FALL MANAGEMENT: HOW TO ASSESS AND REDUCE FALLS WITHOUT ALARMS Presented by: Amber LaPrairie, LOTR.

Transcription

1 FALL MANAGEMENT: HOW TO ASSESS AND REDUCE FALLS WITHOUT ALARMS Presented by: Amber LaPrairie, LOTR

2 Who is at risk for falling? Very High SNF High Assisted Living Low General Population Increased fall risks begin at age 40! Each Year, 1 out of 4 adults over the age of 65, have a fall! **

3 ARE ALARMS BENEFICIAL OR HARMFUL?

4 USE OF ALARMS RESULT IN THE FOLLOWING: DEPRESSION CREATE SLEEP DISTURBANCES CREATE DECREASED MOVEMENT RESULTING IN PHYSICAL DECLINE STAFF CONDITIONED TO JUST TURNING OFF ALARM AND NOT ASKING WHAT THE RESIDENT NEEDS. ALL OF THE ABOVE: INCREASE FALLS TAKING ALARMS OFF MAKE STAFF PAY CLOSER ATTENTION TO RESIDENTS!

5 Centers of Medicare: Long-Term Care Facility Resident Assessment Instrument 3.0 User s Manual; Version 1.15, Oct 2017 RAI USER s MANUAL: Section P (Restraints and Alarms) The new item P0200 (Alarms) has a 7- day look back period and included the following sub items: -P0200A (bed alarm); P0200B (chair alarm); P0200C (floor mat alarm); P0200D (motion sensor alarm); P0200E (wander/elopement alarm); P0200F (other alarm) Defined an alarm as any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected. These may include bed, chair and floor sensor pads, cords that clip to the resident s clothing, motion sensors, door alarms, or elopement/wandering devices.

6 Regulations on use of alarms RAI USER s MANUAL: Section P (Restraints and Alarms) Do not code a universal building exit alarm to an exit door that is intended to alert staff when anyone (including visitors or staff members) exit the door. The efficacy of alarms to prevent falls has not been proven; therefore, alarm us must not be the primary or sole intervention in a resident s fall prevention strategy Adverse consequences of alarm use include, but are not limited to, fear, anxiety, or agitation related to the alarm sound; decreased mobility; sleep disturbances and infringement on freedom of movement, dignity, and privacy. When considering using an alarm as part of a resident s fall prevention plan, use must be based on the assessment of the resident and monitored for efficacy on an ongoing basis, including the assessment of unintended consequences of the alarm use and alternative interventions. Centers of Medicare: Long-Term Care Facility Resident Assessment Instrument 3.0 User s Manual; Version 1.15, Oct 2017

7 Regulations on use of alarms An alarm must be assessed to determine if it also has the effect of a restraint. If an alarm meets the criteria as a restraint it must be coded as both P0100 (physical restraint) and Po200 (alarms) You must evaluate if the alarm effects the resident s freedom of movement when it is in place. Record the frequency that the resident was restrained by any of the listed devices at any time during the day or night; record the frequency that any of the listed alarms were used. Centers of Medicare: Long-Term Care Facility Resident Assessment Instrument 3.0 User s Manual; Version 1.15, Oct 2017

8 Physical Restraints Critical Element Pathway Use Use this protocol for: A sampled resident who has MDS data that indicates a physical restraint is used; or Surveyor observation of a device or practice that may be physically restraining the resident. The goal of using this CE is to determine, for a resident the surveyor has determined to be restrained, whether the restraint is in compliance with the regulations. To be in compliance, the restraint: Must be necessary to treat a medical symptom; Must not be used to discipline a resident or for staff convenience in the absence of a medical symptom; Must not be used because of family request in the absence of a medical symptom; and Must be the least restrictive device possible, in use for the least amount of time per day possible; and the facility must have an active plan in place to decrease usage or for eventual removal of the restraint. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES: FORM CMS (7/2015)

9 Physical Restraints Critical Element Pathway DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES: FORM CMS (7/2015) Staff Interviews Interview staff on various shifts to determine: Knowledge of specific interventions for the resident, including: The restraint(s) being used (and when use was initiated); How often and under what circumstances the restraint(s) is used; When, and for how long, the restraint is released; The potential risks of using the restraint; How the resident is monitored when the restraint is in use; and Interventions that are in place to minimize or eliminate the medical symptom or underlying problems causing the medical symptom. Knowledge of facility-specific guidelines/protocols; and Whether the nurse monitors for the implementation of the care plan, and the frequency of review and evaluation of changes in the effectiveness or resident response to the restraint. What the resident s functional ability is, such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and toilet; and Any changes over the past year such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression.

10 SO WHERE DO WE BEGIN?? HOW DO WE MANAGE FALLS WITHOUT ALARMS OR RESTRAINTS?

11 Keep In mind Every individual is different! All care plans need to address the individual and their deficits

12 ASK WHY? DID THIS FALL OCCUR??

13 10 questions 1. Ask the resident if they are ok? 2. Ask the resident, what were they trying to do? 3. Ask the resident or make a note of what was different this time? * Falling into Culture Change: A Blueprint for a Fall Prevention Program *

14 10 questions * Falling into Culture Change: A Blueprint for a Fall Prevention Program * 4. Make note of what time of day or night? 5. Make a note of who was in the area when the resident fell? 6. Make a note of the position was the Resident found in? A. Did they fall near a bed, toilet or chair? B. How far away from where they were started were they? C. Were they on their back, front, L side, or R side? D. What were the position of their arms & legs?

15 10 questions * Falling into Culture Change: A Blueprint for a Fall Prevention Program * 7. Make a note of what the surrounding area was like? a. Was it Noisy? Busy? Cluttered? b. If in the fall was in the bathroom, what were the contents of toilet? Any contents on floor? c. Look at the lighting? Was it poor lighting- How visible were things? d. Look at position of furniture & equipment or adaptive devices? e. Was the bed set at the correct height?

16 10 questions * Falling into Culture Change: A Blueprint for a Fall Prevention Program * 8. Make not of what the floor was like? a. Was it wet on the floor? Was there urine on the floor? b. Was there carpet or tile? Was the floor uneven? Was the floor shiny? Was there any glare? Was there enough contrast? 9. What was the resident s apparel? What were they wearing? a. Did they have on shoes, socks (non-skid) slippers, or were with bare feet? b. Did they have on poorly fitting clothes? Or poorly fitting shoes?

17 10 questions * Falling into Culture Change: A Blueprint for a Fall Prevention Program * 10. Was the resident using an assistive device? a. Did they use or were using a walker, cane, wheelchair, other? Could they reach it? Could they see it? Or did they forget about it? b. Did the resident have on glasses and/or hearing aides?

18 WHAT S NEXT? Look at the Root Cause

19 Root Cause Analysis 3 AREAS TO INVESTIGATE: Internal/Intrinsic Conditions Environmental/Extrinsic Conditions Operational/Systemic Conditions

20 Root Cause Analysis HOURLY NEEDS Take care of the 4 P s: Position (comfort) Personal (potty) Pain Placement (bed height, items in reach)

21 Internal Evidence Place of Fall: At Bedside: Orthostatic hypotension, incorrect bed placement 20% of adults over age of 65 have Orthostatic Hypotension 5 Feet away: Balance/Gait deficits (referral to Therapy) 15 Feet away: Strength/Endurance deficits (referral to Therapy) In Bathroom, at commode: contents of toilet? Any contents on floor? Odor?

22 Internal Evidence SLEEP DEPRIVATION Mood Irritability, Lack of motivation, Anxiety, Symptoms of depression Performance/Cognitive Changes Lack of concentration, Attention deficits, Reduced vigilance, Longer reaction times, Distractibility, Lack of energy, Fatigue, Restlessness, Lack of coordination, Poor decisions, Increased errors, Forgetfulness Health Sleep deprivation has been associated with an increased risk of these medical conditions: High blood pressure, Heart attack, Obesity, Diabetes Take a Look at SLEEP DEPRIVATION Need 8 hours of uninterrupted sleep for optimal brain function

23 Internal Evidence Sleep Deprivation Implement a sleep program Assess sleep patterns Pair with roommates with similar sleep patterns Increase day time activity Adapt shift changes Decrease noise and light Decrease fluid intake before bed; increase fluids during day; implement toileting programs Look at nutrition and drug effects; use non-pharmacological interventions Educate staff, residents, and family on importance of sleep Take a look at sleep apnea

24 Internal Evidence Take a look at Medications Orthostatic hypotension Medications increase falls in this order: 1. Antidepressants 2. Antipsychotics 3. Diuretics *Are these Meds necessary?*

25 Measuring Orthostatic Blood Pressure Have the patient lie down for 5 minutes. Measure blood pressure and pulse rate. Have the patient stand. Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes. A drop in bp of 20 mm Hg, or in diastolic bp of 10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal.

26 Internal Evidence Nutrients and Drugs How do they affect mental health and the Brain? Affects alertness Affects sleep patterns Affects Cognition Affects Moods Can reduce or increase falls *Can we use foods and supplements as opposed to drugs?*

27 Internal Evidence Incontinence Falls increase due needing to potty Incontinence is one of the top reasons for admittance into nursing homes Around 50% of nursing home residents are considered to be incontinent Physical therapy is able to treat for pelvic floor rehabilitation

28 INTERNAL EVIDENCE VISUAL IMPAIRMENTS..TAKING A LOOK AT HOW OUR RESIDENTS SEE THEIR ENVIRONMENT?

29 Eye Diseases affecting Vision Most Common Eye Diseases: Macular Degeneration Diabetic Retinopathy Glaucoma Cataract

30 Visual Impairments Macular Degeneration

31 Visual Impairments Diabetic Retinopathy

32 Visual Impairments Glaucoma

33 Visual Impairments Cataracts

34 Visual Impairments Vision After a Stoke: Visual Neglect

35 Visual impairments: Oculomotor dysfunction

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37 Internal Evidence: Vertigo Age-Related Dizziness and Imbalance Result of problems with the vestibular, central (brain-related), and vision systems, as well as from neuropathy, psychological causes, and unknown causes. Vestibular disorders: the most common cause of dizziness in older people Responsible for approximately 50% of the reported dizziness in the elderly

38 External Evidence Take a look at the Environment Noise levels Busy activity Visual conditions (not enough contrast/poor illumination/too much glare) Personal items and/or assistive devices not seen or within reach Incorrect bed height Clutter/mats on floor Incorrect footwear

39 External Evidence **Correct bed height** Resident on edge of bed, feet flat on the floor, hips slightly higher than knees Mark proper height of bed on wall with tape on wall Don t use low beds, don t use mats (increase falls) Educate all staff including housekeeping and maintenance staff to monitor proper bed height

40 External Evidence **Correct footwear** Be aware of gripper socks No crepe soles Fully enclosed/slip resistant Easy on/easy off Footwear color contrast to floor No thick soles with a lot of tread (especially on carpet) With Parkinson s use leather soles

41 External Evidence **NO USE OF ALARMS** Use of alarms result in the following: Depression Create sleep disturbances Create decreased movement resulting in physical decline Staff conditioned to just turning off alarm and not asking what the resident needs. ALL of the Above: INCREASE FALLS Taking alarms off make staff pay closer attention to residents!

42 Systemic Evidence Time of day Shift change Break times Day of week Location of fall Type of fall

43 THERAPY How can the therapy department can help educate staff and aide in the reduction of falls? Use Root Cause Analysis Look at place for falls? Is it balance, strength, and/or endurance deficits. Can assist with improving continence Any vertigo? Can address BPPV, Can teach compensatory techniques for VOR deficits Look at mood or cognitive changes? Is resident getting enough uninterrupted sleep? Medications that are affecting resident? Orthostatic hypotension possibly?

44 THERAPY: Helping with the 4 p s Position: Assist with proper and more comfortable positioning Assess and treat contractures to improve positioning Personal (potty) Pain Assist with continence training, if cognitively able Treat to reduce pain Placement Assist with proper placement of items in environment

45 THERAPY Perform environmental assessments and make recommendations: Poor lighting- How visible were things Position of furniture & equipment Correct bed height Assess resident s apparel and type of shoes proper training on using an assistive device Assess any need for glasses and/or hearing aides

46 THERAPY How can the therapy department help educate staff and aide in the reduction of falls? Look at environmental factors? Look at visual deficits (Glaucoma, Diabetic Retinopathy, Macular Degeneration, Cataracts, Visual neglect) Add contrast, increase lighting, reduce glare Help to Improve Balance* Incorporate and help staff comfortable to incorporate standing in every activity and ADL. If going out with family: create Transfer bags: with belts and any items needed to help safe transfers.

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48 References 10/19/11, Last Updated:, and Contact:. "Pelvic Floor Dysfunction." In Mind That Payment Policies Vary from Payer to Payer. Pelvic Floor Dysfunction 1. What Is Pelvic Floor Dysfunction? (2011): 1-8. Women's Health. APTA, 19 Oct Web. 03 Dec < Centers for Medicare & Medicaid Services: Long-Term Care Facility Resident Assessment Instrument 3.0 User s Manual (RAI): Version 1.15; Oct 2017; Section P: pages P-1 P-10. < RAI-Manual-v115-October-2017.pdf>. "Costs of Falls Among Older Adults." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 22 Sept Web. 17 Dec < (d. Keyser, ms, lotr, gtc, personal communication, November 2, 2013) Debra Sokol McKay, MS,OTR/L, SCLV CDE, CVRT, CLVT; Low Vision Rehabilitation: Practical Tools and Techniques for Assessment Treatment and Beyond ; 2010 Department of Health and Human Services Centers for Medicare & Medicaid Services: Physical Restraints Critical Element Pathway; Form CMS-2007 (7/2015); < Department Of Health And Human Services, Usa. "Integrating Fall Prevention into Practice." Integrating Fall Prevention into Practice (n.d.): n. pag. CDC. Web. 15 Dec <Integrating Fall Prevention into Practice>.

49 References Department Of Health And Human Services, Usa. "Measuring Orthostatic Blood Pressure." Measuring Orthostatic Blood Pressure (n.d.): n. page. CDC. Web. 17 Dec <Measuring Orthostatic Blood Pressure>. Falling into Culture Change: A Blueprint for a Fall Prevention Program. Pioneer Network Annual Convention, Seattle, WA. Preconference Intensive. August 12, Sue Ann Guildermann, RN, BA, MA, Cindy Morris, LNHA, BS, MBA, Melinda Jaeger, PT. Retrieved from presentation by Empira. "Falls Aged Care Crisis." Falls Aged Care Crisis. N.p., 20 Feb Web. 05 Dec < Important Facts about Falls." Home and Recreational Safety. Centers for Disease Control and Prevention, 10 Feb < Food For Thought: How Nutrients Affect Mental Health and the Brain. Institute for Brain Potential Conference, Alexandria, LA. November 13, Michael Lara MD. Fuller, COL, MC, USA, George F. "Falls in the Elderly." - American Family Physician. American Academy of Family Physicians, 01 Apr Web. 05 Dec <

50 References Leung, Felix W., and John F. Schnelle. "Urinary and Fecal Incontinence in Nursing Home Residents." Gastroenterology Clinics of North America. U.S. National Library of Medicine, n.d. Web. 10 Dec < (M. Jaeger, pt; personal communication, November 12, 2013) Mandal, MD, Dr Ananya. "What Is Visual Impairment?" News-Medical.net. N.p., 27 June Web. 15 Dec < Matta, MA, Christy. "8 Effects of Sleep Deprivation on Your Health." Psych Central.com. N.p., n.d. Web. 03 Dec < Schubert, PT, PhD, Michael C. "Vision Challenges with Vestibular Disorders." Vestibular Disorder Association (n.d.): 1-7. VEDA. Web. 10 Dec < "Sleep and Chronic Disease." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 01 July Web. 19 Dec < "Types of Vestibular Disorders." Types of Vestibular Disorders. Vestibular Disorder Association, n.d. Web. 10 Dec <