Fall Risk Assessment and Prevention in the Post-Acute Setting A Road Map

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1 Fall Risk Assessment and Prevention in the Post-Acute Setting A Road Map Cora M. Butler, JD, RN, CHC HealthCore Value Advisors, Inc. Juli A. James, RN Primaris Holdings, Inc.

2 Objectives Explore the burden and impact of falls Overview of regulatory environment Risk Assessment who, when, why and how Prevention and intervention Ongoing quality improvement planning

3 Fall Defined Any event in which an individual comes to rest on a lower level BUT There is no universally accepted definition SO Each facility will need to create its own definition to ensure accurate tracking and trending

4 Possible Fall Definitions Observed Falls resident experiences loss of balance while walking or transferring and comes to rest at lower level (floor, ground, bed, chair, etc.) Unobserved Falls resident found on floor and no one (including resident) knows how they got there Assisted Falls resident or staff member lowers resident to floor Near Falls resident experiences sudden loss of balance (slip, stumble or trip) but able to regain balance. Includes incidents except for those where resident would have fallen but staff intervened.

5 Frequency of Falls in Older Individuals According to the U.S. Centers for Disease Control and Prevention: Each year, a typical 100 bed nursing home reports falls with many falls going unreported. Between 50% and 75% of nursing home residents fall each year, which is twice the rate of falls among older adults living in the community. Patients often fall more than once with the average being 2.6 falls per person per year. About 35% of fall injuries occur among residents who cannot walk. About 10%-20% of nursing home falls cause serious injuries; 2%-6% cause fractures.

6 Frequency of Falls in Older Individuals According to the U.S. Centers for Disease Control and Prevention: Nursing Home Residents Age Million

7 Frequency of Falls in Older Individuals According to the U.S. Centers for Disease Control and Prevention: Death From Falls 5% Age 65+ Living Arrangements 20% Not Living In Nursing Home 95% Living In Nursing Home

8 Consequences of Falls in Older Individuals Mortality About 1,800 people living in nursing homes die from falls each year. Morbidity Falls with or without injury carry a heavy quality of life impact. A growing number of older adults fear falling and, as a result, limit their activities and social engagements. This can result in further physical decline, depression, social isolation, and feelings of helplessness.

9 Psychosocial Trauma Altered Self-Image i. Feelings of frailty and incompetence Increased Anxiety i. Inability to feel safe in their environment ii. Heightened sense of vulnerability iii. Embarrassment Decreased Mobility i. Increased isolation and fewer opportunities for social interaction ii. Consequences of Falls in Older Individuals Concern that family will worry Depression i. Loss of autonomy

10 Consequences of Falls in Older Individuals Family Concerns Guilt Blame Overcompensate

11 Institutional Effects Healthcare Costs Labor Costs Equipment Costs i. Utilization Costs Litigation Costs Effects on Staff i. Staff frustration with balancing ii. iii. Consequences of Falls in Older Individuals needs of individual Family Stress, guilt, self-doubt about ability to deliver safe care

12 Fall Risk Factors Intrinsic Factors - age related changes unique to individual Extrinsic Factors environmental changes Individual (Intrinsic) Environmental (Extrinsic)

13 Fall Risk: Intrinsic Factors Visual Changes Illumination Adaptation: movement from one level of illumination to another Change in visual field Alteration in depth perception Cardiovascular System Changes Aging associated physiologic changes that impair blood pressure regulation Aged heart less able to compensate for change in volume Decreased sodium conservation may lead to sodium imbalance/dehydration

14 Fall Risk: Intrinsic Factors Pathological Conditions: Chronic Disease i. Visual Disorders ii. Neurological disorders such as Dementia, Neuropathy, musculoskeletal disorders that result in muscle weakness, Thyroid Disease, Polymyalgia, Osteoarthritis or Deconditioning iii. Cognitive disorders such as Dementia or Depression may lead to misinterpretation of environment iv. Language Disorders may lead to inability to communicate needs v. Multiple risk factors

15 Fall Risk: Intrinsic Factors Pathological Conditions: Acute Disease i. May be an early indication of acute episode of illness (urinary tract infection, pneumonia) Physiologic Response to Medication i. Polypharmacy ii. Pharmacokinetic and pharmacodynamics changes may effect the action of drug

16 Fall Risk: Extrinsic Factors Physical Environment Devices i. Side rails, restraints, etc. Footwear i. Poor fit ii. Loose iii. Shoe sole material Leather Rubber-crepe Thick soled footwear, such as running shoes or sneakers may decrease proprioception

17 Fall Risk: Extrinsic Factors Situational Circumstances Length of stay i. Falls most frequent during first and third week of stay ii. Week one lack of familiarity iii. Week three increased independence

18 Risk Factors for Institutional Falls Falls History of falling Decreased vision Lower extremity dysfunction Gait or balance disorder Cardiovascular disorder Bladder dysfunction Special toileting needs Cognitive or emotional disorder Communication disorder Medications

19 Risk Factors for Institutional Injury Falls History of falling Advanced age Lower extremity weakness Ambulation with a cane or walker Poor vision Confusion and dementia Immobility

20 Fall Risk Clinical Assessment and Evaluation: MDS Physical Functioning & Structural Problems Bed mobility Transfer Walk in room Walk in corridor Locomotion on unit Toilet use Test for balance Modes of Locomotion Modes of transfer Changes in ability to perform ADLs

21 Fall Risk Clinical Assessment Evaluation and Reporting Impact Act of 2014 Improving Medicare Post-Acute Care Transformation Act Applies To LTCHs, IRFs, SNFs and HHA Phased In January, 2016 January, 2019 Requires i. Specific patient assessment data reporting i. Medical conditions and co-morbidities ii. Functional status mobility, self-care, major falls iii. Cognitive function iv. Impairments

22 Evidence-Based Fall Risk Assessment Tools

23 Fall Risk Clinical Assessment & Evaluation Individual Risk Factors Simultaneously Occurring Sensory impairment (vision, hearing) Postural hypotension Reduced lower extremity strength Impaired gait and balance Impaired mobility Use of ambulation assistive devices Bladder dysfunction Altered cognition Polypharmacy (four or more medications) Sedatives, psychotropics, hypnotics and antihypertensives

24 Preventative Strategies To Reduce Fall Risks A. Medical Strategies Medication Reconciliation & Evaluation (changes, classes of drugs) Acute Illness Chronic Illness B. Rehabilitation Strategies Exercise Footwear Hip Protectors Ambulation Devices Wheelchairs C. Environmental Strategies Illumination Floor Surfaces Furnishings Bathroom A Zone of Optimality C B

25 Implement Fall Prevention Programs Multi-disciplinary safety committee to develop institution guide fall prevention program In-service inter-disciplinary staff education program Mechanism to identify residents at increased fall risk on admission and for each nursing shift if change of condition occurs Mechanism (visual) for identifying residents immediately after fall Formal program and policy for reporting and investigating incidents Implementation of strategies to prevent falls and follow-up review of fall preventative strategies

26 Implement Incident Reporting Policy Components of Policy for Incident Reporting The policy clearly defines what events constitute a reportable fall. The policy clearly describes what actions to take in the event of injury and/or acute medical conditions. The policy clearly describes fall precaution measures to follow in order to prevent recurrence. The policy clearly outlines a step-by-step process to follow for completing the incident report. The policy clearly describes a step-by-step process to follow after the incident report is completed. The policy describes a process to inform all staff involved in patient or resident care of the current policy. The policy describes a time period in which statements are updated to reflect institutional attempts to practice reasonable standards of care related to fall prevention.

27 Post Fall Assessment Rule out injury and obtain treatment as appropriate Determine causes and circumstances of fall I. Symptoms before and at time of fall II. III. IV. Fall history Location at time of fall Activity at time of fall V. Was assistance being provided at time of fall VI. VII. Was resident on fall precaution Environmental hazards (known fall risk)

28 Conduct Root Cause Analysis Based on assessment ask: What happened? Why did it happen? Continue to ask Why questions until all logical causes identified Contributing causes may include: i. Patient related intrinsic factors ii. Patient related activity at time of fall iii. Environmental extrinsic factors iv. Clinical Process Failures risk assessment plan of care

29 Successful Fall Prevention Program Checklist Fall Risk Assessment Care Plan System for identifying fall and injury risk on admission, after fall and with change of condition? Intrinsic and extrinsic factors considered? Process of care planning and implementation targeted toward identified risks? Process that includes multidisciplinary approach to identified risk factors? Mechanism for communicating when patients or residents are at fall risk to all staff?

30 Successful Fall Prevention Program Checklist Postfall Assessment A formal postfall process for investigating falls (to identify why a fall occurred and to prevent further falls)? A postfall assessment that includes circumstances of the fall (symptoms, location, activity), presence of environmental hazards, reassessment of fall risk factors, and root cause analysis (cause of fall)? Monitoring A process of monitoring risk or change of condition on a daily basis? A follow-up process to determine whether interventions are working to reduce fall risks?

31 Successful Fall Prevention Program Checklist Facility Components Fall prevention policies, procedures, and guidelines for staff? Process for promoting a culture of safety throughout the facility that fall prevention is important and that many falls can be prevented? Comprehensive fall prevention education program to increase awareness for all staff and faculty members? Fall coordinator who can support and follow through with the fall prevention initiatives?

32 Successful Fall Prevention Program Checklist Facility Components Continued Process for evaluating the effectiveness of specific strategies and overall approaches to fall prevention? Process for monitoring facility-wide fall and injury patterns and contributing factors as well as implementing appropriate preventions? System for recognizing and rewarding the staff for their fall prevention efforts? Budget to support the fall and injury prevention program?

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