Making The Number of
Falls Fall
Mara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ
Director of Nursing
Spaulding Nursing & Therapy Center, North End
Boston, MA
Objectives:
By the end of this presentations, participants will be able:
Identify characteristics that increase fall risk
Describe the value in individualizing care plans
to reduce the risk of falls
Compile, analyze, and trend data to determine
patterns of falls
Discuss how trending data can be used to reduce
risk of future falls
Definition “FALL”
“An event which results in a person
unintentionally coming to rest
on the ground or another lower level,
not as a result of a major intrinsic event
(such as a stroke) or overwhelming hazard.”
Tinetti et al., 1988
Who falls?
#1 risk factor = History of falls
Confused
Medicated
Impaired senses
Incontinent/Urgency
Use of adaptive devices
Elderly
Falls are often multifactorial.
Where do they fall?
In the Community:
35%-40% all 65+ y fall once or more/yr
25% of 70+ years fall/yr
35% of 75+ years fall/yr
20%-30% of falls result in severe injuries
(ex. hip fx, head injuries)
A leading cause of death amg cmty elders
Where do they fall?
In Hospitals:
0.6-2.9 falls/year per bed
4-12 falls per 1000 pt bed days
Where do they fall?
In Nursing Homes:
A 100-bed SNF typically has 100-200 falls/yr
Bwt 50%-75% all SNF residents fall/yr
Avg is 2.6 falls per person/yr
4-12 falls per 1000 pt bed days
1800 die/yr from falls in nsg homes
Trend but consider:
Some falls may not be preventable
without jeopardizing the elder’s
dignity &/or compromising function.
Trend but consider:
0% fall rate is a problem
Under reporting?
Are residents immobile?
Hey! I think he just moved, add one more!
Who falls?
#1 risk factor = History of falls
Confused
Medicated
Impaired senses
Incontinent/Urgency
Use of adaptive devices
Elderly
Falls are often multifactorial.
Multifactorial Falls
Medical
conditions
Medications
Impaired
vision & hearing
Assistive
Devices
Psychiatric
conditions
Intrinsic Factors
Environment
Social
Issues
Extrinsic Factors
Incident Report:
Keep it:
Brief
Easy
Relevant
Our form:
Spaulding Nursing & Rehabilitation Center, North End
EVENT REPORT FORM
Date:
Use this form for all events other than med events
Time:
Location of occurrence:
Name:
If not a resident:  Visitor  Outside vendor/clinician
 Employee (If yes, position & dpt):
Resident condition at assessment (Check all that apply):
 At baseline  Oriented x 3  Orient x 2  Orient x 1  Variable
 Confused  Anxious
 Reliable historian
 Resisting assist
If not a resident, phone #:
If not a resident, address:
Describe the event (what happened, how was it discovered, how pt was first observed): _________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Describe any known contributing factors: ___________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________________________________________________
For all falls, complete FALL INVETSTIGATION WORK SHEET, collect WITNESS STATEMENTS, & call a HUDDLE!
Other environmental issues noted:
At time of event Resident was:  Dry/Continent
Incontinent of  Urine
 Feces
 Catheter in use  Leg strap
.
.
INDICATE ON BODY LOCATION OF INJURY/INJURIES:
Type of injury: Use # or arrows to locate
 Laceration
 Hematoma
 Abrasion
 Burn
 Swelling
 No apparent injury
 Complain / Shows signs of pain
(with or without visible injury)
 Pain Rate 1-10
.
Other – specify:
.
NURSE’s NOTE with VS written  YES & OrthoVS for all falls  YES
.
.
Fall investigation form:
Spaulding Nursing & Therapy Center, North End
FALL INVESTIGATION WORKSHEET
Resident Name:
VS when found:
Date of fall:
Time of fall:
Note: If pt unable to stand, sit, or cooperate with VS assmt, document this in the Nurses’ Note.
(temp x 1 only)
Lying: BP:
Sitting: BP:
Standing: BP:
AP:
Resp:
Temp / route:
AP:
Resp:
Temp / route:
AP:
Resp:
Temp / route:
Pt’s statement:
.
PRIOR TO THE FALL:
Where last seen?
..
How long since last seen:
 Dark  Light
Floor:  Dry  Wet
 Barefoot  Regular socks  Non-skid socks
 Slippers  Shoes/sneakers  Tied  Untied
Lighting:
Shoes:
Activity prior to fall:
Continence:
 Dry  Incont of urine  Incont of feces
 Time since last void/toileting
.
 Catheter  Leg Bag
Mental Status (MS) Prior to Fall:
Equipment in Care Plan:
Equip. in use at time of Fall:
 Oriented X 3  Oriented X 2  Oriented X 1
 Forgetful  Poor Safety Awareness  Impulsive
 Lethargic  Restless/Agitated
 MS varies
 Other (describe):
Describe MS after Fall):  No change
 Change: :
 Cane
 Walker
 Wheelchair
 Seat belt
 Brace (type):
 Gait belt
 Side rail(s)-how many
 Mechanical lift
 Other:
 Cane
 Walker
 Wheelchair
 Seat belt
 Brace (type):
 Gait belt
 Side rail(s)-how many
 Mechanical lift
 Other:
.
.
 In-place  Connected  Sounding
If not sounding: .  Turned ‘off’  Low/dead battery
Alarm:
Type of alarm:
.
 Within reach
Call bell functioning:  Ringing  Hall light on  Not working
Call bell:
.
.
.
.
.
.
Fall investigation form:
2nd half of page
Check all that apply:
 Change in med, dose or schedule in past 72 hrs
 Fall within the last 30 days
 Acute change of condition:
 Recent change of function:
.
.
This event was witnessed:
 No
 Yes – Have staff witness(es) complete WITNESS STATEMENT FORM
 Yes – If witnessed by another resident or visitor, document their observations on WITNESS STATEMENT FORM
Evaluation:
This fall is thought to be due to:
 Cardiovascular condition
 Neuromuscular condition
Notes & Care Plan:

 Orthopedic condition  Cognitive condition
 Other (describe): ___________________
 Vision impairment
 Environmental condition ___________________________________
The care plan is updated based on this assessment.
Nurse initials
Signature of person completing this worksheet:

Nurse’s note written about this fall.
Nurse initials
Date: _______________________
HUDDLE :
Spaulding Nursing & Therapy Center, North End
Huddle Worksheet
Patient’s name:
Time of fall:
Location of fall:
Time Huddle was called:
.
.
.
.
.
Report of what happened:
.
Report of intervention:
Rehab Screen needed:  Yes
Type of service needed:  PT
 No
 OT
Members Present at Huddle:
1.
2.
3.
4.
 SLP
Huddle in Progress
Join the HUDDLE!
Help prevent the next fall!
How are we doing?
We did a terrific job in
preventing falls
in August!
FALLS
May ‘10
June ‘10
19 falls
24 falls
15 residents
15 residents –
1 resident fell 5 times!
July ‘10
25 falls
13 residents –
1 resident fell 5 times!
August ‘10
11 falls
8 residents
Mr SS fell twice.
Mr EM fell three times.
Let’s do even better in September.
Join the HUDDLE on your unit.
Help us prevent the next fall.
Thank you for all your hard work & care!
Trend but consider:
Fall numbers will rise while
“frequent fallers” are in the house
& fall when they leave.
ay
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2011
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Our fall data:
30
25
20
15
10
5
0
Our fall data:
30
25
20
All Falls
15
10
Falls with
injuries
5
0
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ar
ay
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2010
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ep
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Trending all events:
1-May 2
2-May
2-May
4-May
4-May
5-May
5-May
5-May
4
3
4
4
Employee
Elopement
Allegation
Other
Other Skin
If yes,injury type
Bruise
Fall
See log* Rpt DPH
EVENT BY TYPE
Rsdt-Rsdt
Resident
Yes
Time
No
Unit
Date
FALL / RELATED INJURIES
7:35a Bernard
10:10a Carolyn
11:30a Dora
2:00p Edward
1
2 5:15p Geraldine
3 12noon Howard
Bruise1
1
1
Other 1Skin
1
1
1
1
1
1
1
abrasion
4 7:10p Kate
3 2:30a Louise
TOTALS
1
1
1
Other/Misc
7
4
3
c/o hip pain
seated in corridor for observation;
witnessed evt: pt rose from chair & fell to left
rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb
Employee
0
1
2
2
See Employee Event Log
Roommate summoned staff; rsdt found on floor beside bed;
rsdt report tried to go back to bed w/o help
missing hearing aide
found on floor outside of room; said going to work; no injury; restless
1
Allegation
1
3-May
Spilled hot soup in lap; denies pain; area pinkened immediately post event
In main DR; tried to help peer to her seat; witnessed fall to knees
Elopement
8-May
1
leaned forward from WC and fell to floor; laceration on eyebrow
sent to ER; wound sutured
Bruise found on posterior hand; phlebotomy draw yesterday
Fall from toiled during BM
Skin tear noted on LLE; rsdt says bumped on leg rest of WC
1
1
See Med Event log
Resident-to-Resident
1
STAFF: Frost, Frank
6-May 3 3:15p Imogen
6-May 4 2:00p Joyce
7-May 4 6:20p Kate
7-May
Notes & Other Events
Anne
Med
event if yes, date
See Med Event log
0
0
1
1
2
Trending all events:
1-May 2
2-May
2-May
4-May
4-May
5-May
5-May
5-May
4
3
4
4
8-May
Employee
Elopement
Allegation
Other
Other Skin
Bruise
If yes,injury type
Anne
7:35a Bernard
10:10a Carolyn
11:30a Dora
2:00p Edward
1
1
1
2 5:15p Geraldine
3 12noon Howard
1
1
4 7:10p Kate
3 2:30a Louise
TOTALS
1
1
1
1
1
1
1
1
1
1
7
4
All falls
3
See Med Event log
1
3-May
See Employee Event Log
Spilled hot soup in lap; denies pain; area pinkened immediately post event
In main DR; tried to help peer to her seat; witnessed fall to knees
1
abrasion
Roommate summoned staff; rsdt found on floor beside bed;
rsdt report tried to go back to bed w/o help
missing hearing aide
found on floor outside of room; said going to work; no injury; restless
1
1
1
Notes & Other Events
Med
event if yes, date
leaned forward from WC and fell to floor; laceration on eyebrow
sent to ER; wound sutured
Bruise found on posterior hand; phlebotomy draw yesterday
Fall from toiled during BM
Skin tear noted on LLE; rsdt says bumped on leg rest of WC
1
STAFF: Frost, Frank
6-May 3 3:15p Imogen
6-May 4 2:00p Joyce
7-May 4 6:20p Kate
7-May
Fall
See log* Rpt DPH
EVENT BY TYPE
Rsdt-Rsdt
Resident
Yes
Time
No
Unit
Date
FALL / RELATED INJURIES
seated in corridor for observation;
witnessed evt: pt rose from chair & fell to left
rsdt c/o hip pain; ROM at baseline; Xray neg; resumed baseline activ/amb
c/o hip pain
See Med Event log
0
1
2
2
0
With or w/o injury
0
1
1
2
Fall Risk Assessment Tools:
Valid?
For what population? In what setting?
But if nearly
every one is at risk. . . . .
is it useful???
What’s been tried?
Staff education
Reprimands for high fall rates
Rewards for low fall rates
Falling Stars & Falling Leaves
Colored bracelets or socks
Bed & chair alarms
Restraints
Falling Stars/Leaves
On door jams, foot boards, bracelets, care cards
Be realistic
Policies
Forms & Documentation
Interventions
What’s been tried?
Staff education
Reprimands for high fall rates
Rewards for low fall rates
Falling Stars & Falling Leaves
Colored bracelets
What
Colored slippers
Bed & chair alarms
Restraints
else?
Lots strategies work
Most do work In the SHORT TERM
To sustain results, best =
QI principles
Trending
Sharing trends with staff
Varied reminders & education
“Borrow ideas” from other SNFs
For example:
Mind your ‘P’s!
Tend to the
pain.
Toilet the patient.
Reposition for
safety
& comfort.
Place within
reach.
Things plugged into pts.
PAIN
POTTY
POSITION
PERSONAL ITEMS
PLUGS
Prevent the next fall.
Reasons to limit restraint use
#1:
RESTRAINTS DO NOT REDUCE
FALL RATES
Reasons to limit restraint use
#2:
RESTRAINTS MAY INJURE
OR KILL PATIENTS
Reasons to limit restraint use
#3:
RESTRAINTS JEOPARDIZE
SURVEY RESULTS
Reasons to limit restraint use
 Increase risk of complications
Skin breakdown
 Isolate
Decrease mobility
 Injure
Disorient
 Risk death
  Liability
Frighten
 F-Tags
Remember when?
1980’s
Admission orders:
 PRN Tylenol
 PRN MOM
 PRN Haldol
 PRN Vest restraint
Miles & Irvine, 1992
S Miles,
S Miles,
S Miles, 1996
When falls occurred pre-OBRA:
Nurse assessed for gross injuries
Nurse put bandage on boo-boo
Nurse tied Mrs B to her chair
Nurse tied chair to the handrail
When falls occurred post-OBRA:
MDS prompts consideration:
Facility QI trending:

Infection?

Location?

Medication?

Time?

Glasses/vision?

Equipment?

etc.

Personnel
Respond to trends:
Staff education
Address “not-my-patient” syndrome
Toileting schedules
Activities
EVERY one involved?
Nurses & Nsg Mgt
Nursing Assistants
Restorative Aides
PTs & OTs
Resident
Resident’s family
Maintenance staff
Housekeepers
Dietitians
Dietary aides
Staff Development
Pharm Consultant
Administrator
Medical Director
Facility-wide interventions
All staff involved
Remove clutter
Assess staff competence w/ transfers
Assess staff competence w/ equipment
Assess, address & reassess individuals
Individualize interventions
Consider the falls:
Clinically?
From what position?
Where?
When?
Circumstances?
Falls from what position?
Falls from
BED
↓
Falls from
CHAIR
↓
Falls from
STANDING
↓
Benefit from PT?
Need assistive devices?
Develop menu of
possible interventions
Falls where?
Bedroom?
En route toilet?
Toilet?
Outside?
Activities?
Falls when?
During night?
Early AM?
Late afternoon?
Bwt dinner & bed?
After certain activity?
Change of shift?
Summary:
For individual:
Assess
Educate
Address
Reassess
Re-address
For population:
Assess/trend
Educate
Address
Continue to monitor
Re-address
Summary:
“Falling itself is not a diagnosis
but a symptom of multiple underlying diseases,
the effects of certain medications …,
and /or environmental hazards or obstacles
that interfere with safe mobility”
(Tideiksarr, 1993)
Summary:
Therefore, individual assessments must be
frequent and interdisicplinary.
And each rsdt’s care plan must also be
frequently reviewed and interdisicplinary.
Summary:
And…
Trending must be continuous, thoughtful,
& interdisciplinary.
Facility-wide interventions must be thoughtful,
interdisciplinary, & continuously reviewed,
reinforced, and changed as trending indicates.
Summary of strategies:
Include ‘front line’ staff in developing care plans
Include ‘front line’ staff in changing practice
Trend falls
Share fall trends with staff
Periodic and varied in-services
Fliers (in staff-access areas)
Be creative
Share/adopt strategies from other facilities
Discussion. . .
To reach Mara:
Mara Aronson, Director of Nursing
Spaulding Nursing & Therapy Center, North End
70 Fulton Street
Boston, MA 02109
(617) 726-9702
MEAronson@partners.org