1. IN-SERVICE TRAINING GUIDE
Fall Prevention
Don't Fall for IT!
IN-SERVICE TRAINING GUIDE
Falls have come to be recognized as a major threat to the safety, health & independence of elderly people.
Awareness of various factors associated with falls in the elderly and an understanding of some of the methods of preventing falls can help in making appropriate decisions about necessary interventions.

2. Process Objective To increase the awareness of reasons for falls
Identify the residents in your home
that are at risk
1. Falls among nursing home residents occur frequently and repeatedly.
2. About 1,800 older adults living in nursing homes die each year from fall-related injuries and those who survive falls, frequently sustain hip fractures and head injuries that result in permanent disability and reduced quality of life

3. How big is the problem?
Each year, one in every three adults age 65 and older falls
Among older adults (those 65 or older), falls are the leading cause of injury death
1. Falls can cause moderate to severe injuries, such as hip fractures and head injuries, and can increase the risk of early death.
2. They are also the most common cause of nonfatal injuries and hospital admissions for trauma.

4. How big is the problem?
Many people who fall, even if they are not injured, develop a fear of falling
Residents are most likely to fall during the first two to three weeks after admissions into a healthcare facility
This fear may cause them to limit their activities, which leads to reduced mobility and loss of physical fitness, and in turn increases their actual risk of falling.
CDC states: In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.
In 2010, the direct medical costs of falls, adjusted for inflation, was $30 billion.

5. How big is the problem?
The number of falls per year is expected to increase as the population increases
Each year, a typical nursing home with 100 beds reports 100 to 200 falls
Most fractures among older adults are caused by falls
In addition to these numbers, there may be many falls in the general population that go unreported.
The most common are fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.
Injuries caused by falls increase the resident’s risk of death, decrease the resident’s ability to function, and reduce the quality of life.

6. How big is the problem?
Majority of falls occur during routine activities
Bathroom, most likely place for fall to occur
Use extra precautions when pets are around– they can get under foot
People who fall can suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. These injuries can make it hard to get around or live independently, and increase the risk of early death.

7. Who is at risk?
The death rates from falls among older men and women have risen sharply over the past decade
Falls may be a warning sign of an acute underlying medical issue.
An acute change in a resident’s condition may be related to an un-witnessed fall
1. Men are more likely than women to die from a fall. After taking age into account, the fall death rate in 2009 was 34% higher for men than for women.
2. People age 75 and older who fall are four to five times more likely than those age 65 to 74 to be admitted to a long-term care facility for a year or longer
3. Rates of fall-related fractures among older women are more than twice those for men.

8. Who is at risk?
About 5% of adults 65 and older live in nursing homes but nursing home residents account for about 20% of deaths from falls in this age group
Between half to three-quarters of nursing home residents fall each year
That’s twice the rate of falls for older adults living in the community.

9. Who is at risk?
Residents often fall more than once
About 35% of fall injuries occur among residents who cannot walk
1. Patients often fall more than once. The average is 2.6 falls per person per year.

10. Why do falls occur more often in nursing homes?
Falling can be a sign of other health problems
People in nursing homes are generally frailer than older adults living in the community
Nursing home residents have more chronic conditions and have more difficulty walking
They also tend to have thought or memory problems
Difficulty with activities of daily living and needing help to get around or take care of themselves are all factors linked to falling and to people living in a nursing home.
Caregivers who work with the “at risk” must be able to recognize the risk factors for falling and find ways to help reduce those risks and prevent falls before they happen.
Physical changes due to the normal aging process, such as vision & hearing loss, can increase someone’s risk for falling

11. Most common causes of nursing home falls?
Medications can increase the risk of falls and fall-related injuries.
Muscle weakness and walking or gait problems
Environmental hazards in nursing homes cause 16% to 27% of falls among residents.
Drugs that affect the central nervous system, such as sedatives and anti-anxiety drugs, are of particular concern. Fall risk is significantly elevated during the three days following any change in these types of medications.
These problems account for about 24% of the falls in nursing homes.
Such hazards include wet floors, poor lighting, incorrect bed height, and improperly fitted or maintained wheelchairs.
Other causes of falls include difficulty in moving from one place to another (for example, from the bed to a chair), poor foot care, poorly fitting shoes, and improper or incorrect use of walking aids.

12. Tips to Remember….
Clutter- Most res live in small, shared rooms. A clear space of 2-3 feet around the bed is needed. Keep over bed tables across the bed when not in use. Secure cords out of walking area.
Bed Wheels – an unstable bed can roll out from underneath the resident during transfer.
Light Furniture- Can tip over when res uses it for support.
Chairs with out arms - should not be used. Use B/S commodes with caution and be sure they have rubber tips on all 4 legs.

13. More Tips to Remember…
Poor lighting – Elderly persons need 2-3 times more light than young adults to see clearly.
Hard to reach items – If a resident has to reach beyond her center of gravity, she may fall. Keep call lights, water pitchers, glasses & phone within easy reach.
Footwear – Painful foot conditions may prevent resident from distributing weight evenly when standing and from wearing safe shoes.

14. Fall Prevention / Solutions
It requires a combination of medical treatment, rehabilitation, and environmental changes.
The most effective interventions address multiple factors or use a multidisciplinary team.
Fall prevention interventions can be implemented at the organizational, staff or patient levels.
Falls are the responsibility of every team member in the nursing home. Do not leave those closest to the resident out (CNAs & housekeeping & maintenance) when looking for causes and solutions. Falls have come to be recognized as a major threat to the safety, health & independence of elderly people.
Awareness of various factors associated with falls in the elderly and an understanding of some of the methods of preventing falls can help in making appropriate decisions about necessary interventions.

15. Fall Prevention / Solutions
Immediately assess the resident and the surrounding environment after a fall
Educating staff – everyone is part of solution!
Reviewing prescribed medicines
Making changes in the nursing home environment
Assessing residents after a fall to identify and address risk factors and treat the underlying medical conditions.
Educating staff: How to assess the area around the fall; look for risk factors; don’t assume the obvious- truly investigate and brainstorm for prevention strategies
Reviewing prescribed medicines to assess their potential risks and benefits and to minimize use.
Making changes in the nursing home environment to make it easier for residents to move around safely. Such changes include putting in grab bars, adding raised toilet seats, lowering bed heights, and installing handrails in the hallways.

16. Fall Solution Suggestions
Providing patients with hip pads
Exercise programs
Teaching behavioral strategies
Providing residents with hip pads that may prevent a hip fracture if a fall occurs. There are may options. Be certain to research before deciding on one brand.
Exercise programs can improve balance, strength, walking ability, and physical functioning among nursing home residents. However, such programs do not appear to reduce falls.
Teaching residents who are not cognitively impaired behavioral strategies to avoid potentially hazardous situations is a promising approach.

17. Unsafe Behaviors
Resident tries to stand, transfer, or walk alone unsafely
Resident climbs over bedrails or tries to get out of bed alone unsafely
Resident walks or paces when too tired to be safe
Resident propels wheelchair or walks alone in unsafe areas such as outdoors on rough pavement or in a parking lot
Resident is combative during care
To manage these behaviors, it is important to learn about the behavior pattern – how often, at what time of day, and where it occurs. It is helpful to know what triggers the behavior , what the resident is trying to do, what they may be thinking, as well as what has been tried in the past to mange the behavior and what seems to work the best.
The resident ‘s medical status should be evaluated to determine if an infection, low or high blood sugar, malnutrition, UTI may be contributing to the behavioral symptoms.

18. Unsafe Behaviors
Behavior Patterns – how often, what time of day & where?
Triggers – is there something that usually happens just before?
Motivation – attempt to better understand the resident’s needs.
Staff Experience – what has worked and not worked in the past?
Medications – consider side effects
& medical problems.
You can get information by watching the resident, by talking to staff, family members and the resident, and by reviewing the resident’s records. Remember that the resident behaves as they do for a reason. If you can understand the reason, you have a better chance of managing the behavior.

19. Process Indicator Approach
Assessment and problem recognition
Diagnosis and cause identification
Treatment and management
Monitoring
Assessment – the purpose of this step is to provide a rational basis for deciding whether there is a risk or problem and what to do about it.
Diagnosis- the facility attempts to identify causes & explanation for the problem
Treatment/Management- the facility uses above info to decide how to manage a situation. They seek and address.
Monitoring- Consider effectiveness of the interventions and make a systematic determination about what to do next.

20. Assessment Vision problem? Related medical? Pain Assessment?
Improper use of a device?
Independent in ambulation ?
1. Did evidence suggest a vision problem could have contributed to the fall?
2. Did related medical conditions contribute to the fall?
3. Did the resident experience pain while attempting to ambulate?
4. Was the fall related to improper use of a device, a gait/balance problem, or repositioning difficulty?
5. Was the resident independent in ambulation at the time of the fall or on a restorative rehab program?
Discover the “whats” and “whys” of the fall

21. Assessment is the cornerstone of a fall prevention program.
Taking an adequate history
Identifying those at risk
Identifying acute and reversible problems
Communicating with the physician
Wheelchair positioning assessments to become a component of the initial occupational therapy assessment of all admissions
Medical reasons to consider: Delirium, Adverse Drug Reaction, Dehydration, Infections

22. Cause Identification
Immediately ask the resident what they were trying to do just before the fall
Search for underlying medical problems
Assessment of environmental factors
Review of medication regimen
Physician involvement in diagnosis of the problem
When is an evaluation not necessary
Observe the way the resident :
GETS OUT OF BED
WALKS
TURNS
IN/OUT OF CHAIRS
USES BATHROOM
Observations may reveal environmental solutions to prevent falls.

23. Factors to Consider After a Fall
Time of day
Time since last meal
Medications, (including Over The Counter)
What was resident doing or trying to do
Usual or unusual activity
Standing still, walking, reaching up or down
Changes in environment
Refusal to use assistive devices
Effectiveness of previous safety measures

24. PAST FALLS Information on previous falls Time
Activity during that time
Body position during that time
Purpose of activity during fall
Environmental concerns
Pattern of falls
“Occasional Faller”
“Recurrent Faller”
Look for similarities of current fall and past fall to find the root cause in order to put the most effective intervention in place.

25. Remember A fall without injury is still a fall
A fall without a witness is still a fall
The distance of the fall is not a factor in determining a fall

26. Care Plan
Development of a care plan that contains cause-specific interventions to prevent or minimize resident falls
A fall requires an intervention and an update to plan of care!
It may be necessary to use a combination of interventions

27. Program Interventions
Bowel and bladder program
Activities program
Rehabilitation: gait training, muscle strengthening, balance training
Education programs about safety
Programs for residents who seem to “wander”
Nutrition and hydration program

28. Teamwork Empowerment of all staff Caregiver Involvement
Housekeeping, Maintenance, and Dietary Staff
Active Involvement
Medical Director
Both clinical and non-clinical staff should observe residents for any potential risk factors / behaviors
Focus on medical factors contributing to falls, including possible medication side effects / interactions and suggestive laboratory data

29. Documentation
Document in the patient’s record, the facts pertaining to the fall and treatment.
Complete other institutional documentation as directed.
Completion of Incident and Accident Form (Best Practice) Daily review of above for:
ICP Team Approach to Intervention Identification
Monitor adequate documentation of actions taken (Care Plan)
Evaluate effectiveness of Intervention
Monitor and adapt POC as indicated
I & A reports should be reviewed daily by ICP Team and MUST be completed entirely with special attention to what will be done to prevent reoccurrence. This MUST be added to the care plan! It is very difficult to identify effective interventions (a team approach is VITAL!)

30. Summary Falls can be reduced or eliminated Do a thorough assessment
Correct what you can
Place on correct prevention program based on assessment
Document all the steps of the process
The importance of effective risk assessment, care planning and monitoring of interventions on an interdisciplinary basis is vital to success
If a concern for falls is triggered during the survey process, the facility will be given the opportunity to demonstrate that it has followed steps to support an appropriate care process related to falls and fall risk Evidence of appropriate care processes will be considered in determining whether a negative outcome attributed to a deficient facility practice.

31. Q A & A Committee
Fall Team should track outcomes of care plan interventions and report the results monthly to the facility’s Q A & A committee.
They should also include details of all incidents and trends related to falls and injuries. Also, note successful interventions; resident and facility specific.
Discussion of plans to further educate staff, residents and their families should also be included in documentation.
Facilities using this approach can feel confident that an outcomes-based system is in place for residents at risk for falls and injuries.

32. Your Turn……
Questions? Concerns? Comments?

33. Thank you for all that you do to keep our residents safe!