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©Pathway Health 2013 Fall Prevention: It’s Still a Crucial Quality of Care Issue Kim Stenzel, RN Pathway Health
©Pathway Health 2013 1.Discover components of a successful fall prevention program. 2.Review the “Real Truth” on the use of alarms in nursing home. 3.Discuss steps into maintain a successful fall prevention program Objectives 2
©Pathway Health 2013 If injured, it can take months to recover, often in a nursing facility, & mobility can be permanently changed. By offering effective fall prevention programs, we can reduce falls & help older adults live safer, happier, longer lives. Resident Considerations
©Pathway Health 2013 Establish your commitment to Independence and Safety Educate about fall risk factors & prevention strategies for older adults, families, & caregivers Environmental assessment & intervention including resident input Exercise must be offered as a way to promote independence! An Effective Program
©Pathway Health 2013 Establish your commitment to Falls & Injury Prevention Pre-admission considerations Admission assessment ALWAYS include them in assessment findings & education if responsible, or with resident permission Resident/Family Alliances 5
©Pathway Health 2013 Run a report of Current Mobility Status for this quarter and last quarter – walk in room, walk in corridor Compare it to report from last quarter Have there been changes, declines? Use Your Data – MDS 6
©Pathway Health 2013 By location, diagnosis, behaviors, and functional status – the more detailed your information is, the more effective your root cause analysis will be. Location - room, hallway, bathroom Devices in use, call lights, alarms etc. What to Look For - Trending 7
©Pathway Health 2013 Getting to the reasons for the mobility decline and other risk factors is called Root Cause Analysis Interview direct care-giving staff, family, & resident for their perspectives regarding why the decline happened Document and analyze interview results Questions 8
©Pathway Health 2013 Poor lighting Loose rugs Poorly fitting shoes Beds or toilets without handrails Clutter External Factors
©Pathway Health 2013 Unsteady gait Balance problems Weak muscles Poor vision/ hearing loss Medications Dementia (memory loss & confusion) Internal Risk Factors
©Pathway Health 2013 Are doors easy to open & close for those with mobility issues? How long are the hallways? Are there are benches along the way to destinations? Is there plenty of closet space & storage available to reduce clutter? Safety in Mind
©Pathway Health 2013 Remain in place, wait for direction? Get up to see what’s wrong? See what you can do to help? Your Response to Alarms? 12
©Pathway Health 2013 “The body registers noise pollution as assaultive. The automatic tightening of muscles to armor (protect) and defend themselves produces sensations that range from mild discomfort to extreme pain. Gentle, appropriate touch can help the body to relax without more intrusive intervention. Caring touch can restore equilibrium and balance.” Integrating Touch Into Our Daily Interactions Posted on June 20, 2013 by Glenn BlacklockJune 20, 2013Glenn Blacklock Why Alarms Don’t Work 13
©Pathway Health 2013 *Risk assessment tools by themselves do not prevent patient falls - they predict them… *National Patient Safety Foundation Professional Learning Series Risk Assessment Tools 14
©Pathway Health 2013 Current Mobility Status Seating Standing Transfers Toileting Needs Footwear Note resident & family response to immediate safety measures – cooperation is the key to accident prevention! Assessment - Mobility 15
©Pathway Health 2013 Problems with unsafe, uncomfortable seating can lead to restlessness and falls risk People slide into a position of comfort & support. However... everyone fatigues out of the ideal sitting posture. Body type & disability often prevent ideal sitting posture. Seating Challenges 16
©Pathway Health 2013 Knees are higher than hips placing pressure on the coccyx When the Seat is Too Low
©Pathway Health 2013 Knees are lower than hips, contributing to a slide to the floor When the Seat is Too Low
©Pathway Health 2013 Untreated, pain leads to: Restlessness Irritability Depression Reduced mobility Atrophy, weakness Pain 19
©Pathway Health 2013 Predict the Next Fall 20
©Pathway Health 2013 Independent Walking! 21
©Pathway Health 2013 Practice to reinforce! Stand up slowly after sitting or lying down. If lying down, sit up first, remain seated for a few minutes, then stand slowly Mandatory Return Demo 22
©Pathway Health 2013 TIMED GET UP AND GO TEST 1.Patient is in a seated position. 2.Place a visible object 8 feet away from the patient. 3.Have the patient get up and walk around the object and sit back down. Allow them to practice once. Then time them 3 attempts. What to Watch 23
©Pathway Health 2013 On admission and periodically: Watch them in action to assess correct use Therapies evaluation to identify modifications Do not let the device be a potential cause for falls Use of Devices 24
©Pathway Health 2013 Assess For Risks As You Go 25
©Pathway Health 2013 Do not wait until a fall happens to check for: Effects Side effects Interactions Plan for Falls Prevention! Anticipate Medication Risks 26
©Pathway Health 2013 Hypertension Angina Parkinson's Disease Urine Output Constipation Heart Rate & Rhythm Pain These Conditions = Risk 27
©Pathway Health 2013 Involuntary movements Low blood pressure with position changes Heart rhythm changes Cause drowsiness, imbalance, incoordination, slowed reactions, dizziness, confusion. Poor impulse control Hyperglycemia Psychotherapeutic Effects 28
©Pathway Health 2013 Excessive decrease in ability to form blood clots can cause bleeding, leading to anemia, weakness & dizziness. Watch for bruising easily, unusual bleeding around gums, blood in urine, or rectal bleeding. Anticoagulants 29
©Pathway Health 2013 *Risk assessment tools by themselves do not prevent patient falls - they predict them… *National Patient Safety Foundation Professional Learning Series Risk Assessment Tools 30
©Pathway Health 2013 On admission* Upon transfer from one unit to another* With any status change* Following a fall* At regular intervals* *How soon? When to Assess? 31
©Pathway Health 2013 www.cdc.gov/injury/STEADI 32
©Pathway Health 2013 To get the most out of critical times around an event Staff on the scene must be coached in skills of observation and critical thinking Begin Immediately 34
©Pathway Health 2013 Delaying the investigation until morning or Monday, or whenever the DON or Risk Manager gets around to it will not improve your outcomes or statistics. Don’t Wait! 35
©Pathway Health 2013 Assigned nurse/care assistants/Others on duty Supervisor Dining Services Staff Housekeeping/Maintenance Administrator/Clinical Managers More eyes & ears = more thorough perspectives Assemble Key Players 36
©Pathway Health 2013 Placement of the person’s body at the time of the fall What was the person trying to do? Was it unusual or typical – has it happened before? Observations + Questions 37
©Pathway Health 2013 If they don’t, or didn’t wait – WHY? what makes them unsafe to do it independently ? weakness, stiffness, dizziness…? And Then What? 38
©Pathway Health 2013 If they are known not to call for help, what are you doing to make it safer for them? Strengthen, loosen up, address causes of dizziness Compensation VS Restriction 39
©Pathway Health 2013 Make immediate modifications based on causes Communicate interventions & rationales to everyone to reinforce safety as soon as possible Critical Investigation Elements 40
©Pathway Health 2013 On the Scene Investigation alarmed chair Alarmed
©Pathway Health 2013 Environmental review at the time of the event by on-shift staff Make immediate modifications Add to care plan immediately Communicate interventions & rationales immediately Critical Investigation Elements 42
©Pathway Health 2013 Can You Predict the Next Fall? 43
©Pathway Health 2013 Watch them in action to assess correct use Therapies evaluation to identify modifications Do not let the device be a potential cause for falls Use of Devices 44
©Pathway Health 2013 Making Rounds / Supervision 45
©Pathway Health 2013 Who Should Observe and Correct? 7
©Pathway Health 2013 Assess As You Go 47
©Pathway Health 2013 Safety Rounds 48
©Pathway Health 2013 Muscle weakness – Exercise, therapy Gait problems - Exercise, devices, modifications, therapy Balance problems- Exercise, therapy, devices Arthritis, Degenerative Joint Disease – Exercise, therapy Impaired ADLs – Exercise, therapy, devices, modifications AMERICAN Geriatric Society High Fall Risks - Compensate 49
©Pathway Health 2013 To get the most out of critical times around an event Staff on the scene must be coached in: −skills of observation −critical thinking Begin Immediately 50
©Pathway Health 2013 Assigned nurse/care assistants/Others on duty – Supervisor – Dining – Housekeeping/Maintenance – Administrator/Clinical Managers More eyes & ears = more thorough perspectives Assemble Key Players 51
©Pathway Health 2013 ‘Person needed to use bathroom’ Urgently? – Why? Does this follow their usual pattern? Do they usually call for help? – If they do, but didn’t, what happened this time? – If they did, why didn’t they wait? What Exactly Happened? 52
©Pathway Health 2013 If they are known not to call for help, what are you doing to make it safer for them? Strengthen, loosen up, address causes of dizziness Compensation VS Restriction 53
©Pathway Health 2013 Maintaining a safer place for your residents to live starts at the top. Supporting all falls prevention efforts is a confident and competent team Including residents and families in risk assessment and intervention will improve your chances for a successful Falls Prevention Program! It’s Up To You!
Step By Step Implementation
©Pathway Health 2013 Address areas on the self-survey… You need to have specific evidence of where you are in the process in order move forward Let’s look at the key points from the self- survey as a guide to prepare our plan... Identify Strengths & Gaps
©Pathway Health 2013 Leadership supports staff participation in all stages of problem solving, providing time & materials. Assure that full support is observable & positively viewed by your staff - Talk it up & follow up with actions! Integrate the process with other efforts & find ways to make the most of times the team gets together. Interview & ask how you can better help them participate! Leadership 57
©Pathway Health 2013 Residents, Family & Staff provide feedback regarding problem identification, intervention development, & goal setting. Get signatures on postings, meeting minutes & plans indicating participation Include QAPI in admission process (packet), staff explain and discuss with residents and families. Include QAPI in orientation & other in-services, give opportunities for all to participate. Facility-wide Participation
©Pathway Health 2013 Test processes & changes on a small sample to work out the barriers & unforeseen issues before full roll out. Take suggestions supported by data (QM’s, QI’s, etc.) Solicit enthusiastic staff, ask for volunteers (one unit, one hallway, etc.) Use PDSA cycle to test, work out the bugs (retest till a smooth process is found, keep measuring results) Small Sample Testing
©Pathway Health 2013 On-going coaching & mentoring should accompany training to assure success. Lead by example, train department heads & supervisors to actively incorporate new information & changes into daily routine. Be a cheerleader & maintain positive support (expect the same from the team). Be patient & consistent, ask how you can help. Coach & Mentor 60
©Pathway Health 2013 Monitor progress, maintain electronic records of projects. Showcase successes. Stay organized, current & connected to the data. Be able to pull out & review, revisit. Record Keeping
©Pathway Health 2013 Establish QAPI as THE process for monitoring quality. Include QAPI discussions at every meeting, add agenda items to all routine meetings. Be sure staff are fluent in answering questions about QAPI and any PIPs in the facility. Remember, surveyors will be using the same process to review regulatory compliance! Use QAPI Format
©Pathway Health 2013 Implement QAPI to develop an effective way of planning, working, & problem-solving together Not only about meeting the minimum standards, but about continually aiming higher Not just about compliance, about inventing better ways of providing care & service HOW CAN YOU DEMONSTRATE THIS MISSION? The Problem-Solving Model 63
©Pathway Health 2013 Uses data to identify your quality issues, & set priorities for action Builds on resident’s own goals for health, quality of life and daily activities Brings the resident and family voices into the decision making process AND *University of MN, Division of Health Policy and Management and Stratus Health Person-Centered 64
©Pathway Health 2013 Teaches staff members the mission of QAPI We can’t do it without them! Critical to Success! 65
©Pathway Health 2013 Action Plan 66
©Pathway Health 2013 67
©Pathway Health 2013 QAPI News Brief Volume1, 2013; http://www.ihi.org/knowledge/Pages/HowtoImprove/Scienc eofImprovementHowtoImprove.aspx http://www.ihi.org/knowledge/Pages/HowtoImprove/Scienc eofImprovementHowtoImprove.aspx – Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.The Improvement Guide: A Practical Approach to Enhancing Organizational Performance – **The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check- Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." [See Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.]The New Economics for Industry, Government, and Education Resources 68
©Pathway Health 2013 Quality Improvement Organizations (QIOs) www.ihi.org/knowlwedge/Pages/HowtoImprove/ default.aspx www.ihi.org/knowlwedge/Pages/HowtoImprove/ default.aspx Advancing Excellence in America’s Nursing Homes http://www.nhqualitycampaign.org/http://www.nhqualitycampaign.org/ Stratis Health www.stratishealth.org/events/recorded/html Oklahoma Foundation for Medical Quality www.ofmg.com Resources 69
©Pathway Health 2013 NCOA – Excellent Resources- Falls Prevention Day – September 22, 2013 http://www.ncoa.org/improve-health/center-for-healthy- aging/falls-prevention/falls-prevention-awareness.html National initiative web site - videos and educational materials. Celebrate Fall Prevention Awareness Week - September 22 – 28, 2013. http://www.stopfalls.org/service_providers/sp_bm.shtml Michigan Falls in the Elderly rates 2011 http://www.michigan.gov/documents/mdch/falls_factsheet_fin al_390532_7.pdf Resources 70
©Pathway Health 2013 Initiatives in Safe Patient Care – Newsletter with CEUs regarding alarms: http://initiatives-patientsafety.org/Initiatives2%20.pdf firstname.lastname@example.org Resources 71
©Pathway Health 2013 Falls Prevention brochure for distribution http://www.michigan.gov/documents/Fast_Facts_About_Older _Adult_Falls_in_Michigan_167793_7.pdf Veteran’s Administration projects http://www.visn8.va.gov/patientsafetycenter/fallsTeam/ VA Falls Prevention Tools and Programs http://www.patientsafety.va.gov/SafetyTopics/fallstoolkit/inde x.html Institute for Person Centered Care http://ubipcc.com/ 72 Resources
©Pathway Health 2013 http://www.patientsafety.va.gov/SafetyTopics/fallstoolkit/ media/morse_falls_pocket_card.pdf Vibrant Living Concepts http://blog.actionpact.com/2013/07/29/vibrant-living- prevents-falls-and-eliminates-need-for-alarms/ http://actionpact.com/index.php/product/eliminating-alarms- and-reducing-falls-by-engaging-with-life Sue Ann Guildermann, RN, BA, MA. Effective Fall Prevention Strategies Without Physical Restraints or Personal Alarms Empira, 4/24/2012 Webinar for Stratis HealthEffective Fall Prevention Strategies Without Physical Restraints or Personal Alarms Resources 73
©Pathway Health 2013 Willy BA; Wheelchair Seating for Elders; On line pamphlet prepared under contract for Mountain Pacific Quality Health– Wyoming 2010. http//:www.mpqhf.com/WCSbooklet508.pdf Illustrations by Chris Willy; Web publication by Mountain Pacific Quality – Wyoming’s 9 th Scope of Work CMS; Wheelchair Seating for Elders by BA Willy. http://www.carf.org/Programs/ProgramDescriptions /AS-Person-Centered-Long-Term-Care-Community/ 74 Resources
©Pathway Health 2013 Newsletter & CEUs – Initiatives in Safe Patient Care http://initiatives-patientsafety.org/Initiatives2%20.pdf www.cdc.gov/injury/STEADI http://www.npsf.org/wp- content/uploads/2013/03/PLS_1302_FallPrevention_L AG_MF.pdf Resources 75
©Pathway Health 2013 http://www.seniorhomes.com/p/assisted-living- safety/ http://www.cdc.gov/homeandrecreationalsafety/im ages/cdc_guide-a.pdf http://www.cdc.gov/homeandrecreationalsafety/im ages/cdccompendium_030508-a.pdf http://www.mayoclinic.org/fall-prevention/art- 20047358?pg=2 http://thebalancemanual.com/4.html?gclid=COii8b bHi7wCFcVFMgodgx8Ajw Resources
©Pathway Health 2013 NCOA – Excellent Resources- Falls Prevention Day – September 22, 2013 http://www.ncoa.org/improve-health/center-for-healthy- aging/falls-prevention/falls-prevention-awareness.html http://www.stopfalls.org/service_providers/sp_bm.shtml Veteran’s Administration projects http://www.visn8.va.gov/patientsafetycenter/fallsTeam/ VA Falls Prevention Tools & Programs http://www.patientsafety.va.gov/SafetyTopics/fallstoolkit/inde x.html Resources
©Pathway Health 2013 Institute for Person Centered Care http://ubipcc.com/ http://www.patientsafety.va.gov/SafetyTopics/fallstoolkit / media/morse_falls_pocket_card.pdf Vibrant Living Concepts http://blog.actionpact.com/2013/07/29/vibrant-living- prevents-falls-and-eliminates-need-for-alarms/ http://actionpact.com/index.php/product/eliminating- alarms-and-reducing-falls-by-engaging-with-life Resources 78
©Pathway Health 2013 Sue Ann Guildermann, RN, BA, MA. Effective Fall Prevention Strategies Without Physical Restraints or Personal Alarms Empira, 4/24/2012 Webinar for Stratis HealthEffective Fall Prevention Strategies Without Physical Restraints or Personal Alarms Willy BA; Wheelchair Seating for Elders; On line pamphlet prepared under contract for Mountain Pacific Quality Health– Wyoming 2010. http//:www.mpqhf.com/WCSbooklet508.pdf http//:www.mpqhf.com/WCSbooklet508.pdf Newsletter & CEUs – Initiatives in Safe Patient Care http://initiatives- patientsafety.org/Initiatives2%20.pdf Resources 79
©Pathway Health 2013 Thank You! Kim Stenzel, RN Pathway Health www.pathwayhealth.com 80
©Pathway Health 2013 QAPI for Nursing Fix It For Good Leah Killian-Smith, BA, NHA, RHIA Leading Age Oklahoma March 9,
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