Fall Prevention Part 2: Identifying the Causes of Falls Sue Ann Guildermann, RN, BA, MA Director of Education, Empira sguilder@empira.org
Objectives Identify the internal, external and systemic conditions and operations that may be the causes of resident falls List the evidence based effective and noneffective interventions to preventing falls in SNFs Discuss the three types of interventions Match the interventions to the identified causes of the fall
What is root cause analysis? RCA is a process to find out what happened, why it happened, and to determine what can be done to prevent it from happening again.
Root Cause Analysis: Root cause analysis (RCA) transforms an old culture that reacts to problems, into a new culture that solves problems before they escalate. Aiming performance improvement operations at root causes is more effective than merely treating the symptoms of problems. Problems are best solved by eliminating and correcting the root causes, as opposed to merely addressing the obvious symptoms with "scattergun approaches" to solutions.
3 Areas to Investigate for Root Cause Analysis 1. Internal / Intrinsic conditions 2. Environmental / Extrinsic conditions * 3. Operational / Systemic conditions
Who is at Risk for Falling... When Everyone Is? Very High Very High SNF High High Assisted Living Medium Low General Population Risk for Falling
Who is at Risk for Falling: Low Risk: 5 25 years old, physically active, mentally alert, few diseases and debilities Medium Risk: 25 45 years old, less physically active, less mentally alert, experiencing diseases and debilities High Risk: 45 65 years old, less physically active, less mentally alert, experiencing more diseases and debilities High Risk: Over 65 years old, less physically active, less mentally alert, experiencing more diseases and debilities
Person Centered at risk causes for falls on admission Mrs. AT, 76 y.o., active, alert, visually impaired due to macular degeneration, slipped and fell on ice getting out of her son s car, fx elbow & shoulder Mr. BL, 88 y.o., early stage Lewy Body Dementia, symptoms increasing, can no longer be cared for in his AL setting Mrs. MW, 69 y.o., 295 lbs., newly diagnosed brittle diabetic, admitted post hip pinning following a fall in her apartment
Falls Admission Risk Assessment 1. On admission document the following statement, Everyone is at high risk for falling. This resident, Mrs. Morris, is at a high risk for falling because. 2. Identify the individual s specific risk factors for being at a high risk for falling. 3. If the person has a recent history of falls, determine the predisposing causes or triggers for the falls 4. Consider psychological / emotional factors; grief, depression, self imposed restriction of activity 5. Focus on lower-extremity balance and strengthening status 6. Individualize admission interventions: to keep the resident safe and minimize falling.
Post Fall Scene Investigation (FSI) Report Data collection tool used to investigate and determine RCA Completed soon after the fall occurs and/or during the fall huddle Completed by nurse in charge on duty at time of the fall Let s look at the FSI report
Post Fall Assessment: Root Cause(s) Analysis: Why did they fall? What were they doing before they fell? But, what was different this time? Where did they fall? When did they fall? What was going on when they fell? So, why did they fall?
Internal Evidence & Causes: Vital Signs + Pain Neuro checks Lab results Diagnoses: specific Medications Vision and hearing status Cognitive, confusion, mood status Recent changes in conditions
Internal Evidence & Causes: What was the resident doing or trying to do just before they fell? Ask them All residents, all the time Place of fall: At bedside, 5 feet away, > 15 feet Orthostatic, Balance/gait, Strength/endurance In bathroom/at commode: contents of toilet Urine or feces in toilet/commode? Urine on floor?
Internal Evidence & Causes: Orthostatic Blood Pressure What is it? Done correctly? How do you take an Orthostatic B/P? CDC Guidelines: http://www.cdc.gov/homeandrecreationalsaf ety/pdf/steadi/measuring_orthostatic_bp.pdf
Internal Evidence & Causes: Grabbing vs. Pushing: Grabbing: due to dizziness to stop from spinning don t move, hold on to resident. Pushing: to get away from being startled/attacked slowly back away from resident. Wandering vs. Pacing Wandering: without a goal, usually provides comfort Pacing: a need not met, rhythmic or repetitive Cognitive Abilities & Mood Status =? Medications: amount and dose Side effects, adverse drug reactions, Black Box Warnings Cascading medications
Internal Evidence & Causes: Unnecessary Medications What makes a drug unnecessary? CMS F329 Unnecessary Drugs General Drugs: Any drug when used; 1. In excessive dose; or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse side effects, which indicate the dose should be reduced or the drug discontinued; or 6. Any combinations of the reasons above.
Internal Evidence & Causes: Primary medications causing falls: Any meds lowering B/P Antipsychotics Antidepressants Diuretics Multiple meds > 9 Cascading Meds Black Box Warning meds
Reasons for the Use of Unnecessary Meds Resident s condition changes need help / desire to help / unable to help Overestimate of effectiveness of drugs; believe drugs will produce desired results Underestimate the side effects of drugs Lack of training in non-pharmacological approaches to treatment Patient/family demands Influences of media and drug manufactures
Internal Needs (4 Ps) Causing Falls: Position: Does the resident look comfortable? Ask the resident, Would you like to move or be repositioned? Ask the resident, Are you where you want to be? Report to the nurse. Personal (Potty) Needs: Ask the resident, Do you need to use the bathroom? Ask if they d like help to the toilet or commode. Report to the nurse. Pain: Does the resident appear in to be uncomfortable or in pain? Ask the resident, Are uncomfortable, ache or in pain? Ask them what you can do to make them comfortable. Report to the nurse. Placement: Is the bed at the correct height? Is the phone, call light, remote, walker, trash can, water, urinal, tissues, all near the resident? Place them all within easy reach.
Internal Evidence & Causes: Mood status + cognitive changes + frequent napping, falls, agitation = sleep deprivation / sleep fragmentation #1
Internal conditions causing falls: Vision How do they see? What do they see?
External Clues Internal Causes: Gravity + sedentary life style + reduced mobility = poor posture + risk for falls
Physical Changes As We Age Posture ROM Strength and Balance Loss
Balance Exercise Reduces Risk of Falling Strength training alone may not effectively reduce falls since impaired balance is a stronger reason for falls than poor muscle strength. The greatest effect in preventing falls were seen with exercises that challenged balance. ~ Journal of the American Geriatrics Society, December 2008 Create opportunities to stand and reach Incorporate balance into current activities & ADLs & newly created TR programs
External Evidence & Causes: Noise levels (staff, alarms, tv) Busy activity, busy times Personal items not seen or within reach Visual conditions contrast, illumination Assistive devices not seen or within reach Incorrect footwear Clutter, mats on floor Bed heights incorrect
100 90 80 70 60 50 40 30 20 10 0 22:52:30 23:01:30 23:10:30 23:19:30 23:28:30 23:37:30 23:46:30 23:55:30 0:04:30 0:13:30 0:22:30 0:31:30 0:40:30 0:49:30 0:58:30 1:07:30 1:16:30 1:25:30 1:34:30 1:43:30 1:52:30 2:01:30 2:10:30 2:19:30 2:28:30 2:37:30 2:46:30 2:55:30 3:04:30 3:13:30 3:22:30 3:31:30 3:40:30 3:49:30 3:58:30 4:07:30 4:16:30 4:25:30 4:34:30 4:43:30 4:52:30 5:01:30 5:10:30 5:19:30 5:28:30 5:37:30 5:46:30 5:55:30 6:04:30 6:13:30 6:22:30 Noise level in decibels in an Empira member SNF from 10:52 PM to 6:22 AM.
Incorrect Footwear: Gripper socks, crepe soles Open backed, slippers & shoes Poorly fitting difficult on, difficult off! Footwear not contrasted to floor color
Incorrect Beds: Function & Heights The use of low beds to reduce injury Incorrectly heighted beds to the height of the residents Beds placed to prevent mobility
Mats on Floor Reduction Mat creates an uneven floor surface Mat does not go full length of bed Mat is confusing to dementia residents Efficacy of mats has not been proven: VA study Presence of floor mat creates a fall hazard Staff, families and residents trip over mat
Hip Protectors Used by all residents with diagnosis of osteoporosis, hip/pelvis fractures, osteoarthritis Check Veterans Administration Hip Protector Implementation Tool Kit VA tested efficacy of hip protectors some found to be significantly less effective than others
Case Study #1: Mrs. CC, a slightly confused, 84 y.o., SNF resident, is in the early stages of Alzheimer s disease. She wanders into the room of another resident. She believes this is her room and begins straightening the bedspread on her bed. The resident who actually does live in this room begins to shout at Mrs. CC to get out of his room. A nurse comes in to redirect Mrs. CC out of the room; she coaxes her by taking her arm and leading her out. Mrs. CC resists by pulling away and falls. Why did she fall? What would be appropriate interventions?
Lack of Visual Contrast in the Environment
Most Important Environmental Element to Prevent Falls: BUT... No contrast to background
Noise Contributes to Falls
External lesson learned: if we can stop the noise, then we can reduce the falls.
Alarm & Restraint Reduction & Elimination Evidence based studies for the reduction and elimination of alarms to reduce: Falls, depression, skin breakdown, confusion, incontinence, challenging behaviors Results from alarm & restraint elimination
Personal Alarms: definition Personal alarms are alerting devices designed to emit a loud warning signal when a person moves. The most common types of personal alarms are: Pressure sensitive pads placed under the resident while they are sitting on chairs, in wheelchairs or when sleeping in bed A cord attached directly on the person s clothing with a pull-pin or magnet adhered to the alerting device Pressure sensitive mats on the floor Devices that emit light beams across a bed, chair, doorway Architectural alarms are not an issue
Determine RCA: Why did the alarm go off? Because the person was moving. No! RCA: What does the resident need, that set the alarm off? RCA: What was the resident doing just before the alarm went off? Needs Movements Falls
10 9 8 7 6 5 4 3 2 1 0 Results of Alarm Reduction Alarms being used at all times of the day. CARE CENTER #1: APR - JUNE 2010 FALL TIMES 6-6:59AM 7-7:59 8-8:59 9-9:59 10-10:59 11-11:59 12-12:59PM 1-1:59 2-2:59 3-3:59 4-4:59 5-5:59 6-6:59 7-7:59 8-8:59 9-9:59 10-10:59 11-11:59 12-12:59AM 1-1:59 2-2:59 3-3:59 4-4:59 5-5:59 X axis = times of the day the falls occurred, Y axis = # of falls.
9 9:59 10 10:59 11 11:59 12 12:59PM 1 1:59 2 2:59 3 3:59 4 4:59 5 5:59 6 6:59 7 7:59 8 8:59 9 9:59 10 10:59 11 11:59 12 12:59AM 1 1:59 2 2:59 3 3:59 4 4:59 5 5:59 6 6:59AM 7 7:59 8 8:59 5 4 3 2 1 0 TEAM 2, Fall Times, January - March 2010 No alarms used during night shift X axis = times of the day the falls occurred, Y axis = # of falls.
Care Center #2: Time of Falls April-June 2010 No alarms used during evening and night shifts. X axis = times of the day the falls occurred, Y axis = # of falls.
Alarms Annul Our Attention After you put something in the oven or microwave or clothes dryer, why do you set an alarm on (or the machine has an alarm) that goes off?
Alarms Cause Reactionary Rather than Anticipatory Nursing Without alarms we had to learn to anticipate the needs of our residents. nurse in charge Without alarms we had to pay closer attention to the residents. maintenance engineer We heard, What do you need, instead of Sit down. family member
External lesson learned: if we can stop the noise, then we can reduce the falls.
Internal lesson learned: if we can stop disturbing sleep, If we can increase mobility, then we can reduce the falls.
Systemic Lessons Learned: The operations and management of systems, processes and procedures has the greatest impact and effect on fall reduction Rarely is the root cause of a fall only a clinical or environmental condition, it is usually the result of an underlying systemic breakdown
Key Systemic Cause to Falls Silo ed task-oriented staff LTC cultural and operational belief that; fall prevention is a nursing responsibility. It s not my job.
Key Systemic Clue to the Cause of Falls: Silo ed, Task-oriented Staff
Systemic Evidence & Clues: Admission 72 hours Room and household / unit change Times of day: Shift change Meal and Break times Days of week Location of fall: Rehab, Memory loss, Long term care Types of fall: transfer, walking, reaching Silo ed, task-oriented, staff ( It s not my job. ) Staff times, staff assignments, # of staff Routines of services: policies and procedures
Fall Causes: Intrinsic - internal, Extrinsic - environmental, Systemic - operations Intrinsic: Needing 4 Ps, Sleep deprivation / fragmentation, Medications (type & amount) Orthostatic B/P, Poor balance Extrinsic: Cognitive status, mood, depression, vision/hearing loss Noise (alarms, staff, TV) lack of environmental contrasts, room / bed assignment, placement of furniture & personal items, illumination / lighting Systemic: Clutter, mats, footwear, floor surfaces, bed heights incorrect Times of day, shift change times, meal / break times, days of week, locations of fall, types of fall, silo ed task-oriented staff, routine assignments (cleaning, stocking, repairing) staffing levels, inconsistent staffing