Preventing Resident Falls

Transcription

1 2017 NCALA Symposium People, Purpose and Passion Winston-Salem, NC October 11, 2017 Preventing Resident Falls Sue Ann Guildermann RN, BA, MA Director of Education, Empira, Inc.

2 Objectives 1. Apply Root Cause Analysis for identification of fall causations 2. Utilize fall prevention and management tools in nursing homes

3 Causation Process & Triage 1. Immediate and urgent actions need to be taken now What will keep them safe for the immediate future? 2. Long term and sustained actions need to be continued What will prevent this from happening indefinitely? 3. Identified causes 4. Match all interventions and solutions to identified causes

4 Empira Fall Prevention & Reduction Program is based on conducting an investigation and analysis into the root causes of each individual fall as well as identifying overall trends and patterns from all falls.

5 Empira s Fall Prevention Program This program is a combination of nationally recognized fall prevention, evidence-based, scientific research studies and the application of cutting edge practices to enhance residents lives. Empira is challenging some of the standards of practice, operational procedures and regulatory requirements for preventing falls and for providing cares and services in skilled nursing facilities.

6 Fall Prevention Resource VA s National Center for Patient Safety Falls Toolkit: Fall prevention is an important and timely issue. As of March 2015, falls represented the number one category of root cause analyses submitted to the NCPS Patient Safety Information System, an internal, confidential, non-punitive reporting system. Post Fall Huddles guide Beveled Floor Mats guide

7 Background & Process Empira awarded 3-year MN DHS PIPP grant, began 10/1/08 ~ A project implementing best practices from evidence based studies ~ Goal: Reduce QI/QMs; Falls, Depression & Anxiety, Decline in LL ADL, Decline in movement 16 SNFs, 4 companies participate Fall Prevent project Fall Risk Coordinator in each SNF reports to administrator who oversees the program it s not a nursing program! Project funding completion date: 10/1/11

8 Results after 2½ years Prevalence of Falls (number of residents who have fallen) decreased by 31% (QI 1.2) Incidence of Depression decreased 20% (QI 2.1) Incidence Worsened ADLs decreased 17% (QI 9.1) Incidence Worsened Room Move decreased 12% (QI 9.3) Falls per 1000 resident days (number of falls that occurred) decreased by 14% Recurrent Falls double digits to single digit * Compared to a baseline from July 1, 2006 to June 30, 2007

9 Two Tiered Approach Proactive (pre fall prevention) Speculate on specific risk factors for falls Actions based on assessment of conditions specific to individual resident Interventions based on standard predictions Reactive (post falls action) Investigate current falls that occur Collect factual evidence from the fall event Match interventions to the causation of falls

10 Root Cause Analysis 3 Categories Internal Causes Problem: infections External Causes Operational Causes

11 Fall Prevention & Management Process Step 1: Conduct Root Causes Analyses Go to Fallen Person Check, Call, Care Nursing Triage & Assess Post Fall Huddle Post Fall Scene Investigation Form Falls Log Falls Tracker Report Step 2: Determine and Prioritize Causes; Internal, External, Operational Selection Process Identify & Prioritize: Internal, External, Operational Causes Step 3: Determine Interventions, Solutions and Evaluations Interdisciplinary Team Review: Falls Committee Fall Log Falls Tracking Report Monitor, Audit & Measure Evaluate

12 Non-nursing departments responsibilities for falls prior to onset of Empira Fall Prevention Program:

13 When a resident has fallen, staff are expected to go immediately to the resident.

14 What to Do When A Resident Falls Check Immediately go to the person who has fallen Maintain Safety Begin Scene Assessment Encourage the person not to move Call If you are not a nurse call for a nurse Care Begin 10 Questions Stay for Post Fall Huddle Nurse completes Triage and Assessment

15 10 Questions at the Scene of the Fall 1. Ask resident: Are you ok? 2. Ask resident: What were you trying to do just before you fell? 3. Ask resident or determine: What was different this time? 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? 5. What was the surrounding area like? Noisy? Busy? Visibility? 1. If in or near bathroom; contents of toilet? 2. Position furniture & equipment? Bed height? Cluttered? 3. What was the floor like? Mats? Carpet? Tile? Laminate? 4. a. Wet floor? Urine on floor? Uneven floor? Shiny floor? 6. What was the resident wearing? Describe clothing & foot ware. 7. Was the resident using an assistive device? If yes, what kind? 8. Does the resident wear glasses and/or hearing aids? Were they on? 9. Who was in the area when the resident fell?

16 Nurse s Assessment of Falls 1. Scene Triage 2. Vital Signs 3. Neuro Checks 4. Input from Others 5. Labs 6. Chart Review

17 Assessing Internal Causes: Scene Triage Triage is the assignment of degrees of urgency to wounds, conditions and situations to decide the order of treatment and care. The first action is to establish that everyone is safe. Then observe for: loss of blood respirations consciousness pain Ask, What were you trying to do just before you fell? Determine what to do first and how urgent is it? Scene triage may not necessarily be limited to the above items or in this order.

18 Assessing Internal Causes: Vital Signs Vital Signs are clinical measurements that indicate the state of a person s essential body functions. Blood Pressure Pulse Respirations Temperature Pain Are the vitals signs outside baseline status? If so, did this cause the fall or is it a result from the fall?

19 Assessing Internal Causes: Neuro Checks Neuro Checks are an assessment of the brain, spinal cord and other nerve functions. The assessment includes but is not limited to the following: Level of consciousness, awareness and responsiveness Orientation Appearance and general behavior Sensation Mood, content of thought Eye function Muscle strength, tone, reflexes Coordination and gait Did a neurological injury result from the fall? OR Did a neurological condition cause the fall?

20 Assessing Internal Causes: Labs Lab tests are performed to check the health of a person and/or to diagnose, treat of prevent the onset of conditions or diseases. Blood Urine Sputum Other substances Are there any clues post fall that indicate the need for a lab tests? (e.g. infection, low or high blood sugar?) Review recent labs for additional clues

21 Assessing Clinical Causes: Chart Review Reviewing the person s medical record (chart) regularly will red flag potential problems. Investigate following areas for clues, patterns, and trends: Vitals signs Medications Labs Progress notes Determine any new conditions or changes from baseline status.

22 Post Fall Huddle Performed immediately after resident is stabilized Include all persons in the area at the time of the fall and staff directly caring for the person Meet together briefly to begin determining root causes The huddle includes Review 10 Questions with staff Other investigation questions may include: Who has seen or had contact with this resident within the last few hours? What was the resident doing? How did they appear? How did they behave? Begin completing the FSI form during the huddle Goals: to identify immediate causes of fall and provide prompt interventions to keep person safe

23 Fall Scene Investigation (FSI) Report Please reference the FSI Form included in the course handouts. Data collection tool used to gather clues and evidence to investigate and determine root causes Completed soon after the fall occurs and/or during the fall huddle Completed by nurse in charge and on duty at time of the fall

24 Falls Log Record each fall on a Falls Log, which includes: FSI data Location: bedroom, bathroom, hallway, dining room Time of day and shift Day of week Staffing Identified causes Interventions and solutions Purpose of the Falls Log is to track, monitor and identify any reoccurrences, patterns and trends for evaluation

25 Fall Committee Meeting Meets regularly All appropriate departments represented Goals: to identify facility wide big picture of falls; trends, patterns, specific issues and areas of concern facility-wide, unit/household specific Have all relevant information available; FSI report, MAR, resident s chart, fall huddle findings Agenda: New falls; Review FSI report, huddle findings, review root causes Review interventions Do they match the root cause? Are they weak, intermediate, or strong interventions? Suggestions? Evaluation of previous falls solutions and interventions? Are systems and operational changes needed?

26 Falls Tracker Reports Empira developed a software tracking program specific to the Empira Fall Prevention project It is based on CMS s MDS Casper Reports system Each week the Falls Coordinator, in each of the skilled nursing facilities in our consortium, batches the FSI reports for the previous week and enters them into a protected Empira software program The information and data from these FSIs is collated, aggregated, summarized, trended and patterned Empira then sends a monthly and quarterly Falls Tracker Report (much like a Casper Report) Empira was able to identify facility specific as well as consortium wide causes of falls

27 How to Determine Root Causes of Falls Gather the clues and evidence by using these steps and tools: Go to the resident, stay with the resident Check Call Care 10 Questions Nurse Assessment Post Fall Huddle Fall Scene Investigation form (FSI) Falls Log

28 Root Cause Analysis 3 Categories Problem Internal Causes External Causes Operational Causes

29 Fall Causation by Categories Internal Unmet Needs Clinical Physical External Noise Physical Plant Equipment Clothing Footwear Operational Lack of RCA Policy and Procedures Staffing Lack of Evaluations

30 Fall Causation Categories Internal Unmet Needs Clinical Physical External Noise Physical Plant Equipment Clothing Footwear Operational Lack of RCA Policy and Procedures Staffing Lack of Evaluation

31 Internal Causes: Unmet Needs 5 P Needs: Position change Personal needs Pain relief Placement of items Proper sleep Lesson learned: If we can meet the 5 P needs, we can reduce the falls.

32 Unmet Needs: The 5 Ps Position Change: The person is bored, uncomfortable, unoccupied, restless, agitated. Personal Needs: Physical need for elimination, thirst, hunger. Pain Relief: The person is in pain, uncomfortable, aching, hurting. Physical, mental or emotional Placement of Items: Phone, call light, remote control, tissues, walker, trash can, cup, urinal, are not where they expect them to be or cannot reach them. Proper Sleep: Resident sleep at night is disturbed. Person is getting poor night sleep. Poor sleeping conditions at night.

33 Faulty Assumptions and Incorrect Root Cause to Preventing Falls: When a patient/resident moves = they fall down Prevent movement or mobility = then you prevent the fall No!

34 Internal Unmet Needs Movements + Weakness = Falls A patient/resident has needs = and their needs set them into moving = and because they are weak = they fall down Address the patient s/resident s needs = get them physically active (prevent immobility) = and you reduce their falls Yes! Not Preventing Falls Promoting Function, Sarah H. Kagan, PhD, RN & Alice Puppione MSN, RN, Geriatric Nursing, Vol. 32, No. 1, p January/February 2011.

35 Clues to Identify Unmet Need for Proper Sleep: Mood status + cognitive status + frequent napping + agitation + falls = sleep disturbance / sleep fragmentation #1

36 Internal Causes: Clinical Conditions Diagnoses Medications Vision Conditions Hydration and Nutrition Status Elimination Status Clinical conditions may not necessarily be limited to the above list.

37 Clinical Causes: Diagnoses Diagnosis Stroke Alzheimer's Disease Parkinson s Disease Post Surgical Diabetes Heart Failure Urinary Tract Infection Respiratory Infections Fall Risk Indicators Impaired movement, trouble thinking Communication challenges, trouble thinking, wandering, impulsiveness Shuffling gait, muscle tremors, imbalance, communication challenges Reduced function, pain, anesthesia, weakness Dizziness, tingling sensation or numbness in the feet and/or hands Weakness, fatigue, diuretics, shortness of breath Frequent urination, agitation, pelvic pain Weakness, shortness of breath, difficulty breathing, dizziness High Risk fall diagnoses are not limited to the list above.

38 Clinical Causes: Medications Poly-Pharmacy (more meds = more falls) Number: more than 5 medications Cascading effect Side effects Dose Timing Adverse drug reactions Black Box warning: Drug carries a significant risk of serious or even life-threatening adverse effects

39 Clinical Causes: Common Medications Water Retention Medications (Diuretics) High Blood Pressure Medications Sedatives, Hypnotics and Psychotropic Pain Medications Anti-anxiety Medications Anti-seizure Medications Antidepressant Medications Overactive Bladder Medications High risk fall medications are not limited to the list above.

40 Clinical Causes: Visual Conditions How do they see? What do they see? Let s take a moment to appreciate how a person might see with impaired vision. These are only a approximate representations. I d like to recognize the work of Jenifer Brush, Jon Sanford, and colleagues, Environmental & Communication Assessment Toolkit.

41 Clinical Causes: Hydration, Nutrition and Elimination Status Hydration Dehydration Nutrition Low intake, Low or High blood sugar Elimination Status Urine Incontinence Retention Infection Bowel Movement Loose stools Constipation Blood Fall occurred near bathroom, or commode? Check contents of toilet/commode. Urine or feces in toilet/commode? Describe urine and/or feces. Urine on floor? What would this indicate?

42 Internal Causes as a Result of External Conditions: Gravity + sedentary life style + reduced mobility = poor posture + risk for falls

43 Physical Conditions: Poor Balance, Strength, Endurance Balance is a combination of posture, ROM, strength, reaction time, visual perception, hearing, somatosensory and pain Strength is physical power, energy, sturdiness and robustness Endurance is the power to withstand wear and tear, the ability to continue

44 Physical Causes: Mobility and Ambulation Mobility/Immobility is the ability or inability to move or be moved freely and easily, which includes: Range of motion Reaching Transferring Gait Gait is a person s manner of walking/ambulating. Shuffling: feet dragging, gliding Pacing: a need not met, rhythmic or repetitive Wandering / Strolling: without a goal, may provide comfort Assistive Mobility Devices Wheelchairs, walkers, canes, prosthetics Transfer and reaching devices

45 Fall Causation Classifications Internal Unmet Needs Clinical Physical External Noise Physical Plant Clothing Footwear Operational Lack of RCA Policy and Procedures Staffing Lack of Evaluation

46 Primary external lessons learned: if we can stop the noise, then we can reduce the falls.

47 Noise: Where is it? Nurses stations, kitchens, bedrooms What s causing it? Staff, alarms, pagers, TVs When is it noisy? Shift change, meals, rounds

48 Alarms Annul Our Attention Personal pressure alarms attached on or next to the body of a person activated by movement. Alarms cause us to become reactionary rather than anticipatory care providers After you put something in the oven, microwave or clothes dryer, why do you set an alarm? Or, why do the machines have alarms that go off?

49 External: Physical Plant, Visibility Each of next set of slides represent examples of an environment with poor lighting and poor visibility These environmental conditions can contribute to and be underlying causes of falls

50 An Important Environmental Element to Prevent Falls: BUT... No contrast to background linen:

51 External: Floor Surfaces Uneven surfaces: carpet linoleum wood tile Layered surfaces: mat/rug carpet/wood Uneven doorways, thresholds Slippery floors: wet, smooth surfaced, tension surface Carpet: loose, dense, thick, surface tension

52 External: Poorly Fitted Clothing & Footwear Poorly fitted clothes can contribute to and cause falls Clothes too loose, too long, too tight Uncomfortable

53 Incorrect Footwear Poorly fitted shoes, slippers Open back shoes, slippers, flip-flops Gripper socks (cautionary use!) Crape sole shoes

54 Fall Causation Classifications Internal Unmet Needs Clinical Physical External Noise Physical Plant Equipment Clothing Footwear Operational Lack of RCA Policy and Procedures Staffing Lack of Evaluation Disclaimer: Not limited to only these causations

55 Operational: Lack of Root Cause Analysis Absence of Root Cause Analysis leads to an operation that does not identify causation of problems and therefore is unable to match interventions and solutions to the causes. Interventions and solutions can be weak and ineffective when a system does not complete causation identification. Leaders, responsible for overseeing an operation, who do not focus on root cause analyses to solve problems.

56 Operational: Policies & Procedures P & P that do not support resident preferences and their quality of life can increase the likelihood of falls: Disrupting sleep at night by staff awakening people to turn and reposition, take medications, toilet, restock rooms and supplies Not providing opportunities to eat at preferred times Poly pharmacy Toileting plans and programs that do not match resident needs and preferences Lack of engaging activities Staff times (shifts) and assignments that do not support resident needs

57 Primary operational lessons learned: If we do not align operations and systems to support resident preferences and seek to improve their quality of life, then we increase their likelihood of falling.

58 Not monitoring, auditing, measuring and evaluating How will we know if it s working?

59 Lack of Evaluation Process or operations do not include: Auditing for implementation, program progress Monitoring status Measuring objectively Evaluating effectiveness and ineffectiveness

60 Identification of Root Causes of Falls: Internal Intrinsic, Environmental Extrinsic, Operational - Systemic Internal: Needs not met, 5 Ps; pain relief, personal needs, position change, personal items, proper sleep. Medications; type, amt, dose, effects. Reduced mobility; poor balance, strength, endurance. External: Noise; Alarms, staff talking, paging, TVs. Poor environmental contrasts, lighting, visibility. Varied floor surfaces. Poor fitted clothing, footwear. Placement of furniture, bed heights, mats. Operational: No RCA. P & P do not support residents needs and preferences. Noisy/busy times of day; shift changes, meal times, activities. Days of week. Locations of falls; rooms, halls, congregate areas. Types of falls; transferring, walking, reaching. Staffing levels/assignments; cleaning, stocking, repairing.

61 Summary Fall Prevention & Management Process Step 1: Determine Root Cause Analysis Tools Check, Call, Care Nursing Triage Assessment Post Fall Huddle Fall Scene Investigation Form Step 2: Solution & Intervention Selection Tools Selection Process Interdisciplinary Team Meetings Step 3: Evaluation Tools Falls Log Interdisciplinary Team Review: Fall Huddle Falls Committee

62 Facility Name: FSI -- Fall Scene Investigation Report Resident Name: Med. Rec. # Room # Date of Fall Time of Fall: AM / PM Admit Date: Staff / Witness present at / or finding resident after fall: 1. Factors observed at time of fall: Resident lost their balance Resident slipped (give details): Lost strength/appeared to get weak Wheelchair / bed brakes unlocked Bed height not appropriate Equipment malfunction (specify): Environmental noise Environmental factors (circle or write in): clutter, furniture, item out of reach, lighting, wet floor, other (specify) FALL DESCRIPTION DETAILS: 2. Draw a picture of area and position in which resident was found. (e.g. face down, on back / R or L side, position of arms and legs, furniture /equipment /devices nearby) *If fall is within 5 feet of transfer surface do orthostatic BP 3. Fall Summary: Found on the floor (unwitnessed) Fall to the floor (witnessed) Intercepted fall (resident lowered to floor) Self-reported fall 4. Fall Location Resident room Activity Room Hallway Dining room/day room Bathroom [CHECK TOILET CONTENTS] Toilet contains urine /feces Shower/tub room Outside building on premises / off premises Other (specify) : 5. What was resident doing during or just prior to fall? Ambulating Attempting self-transfer Transfer assisted by staff Reaching for something Slide out / fall from wheelchair Rolling/sliding out of bed Sitting on shower/toilet chair Other (specify): 6. What type of assistance was resident receiving at time of fall? Assisted per care plan: Alone and unattended Assisted with more help than care plan describes

63 Facility Name: FSI -- Fall Scene Investigation Report Resident Name: Med. Rec. # Room # 7. What did the resident say they were trying to do just before they fell? CONTRIBUTING FACTORS TO HELP IDENTIFY ROOT CAUSE OF FALL: 8. Describe resident s mental status prior to fall: 9. Describe resident s psychological status prior to fall: How does this compare to the resident s usual mental status? How does this compare to the resident s usual psychological status? 10. Footwear at time of fall: Shoes Bare feet Gripper Socks Slippers Socks Off load boots Amputee 12. Did vision or hearing contribute to fall? Yes No Explain: 11. Gait Assist devices at time of fall: None Has device and was in use Has device but was not in use 13. Alarm being used at the time of the fall? Yes No If yes, was it working correctly? 14. Time last toileted or Catheter emptied: AM /PM Continence at above time: Wet Soiled Dry 16. Medications given in last 8 hours prior to fall (check all that apply): Diuretic Anti-depressants Narcotics Anti-anxiety Anti-psychotics Seizure Cardiovascular New meds/changed dose within last 30 days 15. Did fall occur? Next to transfer surface ( assess postural hypotension) 10 from transfer surface (assess balance) > 15 from transfer surface (assess strength /endurance)

64 Facility Name: FSI -- Fall Scene Investigation Report Resident Name: Med. Rec. # Room # 17. Vital Signs: Were temperature, pulse, respirations and/or O2 Sat out of normal range for this resident? Yes No 18. (Blood Sugar check is required for diabetic resident) Was resident s Blood Sugar significant? Not applicable Blood sugar within normal range for resident Blood sugar out of normal range (describe): Did orthostatic BPs suggest the BP change contributed to the fall? Lying 19. Does recent Hgb show evidence of Anemia? Yes Sitting Yes No Standing No Re-Creation of Last 3 Hours Before Fall Below, the primary Nursing Assistant who observed and /or assisted the resident during the three hours prior to the fall will write a description to re-create the life of the resident before the fall: PRINT NAME: Re-enactment of fall (to be done if Root Cause is NOT determined): Fall Huddle (What was different THIS time?) Vital signs abnormal or significant Amount of assistance in effect Alarm Assistive/protective device Footwear Environmental factors/items out of reach Environmental Noise ROOT CAUSE OF THIS FALL: Review of Contributing factors (Check all that apply): Medication Medical status/physical condition/diagnoses Toileting status Mood or mental status Vision or hearing Last 3 hours re-creation issue/s

65 Facility Name: FSI -- Fall Scene Investigation Report Resident Name: Med. Rec. # Room # What appears to be the root cause of the fall? Describe initial interventions to prevent future falls: Care Plan Updated Nurse Aide Assignment updated Printed Name: NURSE COMPLETING FORM: Date and Time: Signature: Summary of meeting: Falls Team Meeting Notes: Conclusion: Additional Care Plan / Nurse Aide Assignment Updates: Signatures with Date and Time:

66 Why are we very concerned about falls? Falls are a major health risk for our elderly population. One out of every three older Americans falls every year. Only 1/2 of all elderly people can live alone or independently after sustaining injuries from a fall. Falls are a significant source of fractures and soft tissue injury. Falls are the most common cause of severe injury in older adults. Who is at the highest risk for falling? Falls are most likely to occur in elderly persons who have: ~ Recently fallen ~ Difficulty balancing, walking or standing up straight ~ Difficulty getting in and out of a chair, car, bed or on and off of a toilet ~ Dizziness ~ Pain ~ Weak bones & muscles ~ Multiple medications ~ Vision and/or hearing loss ~ Memory loss or confusion Our goal is to provide a safe and healthy environment. Our staff has been trained to reduce the risk of falling for you and your family member. We are working to identify the causative factors of falls. The information contained within this brochure is not intended to replace seeking medical attention. This educational information is provided to you by Empira in association with your Assisted Living, Independent Living or Skilled Nursing Facility. Family & Friends: Fall Prevention How You Can Help! I look forward to meeting with you to discuss Fall Safety. Name. Here s how you can contact me: Phone

67 Fall Management Program A fall can happen to anyone at anytime. Illness, surgery, weakness, tests, medication, medical equipment, noise and new surroundings can all contribute to a fall at any age. We need your help! Would you please help us to manage and hopefully reduce falls? Here s what you can do: If your loved one fell or has a history of falling prior to admission, let us know. If your loved falls when out of the facility with you, please tell us. Learn how to properly transfer and move a resident, we will show you how to do this safely. Have them wear non-skid, low heeled, fully enclosed shoes. Instruct and help them to stand up slowly from a lying or sitting position to prevent dizziness. Encourage them to walk often, using their cane or walker, even inside of an apartment, home or in their room. Tell us when you are leaving after your visit, so we can make sure safety measures are in place. Talk with their nurse or doctor if they experience any of these side effects from medications: dizziness, unable to balance, or a change in their ability to walk. And here s what we will also do: 1. We will work with you and your loved one to identify their risks for falling. 2. We will conduct a post fall investigation and assessment to identify the possible causes of their fall. 3. Physical, Occupational and Recreational Therapies will provide programs and services to help keep them strong, oriented and active. 4. We will talk with their doctor and pharmacist to determine if any medications, medical actions, or treatments need to be changed or taken. 5. We will take action by putting interventions into place to reduce the likelihood of future falls from occurring. 6. We will provide equipment and safety devices to reduce their risks for falling.

68 Empira, 2015 Fall Prevention and Elimination; Evidence Based Resources, Reports of Practice, Professional Journal Articles, Public news reports: Root Cause Analysis: 1. Root Cause Analysis, VA National Center for Patient Safety, US Department of Veterans Affairs The Root Cause Analysis Handbook: A Simplified Approach to Identifying, Correcting, and Reporting Workplace Errors, Max Ammerman, October 2015 online in PDF 3. Root Cause Analysis Reports Help Identify Common Factors In Delayed Diagnosis And Treatment Of Outpatients. Health Affairs, Giardina, T.D., et al (2013). 32(8), A Cross-Sectional Study on the Relationship Between Utilization of Root Cause Analysis and Patient Safety at 139 Department of Veterans Affairs Medical Centers. Joint Commission Resources, Percarpio, K.B., & Watts, B.V. (2013). 39(1), Using Root Cause Analysis to Reduce Falls with Injury in the Psychiatric Unit. Hospital Psychiatry, Lee, A., Mills, P.D., & Watts, B.V. (2012). 34(3), Using Root Cause Analysis to Reduce Falls with Injury in Community Settings. Joint Commission Journal on Quality & Safety, Lee, A, Mills P.D., and Neily J. (2012). 38(8), Using aggregate root cause analysis to reduce falls and related injuries. Joint Commission Journal on Quality and Safety, Mills, P.D., et al (2005). 31(1), Using aggregate root cause analysis to improve patient safety. Joint Commission Journal on Quality and Safety, Neily, J.B., et al (2003). 29(8), The Veterans Affairs Root Cause Analysis System in Action. Joint Commission Journal on Quality Improvement, Bagian, J.P., et al. (2002). 28(10), Techniques for Root Cause Analysis, Baylor University Medical Center, Patricia M.Williams, BS, MT, ASCP. Vol. 14(2): pp April Alarm Reduction Sound, and Noise: 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: Website publication: 2. Rethinking the Use of Position Change Alarms. Quality Partners of Road Island, the Quality Support Center for the Nursing Home Quality Initiative, Positional Paper, Joanne Rader, Barbara Frank, Cathie Brady. January 12, = From Institutionalized to Individualized Care. Part 1. The detrimental use of alarms in terms of their effects on residents: 2007 CMS satellite video broadcast training; Reducing_Falls.html

69 4. Effects of a Noise Reduction Program on a Medical-Surgical Unit., Rebecca Taylor-Ford, et al., Clinical Nursing Research, Vol. 17, No. 2, May Management of Falls the Next Step... Moving Beyond Alarms and Low Beds. Molly Morand, BSN, RN, BC, Indiana State Dept. of Health, Indiana Long Term Care Leadership Conference, June 15, Presentation repeated at the AANAC Convention, Las Vegas, NV. October CMS, Guidance to Surveyors of Long Term Care Facilities, March 2009, F252 Environment, Interpretive Guidelines, (h) (1) Some good practices that serve to decrease the institutional character of the environment include the elimination of the widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for several residents for diagnostic purposes only. 7. Wisconsin Success Stories in Restraint and Alarm Reduction, Advancing Excellence Wisconsin Coalition for Person Directed Care. Web conference: June 18, (archived) 8. Staff Solutions for Noise Reduction in the Workplace. Alison Connor, RN, BSN, The Permanente Journal, Vol. 14, No. 4. Fall MI DHS, Departmental Appeals Board, Civil Remedies Division, September 30, 2009, Docket# C , Decision# CR2011. IDR findings following falls with alarm use The Impact of Alarms on Patient Falls at a VA Community Center Living. Poster session 2010 Annual Conference: Transforming Fall Management Practices, Department of Veterans Affairs. 11. Strategic Approaches to Improving the Care Delivery Process, Falls and Fall Risk. Dr. Steven Levenson, MN Joint Coalition Statewide Training. May What s That Noise? An Account of the Journey to an Alarm Free Culture, by Morgan Hinkley, Administrator, Mala Strana Health Care Ctr., Care Providers Quality First Award, June Eliminating Restraints including Alarms. Pioneer Network s Annual Convention, Indianapolis, IN. Preconference Intensive. August 9, Carmen Bowman, MSH & Theresa Laufmann, BSN and DON at Oakview Terrace Nursing Home, Freeman SD. 14. Eliminating Restraints and Alarms by Engaging the Whole Person. Action Pact Culture Change Now Teleconference, August 20, 2010, Carmen Bowman, MSH, Theresa Laufmann, BSN. 15. Evidence-Based Design Meets Evidence-Based Medicine: The Sound Sleep Study. Jo M. Solet, PhD., et al., Validating Acoustic Guidelines for Healthcare Facilities. The Center for Health Design, Research Coalition %20Facilities_Sound%20Sleep%20Study.pdf 16. Elimination of Position-Change Alarms in an Alzheimer s and Dementia Long Term Care Facility, K. Bressler, R. E. Redfern, M. Brown, American Journal of Alzheimer s Diseases and Other Dementias, 26(8) p

70 17. Elimination of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients, R. Shorr, A. M. Mion, et al. Annuals of Internal Medicine, Vol. 157, pp Integrating the MDS 3.0 Into Daily Practice: Promoting Mobility, Reducing Falls, and Eliminating Alarms Through Individualized Care, Series Two, Part Four, Pioneer Network Webinar, Joanne Rader, February 12, Leading a Fall Prevention Program Without Physical Restraints or Personal Alarms, Stratis Health, Quality Improvement Organization for Minnesota, Webinar Archives. April 17 & 24, Physical Restraints and Fall Prevention; Participants will identify effective strategies to eliminating alarms without increasing their fall rate. Healthcentric Advisors, Quality Improvement Organization for Road Island, Long Term Care Leadership Advisory Group. Providence, RI, April 24, Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial. Ronald Shoor, MD, et al., Annals of Internal Medicine, Vol. 157, No 10, pp , November alarms had no statistically or clinically significant effect on fall-related events or physical restraint use. 22. Nursing Homes in State Going 'Alarm-Free,' Liking the Results. The Day, Connecticut. Lisa Chedekel, Published March 25, Friendship Haven Pioneers Alarm Elimination, LeadingAge Iowa s Communique E- Newsletter, Vol. 9, Issue 10, May 15, The Buzz: Facilities Are Going Alarm Free. American Medical Directors Association Journal, Vol. 14, No. 8, Pp. 1 & 7, August Adverse Health Events in Minnesota, Tenth Annual Public Report, Minnesota Department of Health, Page 106. January Quality Improvement in Nursing Homes Testing An Alarm Elimination Program, Neva Crogan, PhD. Alice Dupler, JD. Journal of Nursing Care Quality, Jan-Mar 2014, 29(1): pp Alarm Fatigue: The Human-System Interface. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, Lilly M. Guardia-LaBar MS, RN, Elizabeth Ann Scruth PhD, MPH, Judy Edworthy PhD. et al. June 2014, Volume 28 Number 3, pp Nursing homes find bed, chair alarms do more harm than good, Boston Globe, Steve Maas, March 13, Best Practices for Reducing or Eliminating Alarm Use in Nursing Homes, Connecticut Culture Change Coalition, March 15, Alarms: The New Deficient Practice? Eliminating Alarms and Preventing Falls by Engaging with Life, Teresa Laufmann, RN, Carmen Bowman, MHS, Published by Action Pact, April

71 31. Nursing Homes Phasing Out Alarms to Reduce Falls. Bryna Godar, The Associated Press, July 2, &SECTION=HOME&TEMPLATE=DEFAULT Balance, Strength, Exercise, Activity: 1. Exercise Training for Rehabilitation and Secondary Prevention of Falls in Geriatric Patients with a History of Injurious Falls. K. Hauer, PhD., et al., Journal of the American Geriatric Society, Vol. 49, pp Muscle Weakness and Falls in Older Adults: A Systematic Review and Meta-Analysis. J. D. Moreland, PhD., et al., Journal of American Geriatric Society, Vol. 52, pp , Fall Incidence in Frail Older Women After Individualized Visual Feed-back Balance Training, S. Sihvonen, PhD., Gerontology, Vol. 50, pp November/December Tai Chi and Fall Reductions in Older Adults: A Randomized Controlled Trial. F. Li, PhD., et al., Journal of Gerontological and Biological Sciences, February; 60(2):187-94, Balance Training Program is Highly Effective in Improving Functional Status and Reducing the Risk of Falls in Elderly Women with Osteoporosis. MM. Madureira, PhD., et al., Osteoporosis International, Vol. 18, pp , Effective Exercise for the Prevention of Falls in Older People: A Systematic Review and Meta-Analysis. Catherine Sherrington, PhD., et al., Journal of American Geriatric Society, Vol. 56, pp , Not Preventing Falls Promoting Function, Sarah H. Kagan, RN, PhD. and Alice A. Puppione MSN, RN, Geriatric Nursing, Vol. 32, No. 1, p January/February Correct Bed Heights, Chair Heights, Sit to Stand, Movement: 1. The relative importance of strength and balance in chair rise by functionally impaired older individuals. M. Schenkman, et al., Journal of the American Geriatrics Society, 44(12), Revolutionary advances in adaptive seating systems for the elderly and persons with disabilities that assist sit-to-stand transfers. R. F. Edlich, (2003). Journal of Long-Term Effects of Medical Implants, 13(1), Influence of the relative difference in chair seat height according to different lower thigh length on floor reaction force and lower-limb strength during sit-to-stand movement. T. Yamada, et al., Journal of Physiological Anthropology & Applied Human, Science, 23(6), Association between subject functional status, seat height, and movement strategy in sitto-stand performance. C. Mazza, et al., Journal of the American Geriatrics Society, 52(10),

72 5. Bed and Toilet Height as Potential Environmental Risk Factors, Elizabeth Capezuti, et al., Clinical Nursing Research, 17(1), Equipment Issues and Fall Prevention in Residential Care, Townsend, Robin, et al., Reducing Bedside Floor Mats: 1. Tips and Tricks for Selecting a Bedsize Floor Mat. S.P. Applegarth, Tampa, FL: VISN 8 Patient Safety Center of Inquiry, The Hazards of Using Floor Mats as a Fall Protection Device at the Bedside. A.K. Doig, and J.M. Morse, Journal of Patient Safety. 6(2):68-75, June Bedside Floor Mats, Risky for Patient Falls, American Hospital Association Resource Center Blog, June 24, Staff and Patient Safety: Issues surrounding the use of fall-injury-protection bedside floor mats at a large southeastern VA medical center community living center, Human Factors and Ergonomics in Manufacturing & Service Industries, Melville Bradley. Volume 22, Issue 1, Pages 32 38, January/February Hip Protectors: 1. Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review. British Medical Journal, 332:571, March Efficacy of a Hip Protector to Prevent Hip Fracture in Nursing Home Residents. Douglas P. Kiel, MD, MPH, et al. JAMA. 298(4): , July Hip Protector Implementation Toolkit, VISN 8 Patient Safety. Tatjana Bulat, MD, et al. May Environmental Design: 1. Environmental & Communication Assessment Toolkit, Jenifer Brush, Jon Sanford, et al., Health Professional Press, Energize Your Interior Design for Powerful Person-Centered Outcomes, Lorraine G. Hiatt, Pioneer Network Annual Conference, Current Session A4, Aging Research, Design Education, and the Perceptual Limits in Seniors Housing Design: Development of a Research-Based Design Model for Better Aging Environments, Steven J. Orfield, Orfield Lboratories, Senior Housing & Care Journal, Vol. 21, No. 1, pp