Everyone s FALLing for it! TEAM Fall Prevention and Response

Everyone s FALLing for it! TEAM Fall Prevention and Response

Team Approach Objectives Proactive prevention Root cause Consider all factors

Should I Be Concerned? Falls are the number one cause of facilityincurred injuries facing nursing homes today. Injuries caused from falls increase the care required Strain on facility and family relationships

Quick Facts Falls are the greatest medical malpractice exposure 40% of all nursing home residents fall each year, many more than once 70% of residents die from complications within a year of breaking a hip Greatest risk of falling is during first week of admission

What CMS says: Intercepted fall is still a fall. Fall without injury is still a fall. Distance to next lower surface is not a factor.

Real Life Arkansas May 2000: A resident with Alzheimer s Disease fell twice within 5 days of admission. First fall resulted is bruises. Second fall resulted in a nonpermanent head injury. A 164,000 settlement was reached between family and facility.

What now? Create a sense of urgency Involve all of the staff Identify a Fall Management Team Assign a Process Owner (Project Champion)

Fall Management Team Who should participate? Administrator DON/ ADON /Resident Care Nurse/CNA Medical Director Therapy Maintenance/Housekeeping Dietary MDS Coordinator Social/Activity Director Resident/Family/Friends

Fall Prevention: It Begins upon Admission Discuss with Resident, Family & Friends Fall Management Program addresses- Concerns regarding falls What we identify as a fall What steps you will take to prevent a fall What steps you will take post fall Ask them for their help Past history of falls How to properly transfer and use assistive devices Tell us when they are leaving after their visit

Process Owner Assign a process owner: Does not have to be a Nurse Must believe in process Be the Project Champion Take the lead to ensure completion of process

CNA Fall Management Made aware of Falls that occur during other shifts Do you have a Fall Book? In-service on the new interventions Review audit checklist for devices Alarms Restraints Enablers Positioning devices

CNA Fall Prevention Understand individualized interventions to prevent falls Good History from Resident/ Family/ Friends Get to know your Residents What other factors make increase the risk? Medications

CNA Fall Prevention How do we prevent a fall? Risk assessments Internal Factors Diagnosis Medications Sensory or perceptual problems Pain Blood pressure Fear of falling

CNA Fall Prevention How do we prevent a fall? Transfers to and from bed or chairs Ambulates Uses the bathroom handrails Uses assistive devices Answering the call light Making rounds Looking for hazards Being focused and committed to prevention

What is Root Cause Analysis? RCA is a process to find out what happened, why it happened, and to determine what can be done to prevent it from happening again. Root cause analysis (RCA) transforms an old culture that reacts to problems, into a new culture that solves problems before they escalate.

What might be the root cause for her incontinence?

What might be the root cause of his Fall?

What might be the root cause of her Fall?

AVIOD TUNNEL VISION At the time the accident occurred, people usually behave seeing only one way to perform. They didn t see all the other things they could have done or the outcomes from what they would do. In reconstructing the event, we most often view the event from outside of their tunnel vision. We now have hindsight knowledge. We look at the event seeing all the options the person should have done.

Responding to a Fall Know the appropriate response to a fall Fall training as part of new hire orientation A written copy of plan should be keep in an assessable location for all staff. Take part in Fall Huddles Everyone in area around the Fall meets Discuss fall and possible causes of the fall Reviews 10 questions

When you see a resident who has fallen, do the following: Check, Call, Care

Check, Call, Care 1. Immediately go to the resident, stay with the resident 2. If you are not a nurse, call for a nurse 3. Encourage the resident not to move, Are you OK? 4. Ask them, What were you doing just before you fell? What were you trying to do just before you fell? 5. Begin getting answers to the 10 Questions 6. Stay for the fall huddle, assist in getting a fall huddle started

10 Questions 1. Ask Resident: Are you ok? 2. Ask Resident: What were you trying to do? 3. Ask Resident or determine: What was different this time?

10 Questions 4. Position of Resident? A. Did they fall near a bed, toilet, or chair? How far away? B. On their back, front, L side, or R side? C. Position of their arms & legs?

10 Questions 5. What was the surrounding area like? A. Noisy? Busy? Cluttered? B. If in bathroom, contents of toilet? C. Poor lighting- Visibility? D. Position of furniture & equipment? Bed height correct?

10 Questions 6. What was the floor like? A. Wet floor? Urine on floor? Uneven floor? Shiny floor? B. Carpet or tile?

10 Questions 7. What was the resident s apparel? Shoes, socks (non-skid?), slippers, bare feet? Poorly fitting clothes

10 Questions 8. Was the resident using an assistive device A. Walker, cane, Wheelchair, Merry Walker, other devices

10 Questions 9. Did the Resident have glasses and/or hearing aides on?

10 Questions 10. Who was in the area when the resident fell? Fall Huddle should review all of these questions to help assess what happened, and why did the resident fall.

Fall Huddle Performed immediately after resident is stabilized Charge nurse has all staff, working in the area of the fall, meet together to determine RCA Review 10 Questions with staff

Talk about: Fall Huddle Who has seen or has had contact with this resident within the last few hours? What was the resident doing? How did they appear? How did they behave?

Evidence & Clues What was the resident doing or trying to do just before they fell? Ask them All residents, all the time Place of fall: At bedside, 5 feet away, > 15 feet Orthostatic, Balance/gait, Strength/endurance In bathroom/at commode: contents of toilet Urine or feces in toilet/commode? Urine on floor?

Internal Evidence & Clues Medications Side effects, adverse drug reactions, Black Box Warnings Cascading medications Wandering vs. Pacing Wandering: without a goal, usually provides comfort Pacing: a need not met, rhythmic or repetitive Grabbing vs. Pushing Grabbing: due to dizziness to stop from spinning don t move, hold on to resident. Pushing: to get away from being startled/attacked slowly back away from resident. Cognitive Abilities & Mood Status

External Evidence or Clues Noise levels (staff, alarms, tv) Busy activity Bed height incorrect Clutter, mats on floor Visual conditions contrast, illumination Personal items not seen or within reach Assistive devices not seen or within reach Incorrect footwear

Systemic Evidence & Clues Time of day Shift change Break times Day of week Location of fall Type of fall (transfer, walking, reaching) Staff times, staff assignments, # of staff Routines of services

Hourly Rounding or the Four Ps Position: Does the resident look comfortable? Ask the resident, Would you like to move or be repositioned? Ask the resident, Are you where you want to be? Report to the nurse. Personal (Potty) Needs: Ask the resident, Do you need to use the bathroom? Ask if they d like help to the toilet or commode. Report to the nurse.

Hourly Rounding or the Four Ps Pain: Does the resident appear in to be uncomfortable or in pain? Ask the resident, Are uncomfortable, ache or in pain? Ask them what you can do to make them comfortable. Report to the nurse. Placement: Is the bed at the correct height? Is the phone, call light, remote, walker, trash can, water, urinal, tissues, all near the resident? Place them all within easy reach.

Contrast the Environment

Our residents vision.. Cataracts Normal Vision

Macular Degeneration

Glaucoma

Fall Causes: What we learned Intrinsic poor balance, medications Extrinsic noise (staff, alarms, TV), Systemic Home routines

Transfers Help I need somebody

Confessions of a C.N.A. Need help re: resident transfer policies and possible resident and CNA consequences I am a very experienced CNA, so I should have known better as to how I handled what I am about to tell you about. I'm asking for advice, but at the same time, I'll share some good advice.

And then.i started thinking about policy Experienced CNA's know how it is. For example, I work evening shift and have 12 residents to put to bed between the end of dinnertime and 10:00 pm. 3 of those require hoyer lifts, 2 require a sit to stand machine, and 1 is a 2 person transfer. In addition, my partner has her 12 residents with a similar mix. I think most facilities require 2 people to do a hoyer transfer, many require 2 for a sit to stand (but mine doesn't), and they require 2 people for a 2 person transfer. Plus gait belts and proper transfer procedures must be used.

Help I need somebody not just any body.i need somebody now.. Others in my facility will do a hoyer transfer by themselves, fortunately they do it very safely. Realistically, we feel we don't have time for all that, and perhaps it is true. So we do a hoyer transfer or a 2 person transfer by ourselves. But...

Here is my situation. One day, a particular female hoyer transfer had a large bruise on her leg. I was glad to have been assisted by another person to do the hoyer transfer the evening before. That way I had a witness with me that could vouch that we had performed a safe transfer.

Thinking about our resident This resident is not mobile at all. So any bruises would have to come from consequences of our care, right? or any possible medication conditions, maybe and bruises can be caused by a medical condition. That is also true. what do I know about my resident?

What.oh noo.. Then the other day, another resident had a large bruise on her left side and on her breast. When I put this resident to bed that evening, she did not have this bruise

Trying to remember... I recall this clearly. She is a 2 person transfer, but not bearing weight very well. It was busy, so I did not get help. The transfer went OK, but could have been better, I don't recall anything that could have caused such a bruise.

I'm extremely careful to do a safe transfer in all cases, if I'm not sure that I can, I'll get help. I'm extra careful with a gait belt (admittedly, if I use one) Due to my years of lifting, my arms are strong enough and safe transfers are second nature to me.

and I do anything I can to avoid pressure under the arms and around that area, including providing back support and support under the bottom, as needed according to the condition of the resident.

But the next afternoon I came to work, and I found out the resident did have this bruise.

I know some CNA's complain about this or otherwise don't quite understand, but nursing staff and administration do have to investigate all bruises, for reasons related to state and federal law, particularly to rule out abuse and neglect.

So I truthfully told the nurse on the floor and the nursing supervisor what happened, that is, I performed a 2 person transfer by myself and that nothing out of the ordinary happened and that it was very safe.

The nurse on the floor thought it was caused by a gait belt. This couldn't be, I would not put a gait belt near the breast. When used, it is only for a back up for my transfers, this resident is also very immobile, no way will I allow a gait belt to slide up in such a case. A CNA and this nurse and I also speculated with each other that it was an under the arms transfer that did this.

In my case, I was told by the nursing supervisor that a write up would be coming and next time would be termination, I see this as somewhat fair, the only reason I say somewhat is that one, many were transferring this resident by themselves, and two, I've only been a few months at this facility, and consequences have not been clearly communicated, I did not know the consequence until this write up situation. The nursing supervisor did express that she did not think I did this deliberately.

Also, the resident was immediately changed to a hoyer transfer.

That is my story, what is your input on this? I've never been written up in my 20 years as a CNA, so I'm not sure what to expect. I do know the facility is required to take action, could be reorientation to safe transfers, or disciplinary action or termination. I can accept the write up, as from now on, I will do transfers according to care plan.

If they all don't care what time they go to bed, couldn't you and the other aide just take a half hour or so and just transfer all of those hoyers/two persons? Then you can each go your own way and start getting them ready in their beds? Then move on to your other residents? I mean it sounds like the 2 persons are pretty compromised so they'd probably benefit from being in bed a little earlier. At least then they'd be comfortable while they are waiting.

Resources Fall Prevention and Elimination; Evidence Based Resources, Reports of Practice, Articles: Empira, 2013 Sound, Noise and Alarm Reduction: 1. Nursing Home Alarm Elimination Program: It s Possible to Reduce Falls by Eliminating Resident Alarms. MASSPRO, Quality Improvement Organization for Massachusetts, Nursing Home Initiative: 2006. Website publication: http://www.masspro.org/education.php Strategic Approaches to Improving the Care Delivery Process, Falls and Fall Risk. Dr. Steven Levenson, MN Joint Coalition Statewide Training. May 2010.

Questions? Arkansas Innovative Performance Program (AIPP) 1020 W 4th Street, Suite 430 Little Rock, AR 72201 877-375-5700 (Fax) 501-375-5926 aipp@afmc.org aipp.afmc.org arkansasculturechange.com nhqualitycampaign.org THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT.