independent
- Room Change
Slide 20: Falls High-Risk Report Calculation Details
- Displays the following contributing ADL Decline and Other Clinical Information:
- Bed Mobility Decline
- Transfer Decline
- Toileting Decline
- Depression Score (PHQ-9 or PHQ-90V) Increase
- Monthly BMI <22 kg/m2
- Significant Weight Change
- Vitamin D Order
- Osteoporosis
- Diabetes
- Visual Impairment
Slide 21: Check Your Understanding: Falls High-Risk Report Quiz
- A resident who wanders according to his most recent MDS assessment has met which of the following high-risk existing conditions (HRECs)?
- HREC 1: Mental Instability
- HREC 2: Gait and Balance Instability
- HREC 3: Fall History
- HREC 4: High-Risk Medication Profile
Slide 22: Check Your Understanding: Falls High-Risk Report Quiz
- High-risk changes of condition data elements are captured from multiple data sources within the facility’s EMR and represent changes in a resident’s clinical condition within how many days of the report date?
- 5 days
- 7 days
- 10 days
- 14 days
Slide 23: Check Your Understanding: Falls High-Risk Report Quiz
- Which of the following sources are used to determine changes in levels of urinary incontinence and activities of daily living?
- Nurses’ notes
- MDS assessments
- Nursing assistant documentation
- Therapy notes and evaluations
Slide 24: Summary of Falls Risk Factors Report
- Provides information regarding the number and percentage of falls that have occurred for residents with each risk factor included in the Falls High-Risk Report
- Note that a fall may be associated with multiple risk factors.
- Can be used by nursing and QI teams to identify trends, support root cause analysis, and target areas for improvement
Slide 25: Summary of Falls Risk Factors Report
- Report displays falls information at the unit or facility level.
- Report can be used to monitor overall prevalence and trends of risk factors associated with falls on a specific unit or facilitywide.
- Data may be trended for 1 month or 3 months.
Slide 26: Summary of Falls Risk Factors Report Calculation Details
- Displays the following data:
- High-Risk Existing Condition
- High-Risk Existing Change of Condition Within 7 Days of Fall
- New Contributing Risk Factor Within 7 Days of Fall
- Additional Information
- Injury
- Falls With Major Injury
- Falls With Minor Injury
Slide 27: Sample Summary of Falls Risk Factors Report
Slide 28: Check Your Understanding: Summary of Falls Risk Factors Report Quiz
- Each resident fall will only be linked to one risk factor on the Summary of Falls Risk Factors Report.
- True
- False
Slide 29: Check Your Understanding: Summary of Falls Risk Factors Report Quiz
- In order for a high-risk change of condition to appear on the Summary of Falls Risk Factors Reports, it must have been noted within how many days of the fall?
- 14 days
- 5 days
- 7 days
- 10 days
Slide 30: Check Your Understanding: Summary of Falls Risk Factors Report Quiz
- A resident’s postfall assessment documents a hematoma on his head, a dislocated hip, and a laceration on his thigh. Which of the following best represents how these injuries will appear on the Summary of Falls Risk Factors Report?
- Fall with major injury=1 and fall with minor injury=0
- Fall with major injury=2 and fall with minor injury=1
- Fall with major injury=1 and fall with minor injury=2
- Fall with major injury=2 and fall with minor injury=0
Slide 31: Contextual Factors Report
- Displays facility trends by contextual factor
- Enables comparison of trends across nursing units and aids understanding of the cause of variance
- Improves the timeliness of root cause analysis and audit process
Slide 32: Contextual Factors Report
- Displays information on day of the week, shift, time of day, and location of fall and if the resident had a room change in last 30 days
- Uses information collected during resident postfall assessments
- Can be generated for a single unit or for the facility as a whole
- Can show data trended for 1 month or 3 months
Slide 33: Sample Contextual Factors Report
Slide 34: Contextual Factors Report Calculation Details
- Displays the following data:
- Day of Week: Monday–Sunday
- Shift: Days, Evenings, Nights
- Time of Day
- Location
- Other: Room Change Within 30 Days of Fall Date
- Total Residents Who Fell
- Total Residents With >1 Fall
- Total Falls
Slide 35: Sample Contextual Factors Graph
Slide 36: Check Your Understanding: Contextual Factors Report Quiz
- Which of the following is the source for the day of the week, shift, and time of a fall on the Contextual Factors Report?
- Nurses’ notes
- Resident Care Plan
- Postfall Assessment
- Physician Progress Notes
Slide 37: Check Your Understanding: Contextual Factors Report Quiz
- For the Contextual Factors Report to display the shift on which the fall occurred, the Postfall Assessment must include a field labeled “shift.”
- True
- False
Slide 38: Check Your Understanding: Contextual Factors Report Quiz
- Within how many days of a resident fall must a room change occur in order for it to be associated with a fall in the quarterly Contextual Factors Report?
- 7
- 14
- 30
- 90
Slide 39: Postfall Assessment Summary Report
- Displays a single resident’s fall details as recorded on the postfall assessment
- Can display trended data for up to six postfall assessments
- Can display more columns if the facility’s EMR vendor has the ability to display additional data
Slide 40: Sample Postfall Assessment Summary Report
Date of Fall | |||||||
---|---|---|---|---|---|---|---|
Fall Date | Date | 10/4/13 | 1/6/14 | 2/11/14 | 2/27/14 | 3/6/14 | 4/17/14 |
Fall Day | Date of Week | Saturday | Thursday | Tuesday | Thursday | Thursday | Thursday |
Fall Time | Time or "not known" | 6:35 a.m. | 5:35 a.m. | 7:15 a.m. | 6:50 a.m. | 6:10 a.m. | 5:15 a.m. |
Shift | Shift | N | N | D | E | N | N |
Fall Witnessed? | Yes/no | N | N | N | Y | N | N |
If yes, who witnessed? | Staff, family, visitor, volunteer, other | Staff | Staff | Family | Staff | Staff | Family |
Name of person who witnessed the fall | text | text | text | text | text | text | |
If no, who found the resident? | Staff, family, visitor, volunteer, other | Staff | Staff | Family | Staff | Staff | Family |
Name of person who found the resident | text | text | text | text | text | text | |
Fall Location | Fall location: room; bathroom; hallway; dining room; activities; therapy; beauty parlor; shower/tub; nursing stations; out of facility; other | Bathroom | Bathroom | Room | Room | Bathroom | Bathroom |
Resident Position When Found | Position when found: supine, lying left, lying right, sitting, other | Supine | Sitting | Lying right | Supine | Sitting | Sitting |
Resident Activity at Time of Fall | Activity prior to fall: walking; transferring; toileting; in bed; in chair; other | Toileting | Toileting | Walking | Walking | Toileting | Toileting |
Potential Causes of Fall | Unknown | ||||||
Behavior – agitation/other | |||||||
Loss of balance (reaching, turning, sudden movement, other) | |||||||
Gait/balance instability | X | X | |||||
Bowel/bladder: trying to get to bathroom on own | X | X | X | X | X | X | |
Personal device or equipment or attached appliance (cane, walker, crutch, O2) – improper use | X | X | |||||
Equipment failure, bed, chair, floor mat alarms | |||||||
Potential medication issue: new med/dose change/suspected reaction | |||||||
Resident chooses not to follow recommendations: alert and oriented | |||||||
Resident unable to follow recommendations: cognitively impaired | |||||||
Other, please describe |
Slide 41: Sample Postfall Assessment Summary Report: Injury Section
Resident Name:
Fall Comments | Free text | ||||||
Fall Injury? | Yes/no | N | N | Y | Y | Y | N |
If yes, what type of injury? | |||||||
Injury Type: Major | Fracture: hip | X | |||||
Fracture: other | |||||||
Joint dislocation | |||||||
Closed head injury with altered consciousness | |||||||
Subdural hematoma | |||||||
Injury Type: Minor | Skin tear | X | |||||
Abrasion | X | ||||||
Laceration | X | ||||||
Superficial bruises, hematomas | X | X | |||||
Sprain | |||||||
Other injury that causes pain | |||||||
Injury Site | Head Upper extremity (UE) Lower extremity (LE) |
LE | LE | LE | LE | LE | UE |
Injury Assessment | ROM upper: full/decreased | Full | Full | Full | Full | Full | Decr |
ROM lower: full/decreased | Decr | Decr | Decr | Decr | Decr | Full | |
Loss of consciousness: yes or no | No | No | No | No | No | Yes | |
Neuro status: usual or not usual (changes noted) | Usual | Usual | Usual | Usual | Usual | Not Usual | |
Bleeding: none, minor, significant |
None |
None |
None |
None |
None |
None |
|
Other | |||||||
Free text | |||||||
Where Resident Was Treated | Facility, ER, hospital admit |
Facility |
Facility |
ER | ER |
Facility |
Facility |
Slide 42: Sample Postfall Assessment Summary Report: Notifications Section
PCP Notified? | Yes/no | Y | Y | Y | Y | Y | Y |
MD Notified | Physician name |
Brewer |
Brewer |
Cannon |
Jackson |
Brewer |
Brewer |
PCP Notification Date | Date |
10/4/13 |
1/16/14 |
2/11/14 |
2/27/14 |
3/6/14 |
4/17/14 |
Family Notified? | Yes/no | Y | Y | Y | Y | Y | Y |
Family Notified | Family name/relationship |
Daughter |
Daughter |
Son |
Son |
Son |
Son |
Family Notification Date | Date |
10/4/13 |
1/16/14 |
2/11/14 |
2/27/14 |
3/6/14 |
4/17/14 |
Family Notification Time | Time |
8:00 a.m. |
8:00 a.m. |
8:30 a.m. |
7:30 a.m. |
8:00 a.m. |
8:00 a.m. |
PCP Exam Performed? | Yes/no | Y | Y | Y | N | Y | Y |
PCP Exam Date | Date |
10/6/14 |
1/17/14 |
2/12/14 |
3/6/14 |
4/17/14 |
|
PCP Exam Time | Time | 8:00 a.m. | 8:00 a.m. | 8:30 a.m. | 8:00 a.m. | 8:00 a.m. | |
PT Notified? | Yes/no | Y | Y | Y | N | Y | Y |
PT Consult | Date |
10/4/13 |
1/16/14 |
2/11/14 |
3/6/14 |
4/17/14 |
Slide 43: Postfall Assessment Summary Report
- Displays the following data:
- Fall Date
- Fall Time
- Fall Witness
- Witness Type
- Witness Name
- Found By
- Fall Location
- Position When Found
- Activity at Time of Fall
- Injury Assessment Notes
- Bleeding
- Suspected Cause of Fall
- Fall Comments
- Fall Injury
- Injury Type Major
- Injury Type Minor
- Injury Site
- ROM Upper
- ROM Lower
- Loss of Consciousness
- Neurological Status
Slide 44: Postfall Assessment Summary Report
- Displays the following data:
- Treatment Location
- Physician Notified
- Physician Name
- Physician Notification Date
- Physician Notification Time
- Family Notification
- Family Relationship
- Family Notification Date
- Family Notification Time
- Physician Exam
- PT Consult
Slide 45: Check Your Understanding: Postfall Assessment Summary Report Quiz
- Up to how many falls are displayed on the Postfall Assessment Summary Report?
- 3
- 4
- 5
- 6
Slide 46: Check Your Understanding: Postfall Assessment Summary Report Quiz
- Up to three residents can be displayed in a single Postfall Assessment Summary Report.
- True
- False
Slide 47: Check Your Understanding: Postfall Assessment Summary Report Quiz
- Suspected Cause of Fall will display one causative factor for each fall.
- True
- False