An All-Out Attack on Falls

The Problem
Data for 2002 from the Center for Health Systems Research and Analysis (CHSRA) at the University of Wisconsin’Madison indicate that New York State long-term care facilities had 14.6% of their resident populations experience a fall. The prevalence of falls and the challenges they present are not new to the industry. According to national data, falls are the underlying cause of death each year for almost 10,000 patients over age 65. Studies suggest that falls are one of the costliest categories of injuries among older persons. The cost involves not only the financial impact but also the emotional impact on the person. Fear of falling may lead to a resident’s decreased confidence in his or her ability to ambulate safely and, potentially, to further functional decline. In turn, this may lead to depression and feelings of helplessness and social isolation. A fall affects not only the resident, but the family, as well, who witness their loved one’s pain and decrease in functional status.

Resident falls are related to multiple factors, and no one intervention on its own may be successful if other relevant factors aren’t identified. Based on a review of clinical and statistical data, quality indicators, resident assessments and resident occurrences, and quality-assurance reports, our facility decided to focus on a project to improve resident safety and decrease the overall number of resident falls.

Our facility consists of four populations, each with different needs. Two of the populations are largely mobile, although many of these residents have cognitive impairment. Three subacute units have clients/residents who, although often independent prior to hospitalization, now have limitations they may not fully recognize. Because these factors contribute to a high risk for falls, there is facility-wide potential to involve all residents in a falls-prevention program.

We decided in the last quarter of 2002 to develop a new process to further evaluate our systems and processes. We wanted to improve resident safety and, more specifically, focus on decreasing the number of resident falls, rather than focusing on the broader target of reducing resident accidents and incidents. Our overall objective was to decrease falls by approximately 20% in one year.

The project began in January 2003 and continued through the end of the year. We used a process published by the Joint Commission on Accreditation of Healthcare Organizations, as well as established quality-assurance principles. Based on the concept of Failure Mode and Effects Analysis (FMEA), strategies involved creating a timeline (figure 1), flowcharts (figure 2), a focus team with specific roles and responsibilities, and audit tools to help measure the outcome.

The use of flowcharts allowed us to analyze any areas that might cause or lead to failure (in this case, falls). These identified areas could then be changed or enhanced, as appropriate. Through the use of the flowcharts and the FMEA model, we were able to redesign our falls-management process and put into effect a new approach that would hopefully lead to the desired reduction.

Barriers Identified
Each potential failure mode of the process was carefully identified, prioritized, and analyzed through the FMEA process (table 1). We focused on the following priority problem areas:

• Standardized preventive interventions that were sometimes ineffective
• Inconsistent, at times poorly completed, investigations and corresponding documentation
• Inadequate review at risk management meetings
• Ineffective resident education/reinforcement
• Inadequate reevaluation of revised care plans’ effectiveness
• A need for enhanced staff education

With all these difficulties in mind, we conducted a preliminary discussion of the project on December 3, 2002. We knew that our entire process for preventing falls and recurrences needed to be reviewed and reevaluated. This would include the method of identifying at admission the resident as high-risk for falls, developing a care plan that would prevent falls and, if the resident does fall, implementing a new process, including investigation, to prevent recurrences.

On January 7, 2003, we formed a team consisting of the Assistant Administrator, who served as chairperson and facility Safety Officer, and was responsible for budgetary allowances and overseeing the entire process; the Director of Nursing/ADNSs, who would be responsible for reviewing the Accident/Investigation Process and the nursing component of the Care Planning Process; the Director of Rehabilitation, who served as chairperson of the risk management meeting and would be responsible for evaluating the risk management process and its implementation, as well as monitoring use of new resident-assist devices; a designee of the Quality Assurance/Performance Improvement/Staff Development Department, who would be responsible for the final review of occurrence reports, evaluating educational needs, and identifying trends related to falls; and the Risk Management Coordinator, who has since expanded her role to become Clinical Care Coordinator and is an integral part of the team responsible for reviewing all occurrences, providing ongoing staff education on the investigative process, analyzing the use of proactive plans/instructions, and identifying patterns/trends needing attention.

Other members of the team who have become involved on a daily basis, especially during care plan meetings and weekly risk management meetings, are the nursing staff, rehabilitation staff, dietitians, social workers, recreation staff, and residents and families (when appropriate). Their collective responsibilities are to evaluate the resident’s plan of care for falls prevention or revise the plan of care if a fall does occur.

By using FMEA, we were able to dissect and analyze each area of failure, rate each area for the likelihood that a failure would occur, and determine, if it occurred, how severe the effects would be for the resident. After this analysis, we would then be able to prioritize the most important areas to be addressed (i.e., “risk priority number,” table 1).

We should note that this approach was the culmination of years of development. During the concept’s early years-the late 1990s-residents who had experienced multiple falls were reviewed at a weekly team meeting aimed at preventing recurrences. We went on to bring residents having experienced one fall to the meeting. As of June 2003, we began to review all new admissions that had been identified as high-risk and to invite them to the meeting to develop and individualize their plans of care and create proactive plans to protect them from falls. Meanwhile, the team has expanded to include input from Housekeeping and Engineering, both of which have contributed helpful information about our residents.

• Was the resident identified as high-risk prior to the fall?
• Was resident/family education provided pre-/postfall?
• Was the fall related to noncompliant behavior and, if so, was this appropriately addressed by the comprehensive Care Plan Team?
• Did recent lab results show any abnormalities that could have been contributory?
• Did any medications contribute to the fall?
• Did evidence suggest a vision problem that could have contributed to the fall?
• Did a gain/loss of weight precede the fall?
• Did related medical conditions contribute to the fall?
• Was the fall related to improper use of a device, a gait/balance problem, or repositioning difficulty?
• Was the resident independent in ambulation at the time of the fall or on a restorative rehab program?
• Could the fall have been prevented?

Audit findings that led us to implement changes in our process starting in 2002 and continuing through 2003 included:

1. an evident correlation between medical problems and falls (i.e., abnormal labs, weight loss, and gait imbalance). We therefore in-serviced staff to be alert to these factors. Our physicians, too, have focused on the various clinical factors contributing to falls. The resulting staff awareness has heightened our ability to implement safety measures and preventive interventions, thus decreasing and preventing occurrences from taking place.

2. decreased vision as a contributing factor. This has led to the use of magnifiers, filters, and various types of supportive lighting.

3. falls involving residents who were deemed independent by a physical therapy assessment that did not identify the residents at a risk for falls. Therefore, an assessment focused on screening ambulatory residents for risk factors was initiated in June 2003. This additional information has heightened caregiver awareness of ambulatory residents’ risk for falls.

4. attempts by some subacute residents to perform independent ambulation and transfer prematurely. Noting this trend and behavioral pattern, our rehabilitation department placed a heightened focus on resident education and continual reminders not to attempt mobility without staff assistance until they were cleared to do so.

5. safety issues with residents who were considered to be relatively independent but nevertheless frail or experiencing mild cognitive issues. These were addressed at resident council in a special program presented by the Rehabilitation Director.

6. evidence that for many dementia residents, education is not an option. To deal with this, we concentrated on using staff-alert devices, making safety-sensitive environmental modifications, and developing recreational and diversional activities to be provided by the interdisciplinary team.

7. wheelchair positioning assessments needed to become a component of the initial occupational therapy assessment of all admissions, and continued regularly depending on resident need.

Results of audit findings based on our “potential failure modes” were compiled and analyzed quarterly, and comparisons were made quarter to quarter. Comparisons between 2002 and 2003 were made of the total number of falls from month to month, quarter to quarter, and year to year. In addition, comparisons of the number of resident falls per patient care days were done for the same period. The results of these studies are discussed under “Program Outcomes.”

Program Directors
Maxine Hall, RN (Manor Building)
Judy Henrys, RN (SNF Building)
Candace Spencer, RN (Subacute Units)
Vivienne Bartley, RN (Pavilion Building)
Juliette Clifford, RN (Evening Program Director)

Team Leaders
Rohinie Hereman, RN
Una Smith, RN
Mercena Mattis, RN
Therese Sigauke, RN
Kira Slipak, RN
Chandroutle Brijlall, RN

Team Liaisons
Lisa Boucher, PA; Lou Kaplan, PA; Pat Spatola (Chief Clinical Dietitian); Kathy Shea (Assistant Director of Social Services); Lillian Rodriguez (Director of Therapeutic Recreation); Carolyn Perito (Assistant Director of Therapeutic Recreation); Lorraine Bernardone (Director of Health Information); Jessica Gangi (Assistant Director of Social Services); Helaine Blye (Director of Speech and Language)

Staff Development
Wavenine Collymore, RN, and Hilma Moore, Staff Development Coordinators

Note: A successful program would not be possible without all staff from Dietary, Social Services, Rehabilitation, Nursing, Medical, Resident Assessment, Security, Case Management, Performance Improvement, Staff Development, Engineering, Housekeeping, and Admissions, who are involved with our residents and families on a daily basis.

We extend special thanks to Morris Tenenbaum, CEO, and Alexander Stern, Administrator, whose support and encouragement are invaluable in every project we undertake.