Skip Navigation U.S. Department of Health and Human Services www.hhs.gov
Agency for Healthcare Research Quality www.ahrq.gov
www.ahrq.gov
The Falls Management Program

Inservice #1: Why Falls Happen

Pretest/Posttest

Name: _______________________________________________ Date: ________________

1. List 3 common safety problems in the resident's room and bathroom.
  a. _______________________________________________________________________
  b. _______________________________________________________________________
  c. _______________________________________________________________________

2. For most residents, the bed should be left in the lowest position. True or False (Circle one)

3. New admissions have the same risk of falling as residents who have been in the facility more than 60 days. True or False (Circle one)

4. List two common problems with wheelchairs that increase a resident's risk of falling.
   a. _______________________________________________________________________
   b. _______________________________________________________________________

5. List three side effects of sedatives that increase a resident's risk of falling. An example of a sedative is Ativan.
   a. _______________________________________________________________________
   b. _______________________________________________________________________
   c. _______________________________________________________________________

Return to Appendix B Contents

Inservice #2: How to Reduce Falls

Pretest/Posttest

Name: _______________________________________________ Date: ________________

1. List 3 ways to improve safety in a resident's room and bathroom.
   a. _______________________________________________________________________
   b. _______________________________________________________________________
   c. _______________________________________________________________________

2. Personal items should be kept within 10 feet of the resident. True or False (Circle one)

3. List three ways to improve the resident's safety during transfer and mobility.
   a. _______________________________________________________________________
   b. _______________________________________________________________________
   c. _______________________________________________________________________

4. Staff should use behavior management skills with residents who have unsafe behaviors. True or False (Circle one)

5. A resident who leans over or slides down while seated in a wheelchair is more likely to fall out of the chair. True or False (Circle one)

Return to Appendix B Contents

#1: Porque las Caídas Suceden

Preprueba/Después de la prueba

Nombre: _______________________________________________ Fecha: ________________

1. Haga una lista de 3 problemas de seguridad comunes en el cuarto y el baño del residente:
   a. _______________________________________________________________________
   b. _______________________________________________________________________
   c. _______________________________________________________________________

2. La cama debe mantener en la posición más baja por la mayoría de los residentes. Verdad o Falso. (círculo uno)

3. Los residentes nuevos tiene el mismo riesgo a los residentes quien están en las instalaciones para más de 60 días. Verdad o Falso. (círculo uno)

4. Haga una lista de dos problemas con los sillónes de ruedas que aumento los riesgos de caídas:
   a. _______________________________________________________________________
   b. _______________________________________________________________________

5. Haga una lista de tres efectos secundarios de sedativos que aumento el riesgo de caídas para residentes:
   a. _______________________________________________________________________
   b. _______________________________________________________________________
   c. _______________________________________________________________________

Return to Appendix B Contents

#2: Cómo Reducir Caídas

Antes de la prueba/Después de la prueba

Nombre: ______________________________________________ Fecha: ______________

1. Haga una lista de tres maneras que aumento la seguridad en el cuarto y baño del residente:
   a. _______________________________________________________________________
   b. _______________________________________________________________________
   c. _______________________________________________________________________

2. Las cosas personal deben estar diez pies de el residente. Verdad o Falso. (círculo uno)

3. Haga una lista de tres maneras que aumento la seguridad durante la transferencia y la movilidad del residente:
   a. _______________________________________________________________________
   b. _______________________________________________________________________
   c. _______________________________________________________________________

4. Personal debe usar habilidades genencia del comportamiento con los residents quien tienen comportamientos inseguros. Verdad o Falso. (círculo uno)

5. Cuando un residente diapositivas abajo en un sillón de ruedas él tiene más riesgo para caídas. Verdad o Falso. (círculo uno)

Return to Appendix B Contents

Why Falls Happen in Nursing Facilities

Facts

  • About half of all residents in nursing facilities fall every year.
  • 30-40% of the residents who fall in nursing facilities fall at least twice.
  • One in every ten residents has a serious injury from a fall, such as a fracture, laceration, or serious head injury.
  • One of the most serious injuries from falls is hip fracture.
  • Falls result in a decrease in the resident's quality of life, an increase in staff time and effort, added costs of medical treatment, and an increase in the nursing facility's costs to settle legal claims.

There are many reasons why residents fall. These reasons are called fall risk factors. Many of these we can change.

Fall Risk Factors We Can Change

Residents' Living Space and Personal Safety

  • Clutter, uneven floors and raised thresholds
  • Broken bed wheel locks, poor lighting
  • Unstable furniture, hard to reach personal items
  • Loose handrails and toilet seats, unsafe footwear and poor foot care

Residents' Transfer and Mobility

  • Unsafe transfer and walking without staff assistance
  • Lack of handrail support in bathroom
  • New admissions or health declines
  • Incorrect height of transfer points
  • Hard-to-manage clothing
  • Unsafe behavior

Equipment

  • Poor maintenance and repair, wheelchair seating problems
  • Improper wheelchair fit, sharing wheelchairs among residents

Psychotropic Drugs

  • Use of benzodiazepines such as Ativan and Xanax
  • Use of antipsychotics such as Haldol and Risperdal

Return to Appendix B Contents

How to Reduce Falls in Nursing Facilities

Residents' Living Space and Personal Safety

  • Remove clutter. Keep a clear path 2 to 3 feet wide around the bed, from the bed to the hall, from the bed to the bathroom, and from the bed to the lounge chair.
  • Keep the bed wheels locked at all times. Report beds with broken wheel locks.
  • Remove lightweight furniture. Keep the overbed table across the bed when it is not in use.
  • Report loose handrails and toilet seats.
  • Report torn linoleum and loose carpet edges. Wipe up wet spots when you see them.
  • Report burned out light bulbs.
  • Keep the call light, water pitcher, glass, and any personal items within arm's length of the resident.
  • Use footwear which has tread on the bottom, a firm shape, and a low, even heel. Use gripper socks when the resident cannot wear safe shoes.
  • Give proper foot care.

Residents' Transfer and Mobility

  • Know which residents need assistance during transfer and walking. Give help when needed.
  • Watch all residents closely during the first 2 to 3 weeks after admission and after a health decline or acute illness. Increase assistance during these times.
  • For most residents, keep bed in the lowest position at all times. Use a raised toilet seat when ordered.
  • Dress the resident in easy-to-manage clothing such as those with elastic bands and Velcro fasteners.
  • Provide toileting, food, drink and activity based on the resident's individual schedule.
  • Check the resident often. Ask volunteers and family to help.

Equipment Use

  • Check the wheelchair brakes often. Report ones that do not hold the chair firmly in place.
  • Report all broken or lost parts of wheelchairs, walkers and canes.
  • Use all of the seating items which are ordered for the resident.
  • Report any resident who leans over, slides down, or leans to one side while seated in a wheelchair.
  • Do not share wheelchairs among residents.
  • Make sure all equipment is labeled with the resident's name.

Psychotropic Drugs

  • Know which residents take a benzodiazepine or an antipsychotic.
  • Watch residents who are on these drugs for side effects such as confusion, drowsiness, dizziness, changes in gait, loss of balance, and changes in mental status.
  • Use behavior management skills to lessen the need for these drugs.

Return to Appendix B Contents

Porqué las Caídas Suceden en Instalaciones del Oficio de Enfermera

Hechos:

  • Sobre un medio de todos los residentes en instalaciones del oficio de enfermera caen cada año.
  • 30-40% de los residentes que caen, cae por los menos dos veces.
  • Uno en diez residentes tuvo una lesión seria de una caida, por ejemplo una fractura, una laceración, o una lesión en la cabeza seria.
  • Uno de la lesión mas seria es la fractura de la cadera.
  • Las caídas estan una resultado de una disminuya en su calidad de vida, un aumento en tiempo y ayuda personal, agregado costes del tratamiento médico, y un aumento en la instalciones del oficio de enfermera costes para pagar demandas legales.

Hay muchos razones porque los residentes caen. Llamamos éstos razones factores de riesgo de la caída. Muchos de éstos podemos cambiar.

Factores de Riesgo de la Caída que Nosotros Podemos Cambiar:

Espacio Vivo y Seguridad Personal del Residente

  • Los desechos, pisos desiguales, y umbrales levantados
  • Las ruedas de la cama trabadas que están rotas
  • Muebles inestables, artículos personales que son duro para alcanzar
  • Las barandillas y los asientos del toliet flojos, inseguro zapatos, y mal cuidado del pies

Transferencia y Movilidad del Residente

  • Inseguro transferencia y caminando sin ayuda personal
  • No barandillas en el baño
  • Nuevos admissions o declinaciones de la salud
  • Altura incorrecta de puntos de transferencia
  • "Ropa dificil"
  • Comportamiento inseguro

Equipo

  • Mantenimiento y reparación pobre
  • Incorrecto ajustes de los sillónes de ruedas, cambiando los sillónes de ruedas entre los residentes

Drugas Psychotropic

  • El uso de benzodiazepines como Ativan y Xanax
  • El uso de antipsychotics como Haldol and Risperdal

Return to Appendix B Contents

Cómo Reducir Caídas en Instalaciones del Oficio de Enfermera

Espacio Vivo y Seguridad Personal del Residente

  • Quite los desechos. Guarde un camino clara dos o tres pies de ancho alrededor de la cama, de la cama al pasillo, de la cama al baño y de la cama a la silla.
  • Siempre mantenga las ruedas de la cama trabadas. Diga cuando las ruedas de las camas están roto.
  • Quite los muebles ligeros.
  • Informe cuando las barandillas y los asientos del toliet están flojos.
  • Informe cuando el linóleo está rasgado y la afombra está floja.
  • Informe bombillas rotas.
  • Siempre mantenga la luz de la llamada, la jara del agua, y cualesquiera cosas del personal cerca a la residente.
  • Use unos zapatos con pisadas, una forma firme, y un talón bajo. Use calcetines del agarrador cuando el residente no puede desgaste unos zapatos seguros.
  • Dé apropiado cuidado del pies.

Transferencia y Movilidad del Residente

  • Sepa cuáles residentes necesitan la mas ayuda con caminando.
  • Mire todos los residentes cuidadosamente para su primer 2-3 semanas y despúes de una enferma.
  • Mantenga la cama en la posición más baja para la mayoría de los residentes. Use un asiento del toliet levantado cuando ordenado.
  • Vesta el residente en "ropa fácil" como ropa con vendas elasticos y sujetadores del velcro.
  • Proporcione tolieting, comida, bebida, y actividades basado en el horario individual de cada residente.
  • Cheque el residente a menudo. Pregunte miembros del familia y unos voluntarios por ayuda.

Uso del Equipo

  • Cheque los frenos del sillón de ruedas a menudo. Informe los que están rotos.
  • Informe perdido y roto partes de los silliónes de ruedas, los bastones, y walkers.
  • Use todos los artículos del asiento que estan ordenado por el residente.
  • Nunca cambie los sillónes de ruedas entre los residentes.
  • Etiquete todo el equipo con el nombre del residente.

Drogas Psychotropic

  • Sepa cuáles residentes toman benzodiazepine o antipsychotic.
  • Mire los residentes que toman éstos drogas para unos efectos secundarios, como confusión, somnolencia, vértigos, perdida de balance, o una cambia en su estado mental.
  • Use habilidades gerencia del comportamiento para disminuya la necesidad por éstos drugas.

Return to Appendix B Contents

The Falls Management Program

Facts

  • 1 in 3 persons > 65 years will fall each year.
  • Of 1.7 million residents in nursing facilities, about 50% will fall each year.
  • Of those that fall, 30-40% will fall two or more times.
  • 10% of residents have a serious injury related to a fall.
  • About 65,000 patients suffer a hip fracture each year.

Consequences of Falls

  • Reduced quality of life
  • Decreased ability to function
  • Serious injury
  • Increased risk of death
  • Increased level of fear
  • Increased level of care
  • Increased paperwork for staff
  • Poor survey results
  • Lawsuits
  • High insurance premiums

The Falls Management Program (FMP)

The Falls Nurse Coordinator will conduct a Falls Assessment of your residents who are found to be at high fall risk during screening and after an initial fall. You will receive a Primary Care Provider Fax Report and Orders asking you to review the results and to order referrals or participate in the assessment as indicated. A copy of the 3-page Fax Report and Orders is attached. It is important that you respond to the fax ASAP so that the nurse coordinator can use your recommendations to develop an individualized care plan. Thereafter, whenever your resident falls, you will receive a Fax Alert. A copy is attached.

Flow chart: 1. Screen all residents: history of fall in past 180 days, initial fall, other MDS triggers. 2. Falls assessment: medds, behavior, footwear, foot care, vision, blood pressure, gait and transfer. 3. Physician, NP, PA role: medication review, podiatric problems, low vision, postural hypotension, unsafe gait, balance, seating. 4. Individualized care plan. 5. Weekly team meeting and followup on unit. 6. Recurrent falls-return to step 3.

Return to Appendix B Contents

Suggestions for Further Assessment and/or Interventions


FMP Findings Suggestions for Further Assessment and/or Interventions

Medications
Antipsychotics
Antidepressants
Benzodiazepines
Other sedatives/hypnotics
Digoxin

Review all medications.
Consider changes if appropriate.
Consider psychiatric evaluation if indicated to reevaluate psychotropic medications.

Postural hypotension

Diagnose and treat postural hypotension:
Review cardiovascular, diuretic and other medications.
Consider blood work for BUN/Creatinine ratio.
Consider TED hose.
If severe, consider prescribing fludrocortisone (Florinef) or midodrine (ProAmatine)

Low vision Consider optometry or ophthalmology evaluation.
Unsafe gait, transfers, and/or wheelchair seating problems Consider OT/PT evaluation.

Conditions that increase fall risk

Cardiac
Postural hypotension
Arrhythmias

Neuropsychiatric
Stroke and TIAs
Parkinson's disease
Dementias and delirium
Dizziness
Depression

Drugs
Antipsychotics
Antidepressants
Benzodiazepines
Other sedatives/hypnotics
Digoxin
Polypharmacy and drug interactions

Others
Poor vision
Incontinence
Dehydration
Use of restraints
Hypoglycemia
Fear of falling
Foot problems

Return to Appendix B Contents

Resources

Guidelines

American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriat Soc 2001;49(5):664-672.

Falls and Fall Risk, AMDA Clinical Practice Guideline. 1998

Web Sites

Agency for Healthcare Research and Quality (AHRQ). Medical Errors and Patient Safety. http://www.ahrq.gov/qual/errorsix.htm

Alabama Quality Assurance Foundation (AQAF), AQAF Long-term care fall prevention project. http://www.aqaf.com

The American Geriatrics Society Position Statements, Recommendations, Guidelines, and Papers.http://www.americangeriatrics.org/products/positionpapers/

Centers for Disease Control (CDC) National Center for Injury Prevention and Control (NCIPC). Falls in Nursing Homes. http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html

Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2001;3:CD000340. http://www.cochranelibrary.com

Quality Indicators for Assessing Care of Vulnerable Elders (ACOVE). Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders. http://www.annals.org/issues/v135n8s/full/200110161-00007.html

Key References

Agostini JV, Baker DI, Bogardus J. Prevention of falls in hospitalized and institutionalized older people. In: US Agency for Healthcare Research and Quality and University of California San Francisco-Stanford Evidence-Based Practice Center, eds. Making Health Care Safer: A critical analysis of patient safety practices. Rockville, MD: The Agency, 2001.

Capezuti E, Strumpf NE, Evans LK, Grisso JA, Maislin G. The relationship between physical restraint removal and falls and injuries among nursing home patients. J Gerontol Series A-Biological Sciences & Medical Sciences 1998;53(1):M47-52.

Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in patiential care facilities: a cluster randomized trial. Annals of Int Med 2002;136(10):733-741.

Kiely DK, Kiel DP, Burrows AB, Lipsitz LA. Identifying nursing home patients at risk for falling. J Am Geriat Soc 1998;46(5):551-555.

Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and metaanalysis: II. Cardiac and analgesic drugs. J Am Geriat Soc 1999;47(1):40-50.

Ray WA, Taylor JA, Meador KG, Thapa PB, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997;278(7):557-62.

Rubenstein L. Falls in the nursing home. Ann Intern Med 1994;121(6):442-451.

Tinetti ME. Preventing falls in elderly persons. N Engl J Med 2003;348(1):42-4.

Return to Appendix B Contents

Letter to Primary Care Providers

[Date}
[Salutations]

RE: Fall Management Program

Dear

I am writing to introduce you to a new quality improvement initiative that our nursing facility will be implementing over the next several months. The Falls Management Program (FMP) is directed at identifying and managing residents at high risk for falls and related injuries. Our leadership is committed to this program, and to continuing to improve care in many key clinical areas such as falls.

The FMP will involve the following:

  • Selection and training of a "falls coordinator" and key members of a team that will implement the program in the facility
  • A new computerized incident reporting system that will generate quality improvement reports
  • Basic nursing assessments on residents who have fallen or who are at high risk for falling, with communication of the results to primary care providers
  • Individualized management plans addressing fall risk factors

As a primary care provider for this facility, you will be involved in the FMP. You will be receiving Fax reports on your residents. These reports will be of two different types:

  1. Results of the nursing assessment, with related recommendations. A Fax order form will be enclosed for your convenience. Please return the Fax order form as soon as possible with your recommendations, so that a management plan can be implemented.
  2. A notification of falls and recurrent falls in patients who have been assessed in the FMP. Please consider further evaluation and management in collaboration with the facility falls coordinator when one of your residents falls recurrently and/or suffers an injurious fall.

Enclosed with this letter are examples of materials from the FMP. If you have any questions or suggestions about this new quality improvement initiative, please do not hesitate to discuss them with me. Thank you.

Sincerely,

Medical Director

Return to Appendix B Contents
Return to Manual Contents
Proceed to Next Section

 

AHRQ Advancing Excellence in Health Care