Prevention and Policy: Falls in Long Term Care
The World Health Organization (WHO) defined falls in the 2007 Global Report on Falls Prevention in Older Age as, “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects.” The definition of falls does not include injury because not all falls cause injury. In fact, the CDC reports that one out of three older people fall each year, but less than half tell their doctor. Falling once doubles the chance of another fall. Insurance carrier actuarial analysis from 2014 showed that long term care liability claims are rising 3% annually, and falls are the most frequent allegation from skilled nursing facilities. On average, the claims had total payments of $131,104-171,960. Beyond consideration of the monetary losses of the facility, falls also have a major impact both physically and psychologically on those injured. Furthermore, the CDC reports that there were 25,464 deaths in 2013 from unintentional falls in the over 65 population in the United States, and falls are the most common cause of hip fractures and traumatic brain injuries. Falls should be among a long term care facility’s top priorities in terms of prevention and policy review.
The dichotomy which exists in long term care fall prevention is in the value placed on quality of life and autonomy where possible, and treatment goals to maximize mobility and minimize restraint. Long term facilities exist not just to prevent injury, but also provide a home for the resident, where the staff attempts to balance safety and precaution with the desires and autonomy of the resident. Janice Morse RN, PhD, the creator of a well-known fall risk assessment tool, the “Morse Fall Scale,” acknowledged as far back as 1987 that not all falls are preventable, and grouped falls into three types: physiological anticipated, physiological unanticipated, and accidental falls. Morse felt that even though some falls may not be preventable, the goal of the interdisciplinary team should still be to do all they could in prevention, and many of the risk strategies that she and her team published in 1987 still stand today as the standard of fall prevention care.
While there are many fall risk assessment and screening tools used throughout the U.S., three tools have been validated in multiple studies: The St. Thomas’ Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY), the Morse Falls Scale, and the Hendrich II Fall Risk Model. It is the standard of care to assess a resident for risk of falls upon admission, and re-evaluate risk upon change in resident condition. Issues which can raise a resident’s risk of falling include:
- History of falls.
- Medications (anti-cholinergics, anti-epileptics, antipsychotics, anti-hypertensives, antihistamines, benzodiazepines, sedative hypnotics, and recent changes in medication regimens).
- Co-morbidities such as osteoporosis, incontinence, cardiovascular disease, and pain.
- Vision changes.
- Decreased strength and mobility.
- Activity of Daily Living (ADL) assistance needs.
- Diabetes (blood sugar irregularities, peripheral neuropathy).
It seems the more of these risk factors a resident has, the more synergistic the risk factors become causing a much higher risk of falls in residents with multiple risk factors. In addition to the skilled nursing facility staff assessing the resident’s risk, the family should be involved in ensuring they have a clear picture of the resident’s health and have realistic expectations of the risks involved if their loved one does not comply with using the call bell and other preventative measures instituted. Keeping the family informed and part of the planning process many times contributes positively to the outcome should a fall occur.
It is not enough to merely identify risk. Once risk has been assessed, resident specific interventions should be identified and implemented. Each resident should have a plan of care which addresses falls and injury risk. Dr. Craig Wilson, in a recent presentation on Fall Prevention, recommended the following universal fall reduction strategies (instituted regardless of fall risk) for all residents:
- Orient new residents to the environment, and instruct residents on the proper use of the nurse call system, ensuring they are operational and accessible for all residents.
- Position important items such as call light, water, and telephone within reach.
- Maintain an obstruction/spill-free environment.
- Remove all electrical cords from traffic areas.
- Place the bed in the lowest position with brakes locked.
- Use non-skid socks or footwear when out of bed.
- Utilize nightlights during evening shifts.
- Reassess ambulation status daily.
- Note and report changes in physical and mental status promptly.
- Never leave a resident unattended in the bathroom.
According to geriatric falls expert Elizabeth Hill, RN, PhD, studies have shown that individuals are at greater risk of falling when they are in the process of performing purposeful actions such as reaching for an object or using the toilet. Therefore, some of the most important interventions your facility can incorporate is the proper use of assistive devices such as grabbers and shoe horns, and hourly rounding. Hourly rounding is not the standard, most long term facilities check on residents at least every two hours, but rounding more often can eliminate many of the falls associated with non-compliance with the call system. Ms. Hill describes the “4 P’s” included in a nursing staff check, which include: Pain, Potty, Positioning, and Possessions.
Other important prevention categories include monitoring devices, such as bed alarms and surveillance, bed rails use to the extent that it assists residents with bed mobility but does not restrain free movement, keeping the bed in a locked and low position, and use of floor mats, larger mattresses, and hip protectors. Use of the interdisciplinary team beyond nursing, such as CNA’s, Occupational Therapy, Physical Therapy, Pharmacists, and Podiatrists can cover many of the reassessment points needed for a comprehensive plan that is continually updated based on resident condition and changes.
Response to Falls to Improve Outcomes and Minimize Risk
Let’s say your facility had a comprehensive and accurate assessment of a new resident, and created and implemented a care plan that was felt to be complete by the entire interdisciplinary team, and yet the resident still sustained a fall with possible injury. What are the immediate important steps for your staff to take? The first steps should focus on the resident’s safety:
- Evaluate level of consciousness and vital signs.
- Ask the resident if there is any neck or back pain, and assess pain all over the body.
- Check the skin for bruising, or injury.
- Notify the doctor, supervisor, and family (the doctor should always be notified before the family and documented as such). Determine with the physician if the resident needs to be transferred to the ED for further evaluation and treatment.
- If the resident stays in the facility, monitor neurological checks for at least 24 hours for unwitnessed falls.
All of the immediate steps should be documented comprehensively, and actions should be timely and documented as such.
Once the resident’s immediate safety is addressed and documented, and all appropriate actions are taken, an investigation should be done. A root cause analysis should be performed, and all plans should be reassessed and tailored to the resident’s new status. If the resident sustained a reportable injury it should be communicated to the State Board of Health. The family should be involved in new strategies for falls prevention.
Policy and Prevention of Litigation
Above all, a facility must have a falls policy in place that is frequently reviewed and updated. New staff should have a set training program for education regarding falls, and each unintentional fall should have a pathway for treatment and documentation that is practiced. The implementation of a “Falls Team” or IDT who reviews each fall, performs root cause analysis, and ensures implementation of new interventions for prevention is not a “standard of care” per se, but is a best practice and can decrease risk in your facility. Should you find your facility in the unfortunate position of defending a fall/injury case, a legal nurse consultant will help the legal team identify strengths and weaknesses in the assessment, prevention, and treatment rendered. If your facility and all its staff are committed to keeping falls from occurring in the long term setting, and continually work to implement interventions based on the residents’ current condition, you will have a low risk of litigation from falls and injury.
1. World Health Organization. (2007). WHO Global Report on Falls Prevention in Older Age. Retrieved October 16, 2015 from the World Health Organization website: http://www.who.int/ageing/publications/Falls_prevention7March.pdf
2. Aon 2014 Long Term Care Liability Actuarial Analysis. http://www.phca.org/docs/Aon_2014_Long_Term_Care_Liability_Actuarial_Analysis_full.pdf.
3. AON 2011 General Liability and Professional Liability Actuarial Analysis. http://www.aon.com/risk-services/thoughtleadership/reports-pubs_2011_long_term_care_survey.jsp
4. CNA Aging Services Report 2012 https://www.cna.com/vcm_content/CNA/internet/Static%20File%20for%20 Download/Risk%20Control/Medical%20Services/AgingServices2012DataAnalysis-SupportingtheNeedforIndustryChange-10-2012.pdf.
5. Falls among Older Adults: An Overview. Centers for Disease Control and Prevention. http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html.
6. MMWR QuickStats: Death Rates* from Unintentional Falls† Among Adults Aged ≥65 Years, by Sex — United States, 2000–2013. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6416a12.htm.
7. Morse, J.M., Tylko, S.J., & Dixon, H.A. (1987). Characteristics of the fall-prone patient. Gerontologist, 27(4), 516-522.
8. Oliver D et al. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ. 1997 Oct 25; 315(7115):1049-53.
9. Morse JM et al. A prospective study to identify the fall-prone patient. Soc Sci Med. 1989; 28(1):81-6.
10. Hendrich AL et al. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003 Feb; 16(1):9-21.
11. Meade, C.M., Bursell, A.L., & Ketelson, L. (2006). Effects of nursing rounds: on patients’ call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70.
12. Bloom, A.S. (2015). Back to Basics: Falls, Wounds, Infection and Death. [DRI Presentation].
13. Wilson, C.J. (2015). Don’t Get Tripped Up: State of the Art Fall Prevention. [DRI Presentation].
14. Hill, Elizabeth (2015). The Latest in Falls and Fall Prevention. [DRI Presentation].