Rapid Fire Team Presentation Template
Name of Presenter:
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Falls Facilitated Learning Series
Who We Are
Name of Organization: Rykka Care Centres
Home Names: Anson Place Care Centre, Cooksville Care
Centre, Dundurn Place Care Centre, Eatonville Care
Centre, Hawthorne Place Care Centre, Orchard Terrace
Care Centre and Wellington Park Care Centre
Number of Patients/Residents/Clients: 1146 beds providing LTC,
Special Programs (Restore/Convalescent) Respite and Short
Stay beds
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Falls Facilitated Learning Series
AIM
From your Team Charter:
To learn and integrate strategies into our organization’s Falls
Improvement Plans to ensure we increase the likelihood of sustaining
change for the prevention of falls and injury reduction while holding the
gains over time. We will be active participants in data submission to
SHN Falls Intervention and network with other enrolled teams in the
National FFLS.
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Falls Facilitated Learning Series
Team Members
Team Roles/Responsibilities:
Executive Sponsor: Derrick Hoare – VP Operations
Team Lead: Susan Veenstra – Director, Nursing & Wellness
Team Members: Debbie Green, Dorie Dulay, Sheila Mathi, Joanne
Owasu, Courtney Bailey, Barb Vanmil, Katherine Shaler from RMI/RCC
and Diana Gillstrom, Celia Lieu and Nirev Patel from Achieva Health.
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Falls Facilitated Learning Series
Review Falls Change Ideas tested to date in your
organization
Changes Implemented
within Organization
Working/Not Working
Facilitators/Barriers
identified
Reviewed current fall strategies
home by home
Worked
Facilitator: as it showed us
our limitations
Developed partnership with
Achieva Health for PT services
Worked
Facilitator: pre/post fall
outcome measures were
obtained for each resident
in the FPP
Falls Risk Committees
started/restarted
Worked
Facilitator: Multidisciplinary
team participating in each
home
Data Analysis completed
Worked
Facilitator: Pre/post
outcome measures obtained
for each resident in FPP
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Falls Facilitated Learning Series
Review Falls Change Ideas tested to date in your organization
Changes Implemented
within Organization
Working/Not Working
Facilitators/Barriers
identified
Location and time of Fall
Data collected
Worked
Facilitator: allowed for
analysis of when falls
happen to be graphed
Fall Algorithms Developed
Working (in progress)
Facilitator: Guide for
Care Providers
Weekly Tracking Tool
Implemented
Working
Facilitator: Enhances
data collection &
analysis
Red Flags Checklist for Safe
Transfers
Working
Facilitator: Info for staff
to conduct safe transfers
Communication Plan
In progress
Facilitator: presently
working on this as PDSA
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Falls Facilitated Learning Series
Measures: Fall Risk Algorithm
Resident Admitted
Fall Risk Assessment Completed within 24
Low Risk of Falling
Medium Risk of Falling
High Risk of Falling
Good basic nursing care provided
- Bed on lowest setting except
when care being provided
- Ensure necessary items are
within reach
- Assess environmental area
- Encourage regular toileting
hours
Reassessed: quarterly, annually,
PRN
Refer to members of
Falls Team
Additional Strategies to consider:
- Re-orientate confused residents
- Assess resident for use of bedrails
- Educate residents re safety
Additional Strategies to consider:
- Position resident close to Nurses’
station
- Consider using sensor alarms
- Consider one-to-one nursing
Refer to Falls Team
Care Conference to
discuss alternatives &
create/adjust CP
Refer to Falls Team
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Falls Facilitated Learning Series
Measures: Post Fall Risk Algorithm
Falls Risk Algorithm After A Fall Occurs
After a fall occurs:
1. Always consider “why did this fall happen?”
2. Review the Falls Strategies that were implemented and the resident current fall risk status.
3. Address the resident’s fear of falling again.
4. Implement appropriate new interventions/strategies as per falls team recommendations
5. Report, discuss, document and communicate.
Fall occurred, complete “Incident Report” in PCC
Did care plan identify resident at High
risk for falls?
NO
Complete “Fall Risk Assessment” to identify
changes in function/status that may have
caused the fall and refer to Falls Team
YES
Follow HIGH risk guidelines for
residents
- Document in PCC under falls
- Include in Care Plan, other
interventions as appropriate
- Referral to Falls Team
- Follow HIGH Risk guidelines for residents
- Document in care plan and PCC
- Include additional interventions as appropriate
- Continue to monitor for fall risk especially when
status has changed
When a resident falls, their fall risk status automatically
changes to HIGH
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Falls Facilitated Learning Series
Measures: Weekly Tracking Tool
This tracking Tool is unique to the Responsive Homes and is used to analyze the
following information:
• Resident’s Name & Room Number
• Date, Time, Location
• Mechanism of Fall: Possible factors that may have contributed to the fall.
• Follow up of Fall: After the PT and RN completed their assessments, what
were the findings?
• Recommendations: Ideas to help prevent the fall from happening again in
the future. Should consider both internal and external factors discussed
above.
• To be implemented on… by… : needs to be specific and give ownership
• Intervention Effectiveness – Were the recommendations implemented
effectively (E) or Ineffective (I). This final column should be filled out one week
after the interventions were completed.
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Falls Facilitated Learning Series
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Falls Facilitated Learning Series
Measures: Samples
Time of Fall
Location of Fall
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Falls Facilitated Learning Series
Sample of Meaningful Information that is shared about fall in a simple but
effective format
Rykka Care Centres … 7-Home Total
200
193
187
191
180
Number of Falls
Falls
162
160
Fallers
140
120
Injuries
100
80
60
40
20
May
June
July
Aug
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Falls Facilitated Learning Series
Lessons Learned on Sustaining Falls
Improvement Work during Action Period
What advice would you give to other teams?
• Keep it simple
• Keep the audience in mind
• Expect to meet resistance
• Persevere as the residents will be the recipient of better care
• We have acknowledged the individuality of each home
What are your key insights?
• Encourage family involvement
• Continuous education
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Falls Facilitated Learning Series
Challenges to Sustaining Falls Improvement
What were some barriers?
• Distance between homes
• Diverse demographics of our resident populations
• Rolling out Communication Document – electronic or hardcopy
• Competing interests
How do you propose to move forward?
• Complete PDSA cycles pertaining to refining communication document with
goal to integrate this discussion into daily resident care conversations.
• Continue to use In-House Falls Teams to support information and knowledge
transfer
• Allow homes to maintain diversity of approach rural vs. urban
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Falls Facilitated Learning Series
6 Month Post FFLS Sustainability Plan (continued)
Action (What Steps are to be taken
to achieve)
1.
1.Implement falls committee review
Ongoing initiative
(weekly/bi-weekly/monthly) , which
reviews each falls for cause and
interventions to prevent recurrent fall
2. Use of weekly tracking documentation
Ongoing Initiative
tool to track falls, document interventions
and Identify responsible person.
3. Review literature for interventions
available for reducing falls. Reviewed
Ongoing Initiative
RNAO Best practice guidelines for
prevention of falls, reviewed residents
first for interventions to prevent falls, and
reviewed the website “fallsinltc” for
interventions to prevent falls. Compiled a
list of interventions appropriate for home
area staff to reference
4. Identification that resident transfer
levels may alter throughout the day, so
Ongoing initiative
transfer logos to be readily accessible for
staff at bedside/point of care.
Falls Prevention Team
1.Education sessions provided to staff on
Ongoing Initiative completed
each shift about falls prevention program weekly up to monthly
and strategies to be used within the
depending on home size.
home.
Falls Education binder created to be
placed on each home area for staff to
reference.
2.Implement the use of a safety checklist
June 2012
that is to be completed
Ongoing
3. Provide ongoing education from RNAO
Best Practice Guideline as well as
Resident’s First on interventions to reduce
falls and
1.
To learn and
integrate
strategies into
our
organizations
falls
improvement
Plan
Ongoing
Education of
staff on falls
prevention
program and
strategies
Timeframe (when to be
done by)
Person Responsible
Goal Description (
AIM)
Metrics (what is to be monitored to
identify achievement
Each resident will have a documented
review and statistics will be present to
Quality Team for each home
Home area staff
Falls Prevention Committee
Lead in conjunction with Staff
Educator
Audit completion monthly with
statistics to Falls Prevention
Committee
Generate a list of potential
interventions available to be used for
individual residents to prevent falls.
Falls Prevention Committee
members
Audit monthly to ensure up to date
information is at bedside/point of care
Falls Prevention Team in
consultation with Staff
Educator and Achieva
Document the # of staff educated
Set goal of 100% by year end.
Falls Prevention Team
Collect checklists monthly and analyze
for compliance/issues to be addressed.
Achieva
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Falls Facilitated Learning Series
6 Month Post FFLS Sustainability Plan (continued)
1.
1.
1.
Identify periods and
location of high
incidence of falls
during 24 hour
period
1.Use this data to arm staff with
information about times and places
that residents are at risk.
Use data to advocate for increased
staffing during high falls period.
2.Change focus of falls to
multidisciplinary in nature and
utilize other staff in home to assist
during identified high risk fall
times (i.e. Activities staff engaging
residents with history of falls in
activities during high falls time
periods – usually pc dinner.
Housekeeping staff to monitor
residents in their home area with
report provided to Charge Nurses
Immediate and ongoing
Ensuring that every
resident has a falls
risk assessment
completed
1.All registered staff educated to
complete falls risk assessment on
admission, readmission, post fall
and with a change in health status.
Upon resident admission,
readmission and after health
status change
Medication Review
is completed
related to high
Risk medications
Line listing kept on nursing unit of
residents who have had a fall.
Pharmacist is to review list and
conduct medication review where
appropriate.
Attending Physician to review
recommendations and adjust
resident medication profile
accordingly.
Weekly/Monthly as per visit
schedule
Immediate and ongoing
Falls Prevention Committee
staff
Falls Prevention Team,
Multidisciplinary Care Team,
Achieva
Registered Nurses and Falls
Prevention Committee.
Charge Nurses, Pharmacist and
Attending Physicians
Falls Prevention Committee
Monitor number of falls at high risk
times with goal to reduce during peak
fall times, during the time frame when
extra activity staff has been added to
the unit to engage the residents in
activities.
Data to be reported and analyzed by
Falls Committee
Risk Management tab in PCC generates
graphs of each residents falls and this
data will be used to trend overall falls
stats. Focus to be placed on repeat
fallers related to efficacy of
interventions.
Monthly Audit for compliance using
assessment tools and data entered into
PCC.
Review monthly drug administration
statistics received from Pharmacy
related to compliance for decrease or
eliminating high risk meds.
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Falls Facilitated Learning Series
6 Month Post FFLS Sustainability Plan (continued)
1.
1.
1.
Ensuring that
every resident has
a falls care plan
1.On admission the admission nurse
develops the falls care plan, with
interventions based on identified risk.
Done within 21 days of
admission as per MOH
guidelines.
Admission Nurse
Monitor the number of admissions and the
number of falls care plans completed with goal
of 100% compliance.
2.With each fall registered staff is to
add the date of the fall to the care plan
and review the care plan, adding
additional interventions as necessary.
3.Education of the registered staff on
the importance of falls care planning
and expectations
4.Track referrals received by PT versus
number of falls recorded.
Also done post fall,
readmission from hospital
and with a change in
condition.
Monthly
Charge nurse
Falls Team to audit care plans to record the
number of fall dates which are added to the
care plan and the number of new interventions
added by the registered staff.
Goal set of 100%
Risk Management
documentation and
incident report
completion post
fall.
All registered staff re-educated on using
the risk management documentation tool
Ongoing
Review documentation in PCC to ensure
accurate
Monthly
Communication of
changes in care
plan, recent falls
to staff
To be communicated to staff at each
shift report. With reminders about
recent falls, and new falls interventions.
Staff are also reminded at each shift
report about falls prevention
interventions such as alarms, crash mats
and restraints.
Monthly at Professional
Practice meetings
Falls Prevention Team ,
Achieva
Ongoing
Falls Prevention Team,
Staff Educator, Achieva
Goal set at 100%
Falls Prevention Team
along with Staff
Educator
DoNPC and/or Falls
Prevention Lead
DoNPC or delegate to audit data entered into
PCC
Charge nurses, Achieva
Focus audits of 24 hour reports are completed to
ensure all resident’s specific safety devices are
discussed.
Statistics to be reviewed at Falls Prevention
Committee.
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Falls Facilitated Learning Series
Next Steps
What are some things you will be working on in Action Period:
• Our goal is to continue to continue to work as a TEAM and decrease
falls.
• Continue to use a multidisciplinary approach in identifying residents
at risk for falls.
• Continue to refine the communication plan acknowledging and
allowing for the diversity of approach by each team in the 7 homes
• Achieve Decrease in falls rate by 20% (Benchmark) Presently at
14.4% Decrease
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Falls Facilitated Learning Series
Contact Information
Name: Susan Veenstra
Email: susan.veenstra@responsivegroup.ca
Phone Number: 416-479-4345 X 222
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