Transcript Survey Survival

Can This Fall
Be
Prevented?
Demi Haffenreffer, RN, MBA
Email: [email protected]
OUTLINE
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Risk Factors
Creating a Culture of Safety
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When an accident happens
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Components of a good fall management program
Requirements and Common Citations
Assessment and Care Planning
Resident Centered Care
What constitutes a fall?
Conducting thorough investigations & assessments
Implementing measures & updating the care plan
Quality Improvement
RISK FACTORS
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Anticipated vs. Unanticipated risk factors
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Unanticipated risk factors
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Anticipated risk factors are those factors we should
address before the resident falls
Measures are implemented after an unanticipated risk
factor becomes known
Seizures, resident to resident behaviors, arrhythmias, CVA,
TIA, a pure accident
Anticipated risk factors
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Fall History
Confused or possible lethargy related to med
Unsteady gait or weak transfer
Syncope or orthostatic hypotension
Other Internal or external risk factors
RISK FACTORS
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Anticipated Internal Risk factors:
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Cardiovascular
Neuromuscular/functional
Orthopedic
Perceptual/Sensory
Overall poor health
Psychiatric or cognitive
RISK FACTORS
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Anticipated External Risk Factors:
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Medications
Appliances or devices
Environmental Equipment issues
Environment overall or situational hazards
Poor assessment and care planning
Poor communication
Lack of staff knowledge
Components of a good Fall Prevention
Program
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Goal Driven
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Prevent avoidable accidents
Prevent repeat falls
Prevent major injuries
Provide quality person-centered care
Prevent citations
Prevent legal actions
Good communication systems
Satisfied customers – residents and employees
Components
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System is consistent
Become a learning organization and
acknowledge high risk and error prone nature
of the work we do & the people we work with
Good, consistent investigation/assessment
procedures when a resident falls
Simple documentation system
Blame free error reporting system but
individuals accept responsibility
Components
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Assessments of risks on admission, quarterly &
with condition changes
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Many prevention strategies (including equipment)
available to staff – including restraints as a last
resort (however the program is based on a restraint
free environment)
Education & orientation
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Multidisciplinary
Continuous Quality Improvement activities to identify
problem/strength areas and improve
Common citations
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Investigation/assessment
not thorough and does
not identify all risk factors.
Investigation/assessment
not timely – resulting in
another incident/fall
before interventions put in
place.
Investigation/assessment
and interventions not
based on facts or
incident.
Citations continued:
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Interventions not followed.
Lack of supervision
No investigation/assessment of accident
occurred – no new preventive plan.
Assessment and Care Planning
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Upon Admission:
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Preliminary assessment with immediate measures
discussed with the resident & implemented
Orientation of the room with an observation of how the
resident interacts with the environment
Increased supervision/observation during the first few
days/evenings/nights
Obtain a general history of past falls – establish trends
Develop an initial care plan
Assessment and Care Planning
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A comprehensive assessment within 14 days
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Assess and proactively implement person and
environmentally centered measures to prevent accidents
Person-centered care plan approaches
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What does the resident want?
Person-centered care
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Begins with the investigation
Resident involved &
informed of data collected,
options, risks and benefits of
each option
Resident decision
Documentation of
assessment/cause &
resident choices
Care planning
Reevaluation & cp updates
What Constitutes a Fall?
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Alleged fall, unwitnessed
Fall
Lowering to the floor
Preventing a fall
Rolling off a low mattress
When to complete an investigation /
assessment?
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Alleged fall, unwitnessed
Fall
Resident found in a
dangerous or risky situation:
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Climbing out of bed
Other
Culture of Safety
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Old Approach
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Resident falls
Minimal investigation
w/ much paperwork
Incident report
Implement an
intervention
24-hour report
Move on
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New Perspective
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Resident falls
Investigative process is
thorough & consistent
w/ as little paper as
possible
Incident report &
stepped investigative
process
24-hour report
Evaluation of
interventions / CQI
Conducting thorough investigations
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Initial step – often
performed by Charge
Nurse
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Immediate protection of
resident as indicated
Begin data collection per
guidelines
Examine area and
equipment
Conduct staff interviews
Determine if care plan was
followed as written
Gather first impressions
Implement initial action &
communicate
Conducting an investigation continued:
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Second step – often completed by the RN Care
Manager
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Clinical assessment of possible causes
 Medications
 Medical
 Cognitive or sensory
 Environment
 Psychosocial
 Physical functioning
Conducting an investigation continued:
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Third step - Ongoing data gathering by RN Care
Manager and/or a department head
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Incident trending based on prior incident information
or log
 Has this happened before?
 Similarities/differences?
 What was implemented in the past?
 Initial identification of root cause
 Staff assignments
 Other more complex environmental issues
Conducting an investigation.
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Fourth Step - Analyze data
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What is the data telling you?
 Report suspected abuse/neglect
How can this be prevented from happening again?
Utilize CAA guidelines to assist with assessment and
investigation.
Use Interdisciplinary team
Summarize findings
Communicate
Conducting an investigation continued:
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Fifth step – CQI and the 5 Why’s
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Analyze all incidents monthly in order to identify
trends and implement action plans (education,
policy changes, etc.) for the safety of the entire
facility and facility population (residents, staff &
families)
Trending and Root Cause Analysis
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Possible system issues:
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Physician orders not followed
Care plan not followed
Failure to assess risk and care plan
Standards of practice not followed
Resident preference not honored
Illness, diagnosis related
Trending and Root Cause Analysis
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System issues continued:
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Staff orientation
Staff on break
Staff training
Equipment mal-function
Environment/maintenance/housekeeping hazard
Trending and Root Cause Analysis
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Action plans for root cause(s) trends
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Staff education
Staff counseling
Resident education
Family education
Change in system e.g. orientation program
Environmental changes
QA surveillance change
Process improvement team
What to
Falls
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for?
What was resident doing?
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Rising?
Sitting?
In bed or out of bed?
During assisted transfer?
To chair or from chair?
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Indicate type of chair
Brakes on w/c/bed
Chair too low
Foot rests appropriate
Self ambulating?
What to
Falls continued:
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What was resident doing?
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Reaching
Assisted ambulation
Sliding/leaning forward out of chair
Location & time of fall?
Side rails?
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for?
Up, down, per care plan?
Malfunctioned
Time since last voided/toileted?
Call light within reach? Call light on?
Time since last meal?
What to
Falls continued:
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for?
Environment/equipment a factor?
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Failed or misused adaptive device?
Device out of reach?
Faulty equipment?
Furniture?
Clutter?
Lighting/glare?
Water on floor?
Uneven floor or if outside uneven pavement?
What to
Falls continued:
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for?
Mobility alarm on? Functioning? Removed by
resident?
Type of footwear?
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Non-skid shoes
Slippers
Socks only
Shoes
Barefoot
What to
Falls continued:
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for?
Care Plan followed as written?
Assigned staff on break?
Staff in orientation?
Medical factors e.g. Parkinson’s
Vital signs – BP lying and sitting
Diabetic? Check blood sugar
What to
Falls continued:
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Medications
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for?
Any new medications?
Meds in last two hours?
Psychoactive
Hypertension
Sedative/hypnotic
Narcotic
If unknown origin
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Interview all staff and visitors going backwards in time to
determine possible time frame for event
What to
Falls continued:
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Physical functioning
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Gait
Upper torso weakness
Vision/sensory – glasses/hearing aide on?
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for?
Need for contrasting colors?
Pain?
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Sitting too long?
Seating Assessment done?
Tired?
Falls Investigation Guides
Overview Guide
Environmental Guide
Falls investigation Guides
Medication Guide
Communication Guide
Case Example # 1
Background: A woman fell at home after getting caught in her small dog’s leash resulting in a fractured right
hip. Following a surgical Open Reduction Internal Fixation (ORIF, hip pinning), she was admitted for skilled
rehabilitative services secondary to the ground level fall. She is alert and oriented and has not experienced any
memory loss.
In the skilled rehab facility, the resident had a fall at bedside
after attempting to self transfer from bed while attempting to go
to the bathroom due to urinary urgency. The resident was found
with a skin tear to her left hand and abrasion to her left knee.
The resident was immediately evaluated/assessed for injury,
treatment needs and to assure comfort and safety.
Resident Falls
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Begin Falls Investigation Guide
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The resident was witnessed resting in her bed at 1030.
The staff heard her call out at 1115.
The fall was not witnessed by staff.
The aide who found the resident stated that she was on her
left knee, that her left hand was bleeding, and that her right
leg was extended straight and in alignment with her body.
The resident does not complain of any increase in right hip
pain and her recent surgical incision is intact to her right
hip. Does state she has pain to her left knee, which was
found to have an abrasion, and her left hand, where a 3 cm
skin tear was found and was bleeding.
The resident does not use side rails.
The resident’s wheel chair was beside her bed but tipped
forward.
The resident stated that she went to sit in her wheel chair
because she became dizzy on standing. Her wheel chair
was tipped forward behind her and the brakes were not
locked.
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st
Gather 1 impressions
Indentify Possible Causes
Use Environment and
Equipment Investigation Guide
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Review factors related to
environment and
equipment
Use the Medication
Investigation Guide
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Resident has a history of Congestive Heart Failure and is
on diuretic therapy.
She has Hypertension and is on two different antihypertensive medications.
She is also on Coumadin as a preventative post surgery
measure.
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The physician was notified and a treatment to left hand skin tear
was ordered as well as an x-ray to her left knee and her right
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Review factors related to
medication use
Use Communication Guide
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Ensure necessary
communication of
information (i.e., to
staff/management, family,
physician, etc.)
Figure 3: RCA/Causal Tree Diagram
Some Interventions
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Non-slip surfaces
Lights are automatic
Raised toilet seats
Half rails- arc rails – transfer poles
Lower beds – Hi/low beds better
Automatic bed controls
Trapezes – merry walkers, etc
Some Interventions
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Bedside commodes
Easy to use call lights
Infant monitors
Pressure pads
Non-slip socks/shoes
Night lights
Assistive devices/Equipment close by
Increased supervision during time likely to fall
Some Interventions
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Toilet schedules
Let them sleep
Familiarity
Concave mattresses or bolsters
Eliminate clutter
Drug reductions
Locks on movable equipment that work
Assess them for pain & treat
Some Interventions
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Benches so residents can rest
Level surfaces
Chair cushions and other non-slip
surfaces/wedges
Move them closer
Keep things in reach on their dominant side
Eliminate the shine
Some Interventions
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Activities
Physician consults (including psych;
audiology, visual & medical)
Hip protectors, helmets, knee and elbow
protectors
Therapy or restorative care
Restraints & alarms - consideration as a last
resort
MAY ALL YOUR SURVEYS
BE SUCCESSFUL & ALL
YOUR RESIDENTS & STAFF
WELL CARED FOR!