1. Quality Improvement in Long Term Care Program
Falls Prevention

2. Falls Management Program
The purpose of a falls management program is to assess each resident fall risk. To assess each resident’s fall risk, ensure the resident’s immediate safety and to ensure further safety and fall prevention through a multidisciplinary approach.

3. FIRST STEPS
We determined the need for an initiative by reviewing and analyzing the Quality Assurance data collected each month.
Review current resident falls assessment from pre-admission information to current data.

4. SCREENING
Review resident applications, many are high-lighted for fall risk.
On admission (and quarterly) a FALL RISK ASSESSMENT is completed:
Identifies history of falls
Medication used
Diagnosis and vital signs
Memory and orientation
Vision and hearing ability
Continence level
Mobility status, including gait analysis
Related behaviours

5. RESIDENT CARE PLAN
When a resident is high/medium risk a care plan is developed to identify the risk.
FOCUS
Potential/ high risk for Falls related to …..
GOAL
Prevention of falls.
INTERVENTIONS
Place wheelchair in tilted back position to prevent exit from chair and improve positioning.
Check q1h to ensure safety.
Have commonly used articles within easy reach.(papers, pen, Kleenx)
Transfer and Change positions slowly.
Reinforce need to call for assistance, check with resident every 1/2 hour to see if she needs assitance
Put 2 siderails up at all times / when in bed for safety.
Seat belt is for safety purposes only. Resident is able to remove
Call bell with in reach when in bed

6. POST FALL ASSESSMENT Date, time, location Head to toe assessment, ROM
ROM, changes to extremities
Skin condition: abrasions, redness (location, size and colour of injury)
Pain
Head injury
Vital signs
Blood pressure : lying and standing (if possible)
Pulse, respirations
Notify physician and family

7. ENVIRONMENTAL FACTORS
Lighting
Call bell within reach
Flooring: wet or cluttered, carpeting
Footwear
Restrictive clothing
Glasses/hearing aide within reach
Use of assistive devices

8. THREE TEARED DOCUMENT 1 st Fall 2nd Fall 3rd Fall
Reminders to use call bell
Physio. assessment requested
Toileting routine reviewed
Initiate q1/2 hour safety check
Floor pad placed at bedside
Safety alarm in use when in bed
Medical assessment
Hip protectors
Upgraded footwear
Installed night light

9. DOCUMENTATION Incident report / line listing
Incidental charting (each shift x 3 days or 9 shifts)
Present a clear account of incident
Factual, precise, descriptive language recording observations
Action taken, MD directive
Vital signs
Family member / SDM: who was notified
Document on shift report

10. REFERRALS Pharmacist Physiotherapist Pharmacological review
Makes recommendations to MD
Education
Physiotherapist
Assess balance (gait) and mobility
Strength and balance training
Needs for physio. / rehab / restorative / assistive devices
Transfer advice
education

11. PREVENTION
Care Plans will be reviewed and updated, review toileting routines, transferring needs and mobility
Prevention strategies will also identify safety equipment such as mattresses on the floor, safety monitors/alarms for chair and bed, hip protectors.
A multidisciplinary team meeting including the resident (if appropriate) and their family will be held following the assessment process to problem solve and draw an action plan for falls prevention.

12. Falls Drills
On the scheduled date, a staff member will be assigned the role of “fallen person”. A case study scenario will be given to this staff member outlining their diagnosis, any injuries and the circumstances surrounding the “fall”.
Once the team discovers the “fallen person”, they will proceed to care for them according to policy and procedure for falls management.
The Falls Drill Report is completed by care team and submitted to the Director of Care. A debriefing meeting will be held following the drill to review the procedure and education as needed.

13. EVALUATION OF PROGRAM 2005 = total falls 799 2006 = total falls 526
2008 to present, focus on sustainability

14. Setting up a Falls Prevention Program
Start small – set goals
Introduce the initiative to the Leadership team, then departmental teams (get buy-in)
Select one unit (the most interested team) to trial the program
Get input and evaluate the program as you go, be open to new ideas
Embrace challenges
Celebrate successes
Maintain the commitment to be Resident Focused

15. Falls Committee In September 2009 we resumed our falls committee
Consisting of RN’s, RPN’s, PSW’s, a Restorative Care Assistant, our Dietician, the Physiotherapist and the Safety & Wellness
Co-ordinator
Each discipline brings a unique perspective on how to prevent falls
A “Frequent Fall Assessment” was created and are reviewed at meetings

16. Frequent Fall Assessment
Age
Device (transfer pole, trapeze)
Aide (wheelchair, walker or cane)
Medical Conditions
Dementia
Pain

17. Physiotherapy Assessment
Tenetti and/or Berg Score
Identified Gait
Balance
Range of Motion
Weakness
Transfers

18. Medications Antianxiety Antidepressants
Treatment of Osteoporosis (specifically Vitamin D)
Analgesics
Was there a medication change?

19. Restraints
Review the use of restraint with the staff, the resident, the family or SDM and the Occupational Therapist
Did the restraint contribute to the fall?
Can the restraint be removed?

20. Post Fall Assessment Review the Post Fall Assessment Environment Time
Location
Behaviour
Footwear
Vital Signs

21. Documentation Review the Chart What were they doing before the fall?
Laboratory Results?
Infections?
Bath day?
Were they ill?
Any behaviours?

22. What interventions have already been tried? Were they effective?
Pattern and Cause
Consider all factors and opinions to identify any pattern and probable cause!
What interventions have already been tried? Were they effective?

23. Suggestions Referrals Actions Pharmacist Review OT Referral
Physician Review
PT Referral
Responsive Behaviour Team
Dietician Review
Safety Checks
Increase Activities
Increase Exercise
Restraint Alternatives
Modify Environment
New footwear
Other……

24. Review with The Resident and Their Family
Discuss the Fall(s) and Review findings
Present Suggestions
Listen
Respect their views
Establish a common goal!

25. Evaluate Evaluate effectiveness of individual cases at Falls Committee
Monitor Falls Prevention Program with Quality and Risk Management Committee

26. ‘Frequent Faller’ case review
Mr. and Mrs. W. are a very pleasant couple who have been married for 60 years. Each have their own room in a nursing home but have chosen to push both beds together in one room and use the other room down the hall, as a sitting area. Both residents have moderate dementia. Mr. W has noticeable weakness, walks stooped over, has difficulties balancing while standing and refuses to use his walker or even to grasp hand rails in hall.

27. Case Review Continued
Mr. W. has had 3 falls at different times of day, all in his room while his wife was assisting him to stand to go to the washroom. Both have call bells within reach, neither remember to use them.
Mr. W. has a diagnosis of Osteoporosis and during his last fall, he obtained a compression fracture. The physician has prescribed Fentanyl Patch and Tylenol #3 prn.

28. Mr. And Mrs. W
One daughter, wants the residents separated, the other three children want their parents to remain together. Mr. and Mrs. W. don’t want to be separated. All agree to adjoining rooms which are not available at this time.

29. Pattern Interventions
The pattern is easy in this case.
For the past 60 years, Mrs. W. has cared for her husband.
It would be unrealistic to expect that to change.
Safety checks were initiated
Both resident were reminded to call for assistance
Mr W. has been co-operative with exercises suggested by PT

30. Some Suggestions
Pharmacist review of treatment of Osteoporosis and Pain Control
OT referral for transferring device (if a pole is there he might use it)
PT referral for strengthening exercise and safe transfers
Adjoining room when available
Review and modify toileting schedule
Continue Safety Checks

31. Looking to the Future
The committee will Identify those at risk using the “Falls RAP Key”
Increase exercise through restorative care initiatives
Explore risks and treatment of Osteoporosis

32. Questions?