Combating Falls in Senior Living

Author: Tammy Bowman

Each year, roughly $50 billion is spent on medical costs related to nonfatal fall injuries in senior living facilities, and $754 million is spent related to fatal falls.¹ These numbers are staggering and don't account for the litigation cost required to defend facilities when negative outcomes occur.

Every senior living facility should have a strong and detailed falls management program. The effectiveness of a falls management program can directly impact a facility's five-star rating or quality measures and the rising cost associated with medical care. A falls management program is the first line of defense in mitigating falls of seniors in long-term care.

Consider these sobering statistics:

• For adults age 65 and older, falls are the leading cause of fatal and nonfatal injuries.²
• Falling once doubles your chances of falling again.²
• Roughly 20% to 30% of falls result in moderate to severe injuries — such as hip fractures, broken bones, head injuries, skin lacerations and bruising — that reduce mobility and independence, and increase the risk of premature death.³
• Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture.²
• Each year, 3 million seniors are treated in emergency departments for fall injuries.²
• More than 95% of hip fractures are caused by falling and usually by falling sideways.²

Training is key when implementing your falls management program

Many elements are involved in creating an effective falls management program. While a plethora of resources are available to help facilities develop a program, the best resource starts at the facility level.

It's imperative that a facility first develop a comprehensive training program to communicate to all staff about the facility's commitment to providing a safe environment and reducing the risk for falls through a falls management program.

Below are key components a facility can use as guidance in developing a program.

• All staff members should be trained and aware of each element of the program and how they play a part in the program's success.
• Staff should be aware of potential environmental issues that may contribute to a high risk of falls, such as wet floors, cluttered hallways, obstructed pathways and other environmental issues.
• Staff should be able to identify residents who are at the highest risk for falls. As part of this facility-specific process, an identifier — such as an image of falling leaves above the bed or a colored bracelet — can be a quick and easy identification tool for high fall risk residents.
• Staff input for identifying a process from direct caregivers — such as certified nursing assistants (CNAs), licensed practical nurses (LPNs) and registered nurses (RNs) — is often key to having an effective program.

Staff training on near-miss events should be part of a holistic falls management program. A near miss is an unplanned event that has the potential to cause, but does not actually result, in human injury, environmental or equipment damage, or an interruption to normal operations.⁴

For example, a CNA walks down the hall and observes a resident trying to get out of bed unassisted. The CNA intervenes, redirects and possibly prevents a fall. This event puts the facility on notice that the resident may start getting up unassisted. The facility should implement appropriate interventions to reduce the risk of a future fall.

Staff should report near-miss events to facility administration to plan accordingly. Training on near-miss events should be conducted upon hire for every staff member and refresher training provided throughout the year.

Compliance and consistent communication plays a key role in making the facility's program a success.

Creating an effective falls management program

Many senior living facilities have a falls management program in place, but recognize that there's always room for improvement. While not all falls and injuries can be prevented, it's critical to have a systematic process for assessment, intervention, planning and monitoring with the goal of minimizing fall risks.

Pre-admission assessment

Taking a holistic and proactive approach during the pre-admission assessment of a resident can capture not only their weaknesses but also their strengths.

Interview the resident and/or family to learn valuable information of the resident's normal routine (bedtime, toileting habits), prior falls history (single best predictor of future falls), behaviors or any other pertinent information to identify the risks and needs of the resident before admission to the facility.

Some facilities may choose to use a fall questionnaire to obtain and document information and seek input from the resident and/or family.

Admission assessment

This interdisciplinary approach determines risks for the resident. This assessment should consider a review of the resident's diagnoses, medications, cognitive status, behaviors, ambulatory status, mobility devices, range of motion and assistance required to complete daily activities such as transfers, ambulation, toileting, bathing, dressing and eating.

If the resident is at risk for falls, the facility could use a falls acknowledgement form outlining that the facility has discussed the risk for falls and the resident and/or family is aware of the risk.

Care plan

This interdisciplinary approach uses the information collected during the pre-admission and admission assessments. The resident and/or family should participate in this process, if possible, to voice the resident's preferences and determine the resident's care needs.

The care plan should clearly identify the risk for falls and what interventions could mitigate fall risks. Information from the care plan should be communicated to all staff responsible for the care and safety of the resident, including any changes or revisions. The care plan will be a working tool for the resident as part of the falls management program. It should be reviewed and revised with any change in the resident's condition, as well as any fall.

Interventions should be clear, concise and realistic, and driven by new medical diagnosis, the addition of a new medication, or the result of a root cause analysis from a fall. The facility should use a tool such as a care plan attendance form that summarizes details discussed, interventions, staff in attendance and resident and/or family involvement either in person or via phone.

This tool should also indicate any input and/or concerns with resolutions voiced by the resident and/or family during the care plan meeting. The facility should refer back to their system for alerting staff of residents at risk for falls.

Fall risk assessment

This assessment tool should be completed upon the admission of a resident to the facility, quarterly, annually (usually scheduled around the Minimum Data Set assessments), and with the occurrence of a fall. It's also recommended that this assessment be reviewed with any changes in the resident's status (diagnosis and medications), as these areas can increase the resident's risk for falls.

Resident and/or family communication and expectations

The pre-admission assessment, admission assessment and initial care plan meeting may be helpful in determining the expectations of the resident and/or family. The facility can take this opportunity to advise the resident and/or family of diagnoses, medications, limitations, etc. that may increase fall risks. Communication with the resident and/or family regarding fall risks is imperative. It should include details that the facility doesn't provide one-on-one care, interventions may not prevent a fall, and injury from a fall could be fatal. Communication regarding interventions and/or goals should also be consistently communicated.

There should be no surprises if the family is notified of a fall. Documentation in the record of family discussion, plan identification and understanding by the family can be helpful in defending future claims.

Incident report and investigation

An incident is a witnessed/reported fall or found-on-floor occurrence. The facility should have a tool (incident report) to record all pertinent facts related to the incident and data for alerting staff that an incident has occurred. The incident report can be used for trending and tracking.

Most facilities use electronic health records that provide this tool. This tool may include:

• Time/date and location of the incident
• Conditions present (lighting, clutter, wet floor)
• Staff present (witnessed or unwitnessed)
• Mobility devices (present and in use, or absent)
• Personal safety devices/alarms (in use and working properly, or absent)
• Injuries identified
• Physician and family notifications
• Brief description of what the author observed or what the resident said at the time of the incident

Once the incident report is recorded, the investigation process should be initiated immediately to obtain information while it's fresh on everyone's mind and witnesses are available. Investigating is a process that documents a timeline of events that led up to a fall in an effort to determine the root cause (what, when, where, why and how). This process may include:

• Interviews with the resident or roommate, staff and visitors
• Inspection of equipment or devices
• Environmental issues
• Use of medications
• Changes in resident's condition
• Position of the bed
• Use of alarm or positioning devices
• Review of the medical record

This list isn't an all-inclusive list of probing questions to get to the root cause of the incident. When the root cause is determined, the care plan should be reviewed to determine the effectiveness of interventions and the possibility of additional interventions to reduce the risk of future recurrence.

The facility should communicate to the staff, resident and family any updates to the care plan. Interventions can be changed at any time as new information becomes available.

Documenting an incident

To preserve documentation of an incident, staff should be educated on the details to be recorded. The goal of documentation is to paint the picture of the incident so the details can be recalled later. The facility may want to consider providing a resource document at the nurse's station outlining details to be recorded following an incident. Details include:

• Date/time of incident
• Type — fall or found on floor
• Location of incident
• Assessments completed to determine injuries
• Injuries identified
• Presence of current interventions in place at the time of the occurrence
• Immediate interventions implemented
• Notifications to physician and family

This list isn't an all-inclusive list of details that should be documented. Incident documentation should be recorded contemporaneously in the record.

Post-fall monitoring

This process won't only allow a facility to monitor for a change in condition of a resident after a fall but also allows the facility to evaluate the effectiveness of the intervention put in place to reduce the risk of recurrence. It's helpful for the resident to be monitored for 72 hours after a fall, with staff documenting every shift of the resident's status and effectiveness of the interventions. The facility should have a system that alerts oncoming staff of which residents require post fall monitoring and documentation. Facility staff should be familiar with their specific facility policy for post fall monitoring.

Tracking and trending

The facility should have a quality assurance program for conducting trending and tracking of falls for each resident, as well as facility wide. This will give the facility insight into similarities of the occurrences in an effort to reduce the risk for recurrence. Typically, this includes comparisons to time of day, weekday vs weekend, staff assignment, location, or a particular wing of the facility. This is also a good time to review policies and procedures along with the falls management program to see if updates or revisions may be needed. Communication is key to the facility's success!

Special called care plan meeting

When a resident has multiple falls or starts to fall with no prior history, the facility should consider holding a special called care plan meeting with the resident and/or family to review trends, previous and current interventions and injuries, and to seek the family's input. The family should already be aware of this information, but it's important for documentation purposes to reiterate this information during the meeting. Explain in detail to the resident and/or family that the resident continues to be at risk for falls due to the specific identified risks, i.e., unsafe/unsteady gait, failure to call for assistance, diagnoses, etc. Discuss prior and current interventions and the identified plan of action going forward. Confirm the resident and/or family agrees and understands the resident continues to be at risk for falls, which could possibly lead to injuries that could be fatal.

The special called care plan meeting is also a great opportunity to discuss the option for the family to provide a sitter, and document the discussion and response of the family. If the family raises the idea of a restraint, the facility should document the use and purpose of restraints and outline the reasoning if a restraint is appropriate or not appropriate for the resident. As a risk management practice, document the content and discussion of this meeting, identify a timeframe for follow-up, and have the family acknowledge their understanding in writing.

Key takeaways

• Train and educate all staff on the facility's commitment to providing a safe environment for residents.
• Train all staff to have an active role in fall prevention.
• Establish an effective communication system to alert all staff of residents that are at high risk for falls.
• Establish pre-admission and admission assessment.
• Establish an effective communication system to notify staff of changes in the care plan, i.e., new/revised interventions.
• Be proactive in recognizing resident and/or family expectations, and provide education related to the risk of falls.
• Maintain ongoing and consistent communication to the resident and/or family on the risk for falls, interventions/goals and continually seek input from the family.
• Establish medical record documentation practices that capture elements of the falls management program.
• Establish a process for alerting/notifying oncoming staff of residents that require post fall monitoring and
• Identify staff members who are skillful and analytical in reviewing and identifying trends in incidents.
• Continually evaluate the effectiveness of the falls management program.

In conclusion, an effective falls management program, communication and training of staff, and setting realistic expectations with the family can reduce the risk of falls for our seniors. As with all things, success will take an ongoing effort by the facility to stay apprised of recommendations and changes that are published by Centers for Disease Control (CDC), Centers for Medicare & Medicaid Services (CMS), The Agency For Health Care Administration (ACHA) and related resources.