Getting a grip on falls prevention
By 1999, the falls rate at Daughters of Israel, a 303-bed long-term care and rehabilitation facility in West Orange, NJ, reached an all-time high, and having the second oldest resident population in the state of New Jersey, as well as a significant resident population suffering from dementia, did not help. I'd like to share a "Falls Reduction Program" we at Daughters of Israel created and implemented, and for which we were presented with an Evercare Quality Improvement Award at the 2008 AMDA Symposium. Many of these ideas can be modeled by other senior care facilities in an effort to improve safety and enhance quality of life.
The first step in our program was to set a goal of reducing falls by 10% annually. We developed a computerized tracking system for incident reports using Microsoft Excel, which enabled us to gather very specific information to help determine the factors causing the fall e.g., resident unit, time, location, use of restraining devices, ambulatory status, resulting injuries, shift, staff involved, etc. The system was expanded over the years as we found new aspects of individual falls to analyze and as we learned to track relationships with recurrent falling, psychosocial issues and environmental factors, among other problems.
Over the next four years, we developed our falls reduction program. This program was interdisciplinary and involved all staff at the facility. We developed fall-related assessment tools, staff education, policies and procedures. We also confirmed that environmental factors could exacerbate falls. For instance, an overly cluttered or busy room, heavily patterned floor covering, glare from the sun onto a very shiny floor, floor covering that went from light to very dark (creating the appearance of a hole for the demented resident) all could contribute to a fall. We learned that these areas could be changed or modified to help in the reduction process. Many cognitive factors also caused falls, including aimless wandering, trying to meet an unmet need, boredom, a visual-spatial disorientation and the inability to recognize objects such as a chair. Ultimately, we learned that this fall "demon" we faced was a multifaceted problem requiring a multi-pronged "attack."
Searching for clues
In order to improve resident quality of life, decrease falls and increase safety, our staff had to become detectives. We looked at and considered all related factors as clues to why a fall may have occurred. Every time a resident fell, we had to go back to the care plan and adjust our interventions based upon the most current fall.
Furthermore, we developed a weighted falls assessment. This assessment tool was used on all residents, and required staff to care-plan on any resident that scored a specific or higher number. These residents were considered at risk for falls even if they had not fallen yet.
Data on the patterning of falls became helpful in care planning and intervention development. We considered how we could lessen the severity of injury and manage the risk of potential injury.
We created our falls tracking system from our falls database. We manipulated the data we collected in order to evaluate fall incidents in many different ways. These reports were reviewed at our weekly quality improvement (CQI) meetings where we determined which resident charts and care plans should be reviewed based upon the data. Each month as an incentive, we awarded a pizza party to the unit that had achieved the lowest fall rate.
Education in care planning and addressing falls was fundamental to the success of our program. All of our nurses and staff that had care plan responsibilities received ongoing education in care planning for falls reduction and safety. Staff was also educated on appropriate use of restraining devices and how to shift from the concept of a restraint-free environment.
Our next step was the development of a falls care plan book and our staff was educated on how to apply the contents. The falls care plan book detailed how to write a care plan specific to falls, including the problem statement, the goals and the interventions. The book also contained a full listing of falls interventions. The lists were organized by the reasons for a fall.
The utilization of falls patterning methodology has provided us with the best insight into individual resident falls. We look for time of day, environmental factors, and examine what was the resident doing at the time of the fall. We look at whether or not there is a cluster pattern to the falls. We list the time and location of each fall and what the resident was doing at that time to help develop a pattern to the falls. This shows us if the falls are occurring mostly at the same time, the same place or when the resident is doing the same thing.
The care plan is extremely important to our falls reduction process. Staff is taught to make realistic choices for each resident based upon their individual falls history. Staff looks at whether the resident can be made safer while still ambulating at will and independently. Most importantly, staff has been taught that if an intervention isn't working it needs to be either modified or removed.
As we have journeyed through this falls reduction process, we have learned that the best way to serve our population in relation to falls is to minimize "staff fall failures." To accomplish this, staff must be properly educated on falls, have the proper tools and time to do their job. They must understand the importance of educating families as to why falls occur and have the skills to talk to families when reporting the facts after a fall has occurred. They must be trained to devise and implement the appropriate follow-up and care plan changes after a fall and most importantly to document it all accurately and in a timely fashion. "If you didn't document it, it didn't happen" is a favorite phrase in training our staff.
Our falls tracking data is now reported monthly instead of weekly since we have added so many other audits to the program. We audit our falls care plans quarterly, which includes comparing the actual incident reports against the fall care plans. Residents for these audits are chosen from multiple data sources including Quality Indicators, daily falls reports, and from falls tracking reports. Through our data analysis, we have also found that the number of falls that each resident may experience has lessened. Our data proves that our ability to stop falls quicker has increased.
When our data showed such dramatic improvement, we asked ourselves, "How did we accomplish this?" After much self-examination, the conclusion we reached was that we had created an interdisciplinary approach in which all levels of staff were intensively invested. No one intervention, one idea, one approach or one discipline made the difference by itself. The core of this interdisciplinary approach was, and continues to be, the data analysis and understanding why the individual falls have occurred. Without this, our program would have been directionless.
A group effort
As we move forward, we plan to further develop our education of families at the time of admission and then ongoing during the resident's stay with us as to why falls occur in the elderly and how the facility will respond to the fall. We are also creating interdisciplinary staff training on educating families regarding the regulations that govern restraints in long-term care facilities.
Working on the reduction of falls is a never-ending process. Our population changes constantly, dementing illnesses progress quickly, and although our facility staff is extremely stable compared to similar facilities, staff does change periodically. These issues factor into our ongoing falls reduction program and require that training be ongoing and constant. Most important is that everyone on our staff is involved in the falls reduction program and knows that falls reduction is a priority for our facility. Although we may never completely stop resident falls, we certainly can minimize the number of falls that occur and try to develop and maintain more effective safety infrastructures as we move forward.
Susan Harris is assistant executive director of Daughters of Israel, a 303-bed long-term care and rehabilitation facility, in West Orange, NJ.