An all-out attack on falls.

Our falls-prevention program began in 1998 and has progressed and grown over the years. We performed an intense review and revision of the program beginning in the last quarter of 2002 and finishing at the end of 2003. We found that a significant decrease in falls can be achieved using a formal program. Our plan is to build on this success by exploring ways to improve the program continuously.

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The Problem

Data for 2002 from the Center for Health Systems Research and Analysis (CHSRA) at the University of Wisconsin--Madison indicate that New York State long-term care facilities had 14.6% of their resident populations experience a fall. The prevalence of falls and the challenges they present are not new to the industry. According to national data, falls are the underlying cause of death each year for almost 10,000 patients over age 65. Studies suggest that falls are one of the costliest categories of injuries among older persons. The cost involves not only the financial impact but also the emotional impact on the person. Fear of falling may lead to a resident's decreased confidence in his or her ability to ambulate safely and, potentially, to further functional decline. In turn, this may lead to depression and feelings of helplessness and social isolation. A fall affects not only the resident, but the family, as well, who witness their loved one's pain and decrease in functional status.

Resident falls are related to multiple factors, and no one intervention on its own may be successful if other relevant factors aren't identified. Based on a review of clinical and statistical data, quality indicators, resident assessments and resident occurrences, and quality-assurance reports, our facility decided to focus on a project to improve resident safety and decrease the overall number of resident falls.

Our facility consists of four populations, each with different needs. Two of the populations are largely mobile, although many of these residents have cognitive impairment. Three subacute units have clients/residents who, although often independent prior to hospitalization, now have limitations they may not fully recognize. Because these factors contribute to a high risk for falls, there is facility-wide potential to involve all residents in a falls-prevention program.

Planning and Implementation Strategies

In 1998, a newly formed management team that included the Assistant Administrator, Director of Nursing, Director of Rehabilitation, and Director of Quality Assurance/Staff Development reviewed many areas of the organization for possible quality-improvement projects. The area of "resident occurrences" (unexpected, unintended events that may or do cause injury) was one. We began developing a risk management team; it included the Director of Rehabilitation, who headed the team; nursing staff; and several other staff members. During the years since, it has grown to include representatives of Social Services, Dietary, Housekeeping, Recreation, Engineering and, most recently, the Medical Director.

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We decided in the last quarter of 2002 to develop a new process to further evaluate our systems and processes. We wanted to improve resident safety and, more specifically, focus on decreasing the number of resident falls, rather than focusing on the broader target of reducing resident accidents and incidents. Our overall objective was to decrease falls by approximately 20% in one year.

The project began in January 2003 and continued through the end of the year. We used a process published by the Joint Commission on Accreditation of Healthcare Organizations, as well as established quality-assurance principles. Based on the concept of Failure Mode and Effects Analysis (FMEA), strategies involved creating a timeline (figure 1), flowcharts (figure 2), a focus team with specific roles and responsibilities, and audit tools to help measure the outcome.

The use of flowcharts allowed us to analyze any areas that might cause or lead to failure (in this case, falls). These identified areas could then be changed or enhanced, as appropriate. Through the use of the flowcharts and the FMEA model, we were able to redesign our falls-management process and put into effect a new approach that would hopefully lead to the desired reduction.

Barriers Identified

Each potential failure mode of the process was carefully identified, prioritized, and analyzed through the FMEA process (table 1, see p. 34). We focused on the following priority problem areas:

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* Standardized preventive interventions that were sometimes ineffective

* Inconsistent, at times poorly completed, investigations and corresponding documentation

* Inadequate review at risk management meetings

* Ineffective resident education/reinforcement

* Inadequate reevaluation of revised care plans' effectiveness

* A need for enhanced staff education

To reach our outcomes goal, the above areas all needed improvement. Other possible barriers to success would include staff reluctance to accept the plan, unavailability of resources, educational program shortfalls, and program structural issues.

With all these difficulties in mind, we conducted a preliminary discussion of the project on December 3, 2002. We knew that our entire process for preventing falls and recurrences needed to be reviewed and reevaluated. This would include the method of identifying at admission the resident as high-risk for falls, developing a care plan that would prevent falls and, if the resident does fall, implementing a new process, including investigation, to prevent recurrences.

On January 7, 2003, we formed a team consisting of the Assistant Administrator, who served as chairperson and facility Safety Officer, and was responsible for budgetary allowances and overseeing the entire process; the Director of Nursing/ADNSs, who would be responsible for reviewing the Accident/Investigation Process and the nursing component of the Care Planning Process; the Director of Rehabilitation, who served as chairperson of the risk management meeting and would be responsible for evaluating the risk management process and its implementation, as well as monitoring use of new resident-assist devices; a designee of the Quality Assurance/Performance Improvement/Staff Development Department, who would be responsible for the final review of occurrence reports, evaluating educational needs, and identifying trends related to falls; and the Risk Management Coordinator, who has since expanded her role to become Clinical Care Coordinator and is an integral part of the team responsible for reviewing all occurrences, providing ongoing staff education on the investigative process, analyzing the use of proactive plans/instructions, and identifying patterns/trends needing attention.

Other members of the team who have become involved on a daily basis, especially during care plan meetings and weekly risk management meetings, are the nursing staff, rehabilitation staff, dietitians, social workers, recreation staff, and residents and families (when appropriate). Their collective responsibilities are to evaluate the resident's plan of care for falls prevention or revise the plan of care if a fall does occur.

By using FMEA, we were able to dissect and analyze each area of failure, rate each area for the likelihood that a failure would occur, and determine, if it occurred, how severe the effects would be for the resident. After this analysis, we would then be able to prioritize the most important areas to be addressed (i.e., "risk priority number," table 1).

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We should note that this approach was the culmination of years of development. During the concept's early years--the late 1990s--residents who had experienced multiple falls were reviewed at a weekly team meeting aimed at preventing recurrences. We went on to bring residents having experienced one fall to the meeting. As of June 2003, we began to review all new admissions that had been identified as high-risk and to invite them to the meeting to develop and individualize their plans of care and create proactive plans to protect them from falls. Meanwhile, the team has expanded to include input from Housekeeping and Engineering, both of which have contributed helpful information about our residents.

Identifying outcomes is an important part of a project such as this. When we began in January 2003, we developed a Prevalence of Falls Audit Tool that allowed every department to audit and analyze specific issues involved in a fall in order to establish department-specific patterns and trends. The audit asked questions such as:

* Was the resident identified as high-risk prior to the fall?

* Was resident/family education provided pre-/postfall?

* Was the fall related to noncompliant behavior and, if so, was this appropriately addressed by the comprehensive Care Plan Team?

* Did recent lab results show any abnormalities that could have been contributory?

* Did any medications contribute to the fall?

* Did evidence suggest a vision problem that could have contributed to the fall?

* Did a gain/loss of weight precede the fall?

* Did related medical conditions contribute to the fall?

* Was the fall related to improper use of a device, a gait/balance problem, or repositioning difficulty?

* Was the resident independent in ambulation at the time of the fall or on a restorative rehab program?

* Could the fall have been prevented?

Audit findings that led us to implement changes in our process starting in 2002 and continuing through 2003 included:

1. an evident correlation between medical problems and falls (i.e., abnormal labs, weight loss, and gait imbalance). We therefore in-serviced staff to be alert to these factors. Our physicians, too, have focused on the various clinical factors contributing to falls. The resulting staff awareness has heightened our ability to implement safety measures and preventive interventions, thus decreasing and preventing occurrences from taking place.

2. decreased vision as a contributing factor. This has led to the use of magnifiers, filters, and various types of supportive lighting.

3. falls involving residents who were deemed independent by a physical therapy assessment that did not identify the residents at a risk for falls. Therefore, an assessment focused on screening ambulatory residents for risk factors was initiated in June 2003. This additional information has heightened caregiver awareness of ambulatory residents' risk for falls.

4. attempts by some subacute residents to perform independent ambulation and transfer prematurely. Noting this trend and behavioral pattern, our rehabilitation department placed a heightened focus on resident education and continual reminders not to attempt mobility without staff assistance until they were cleared to do so.

5. safety issues with residents who were considered to be relatively independent but nevertheless frail or experiencing mild cognitive issues. These were addressed at resident council in a special program presented by the Rehabilitation Director.

6. evidence that for many dementia residents, education is not an option. To deal with this, we concentrated on using staff-alert devices, making safety-sensitive environmental modifications, and developing recreational and diversional activities to be provided by the interdisciplinary team.

7. wheelchair positioning assessments needed to become a component of the initial occupational therapy assessment of all admissions, and continued regularly depending on resident need.

Quarterly statistical data based on the audit tools we developed were used as an internal benchmark to determine the effectiveness of the new process. We used other published statistical data, such as the CHSRA reports, to compare the facility's performance with that of other nursing homes. According to current CHSRA data, approximately 14.6% of the population in the comparison group of 200 facilities statewide experienced a fall during the 12-month review period. In comparison, our facility is below the average; nevertheless, we chose to attempt to reduce the total number of falls even more.

Results of audit findings based on our "potential failure modes" were compiled and analyzed quarterly, and comparisons were made quarter to quarter. Comparisons between 2002 and 2003 were made of the total number of falls from month to month, quarter to quarter, and year to year. In addition, comparisons of the number of resident falls per patient care days were done for the same period. The results of these studies are discussed under "Program Outcomes."

Program Components

An important component that was long-identified and became an even stronger focus in 2003 was staff education. In our move from the old process to the new process, we identified a need for more staff education on assessment of resident factors predisposing them to falls and on learning from the postfall investigative process, so that we could provide all residents with the best preventive care plans possible. In-services focused on areas such as factors leading to falls (psychotropic medications, behavior management and other physical safety issues, appropriate documentation, etc.) and the postfall investigative process. We revamped our Accident and Incident form and accompanying documents to make them more user-friendly and increase compliance with the investigative process. Outside speakers, including a representative from the state attorney general's office, were invited to provide facility-wide education on investigations in general.

We have also developed an electronic database that generated reports on data such as the number of occurrences monthly, location, type, and other fall-related factors. These reports enabled us to identify problems, patterns, and trends in time to implement specific preventive measures.

Monitoring devices, such as bed and chair alarms, have been used for many years in our facility and elsewhere. We have expanded upon the use of new and different types of devices available in the market (i.e., motion sensor alarms attached to walls and automatic wheelchair brakes that activate when the resident rises or is removed from the seat, as well as various types of wheelchair alarms, including seat belt buckle alarms, sensor pad alarms, and cushion alarms).

The addition of more direct caregiver involvement, as well as input from the Engineering, Housekeeping, and Admissions staff, has enhanced development of specific protocols for more appropriate intervention. These protocols are presented to the Safety Committee as well as the Quality Assurance/Performance Improvement Committee for review and approval prior to implementation. After protocols are approved by the committees, they are distributed to all departments for staff education on them.

Active involvement by the Medical Director in risk management meetings since August 2003 has also contributed to our success. The Medical Director has focused on medical factors contributing to falls, including possible medication side effects/interactions and suggestive laboratory data. He recommends treatment adjustments, as indicated, to the unit medical staff.

Program Outcomes

We saw a decrease of 283 falls from 2002 to 2003--a 23.27% reduction (figure 3, see p. 33). In terms of resident falls per 1,000 patient care days, this was a decrease from 4.76 falls per 1,000 resident care days in 2002 to 3.66 falls per 1,000 resident care days in 2003.

Review of the CHSRA reports shows that we have continued to rank below the comparison facility groups in falls incidence and have seen our percentages decrease during many months (table 2). Overall, our percentile rank has been less than 50% and has gone as low as the 17th percentile.

Among other results, we have found that the use of various resident-assist devices mentioned earlier, such as automatic wheelchair brakes, bed and wheelchair sensor pads, motion sensor pads, motion sensors, and wheelchair seat belt alarms, has greatly enhanced resident quality of life. Approximately 70% of residents using such devices have experienced no further falls.

Another noteworthy outcome can be seen in the compliance statistics derived from the resident fall audit tool. This tool asks questions such as: Is there a completed investigation report that accurately summarizes the investigation, with a conclusion? Was the resident identified as high-risk for an accident/incident on the care plan? Are preventive measures appropriate to resident/specific circumstances being initiated or in place to prevent future occurrences? Overall compliance with such criteria was 96% by the last quarter of 2003, compared with an overall compliance rate of 65.2% for the same time period in 2002--an overall improvement of 30.8% in one year. Specific changes in policies and procedures, as well as staff education and our ongoing reconstruction of the risk management program, are credited with contributing to this improvement.

The decrease in resident falls has increased staff satisfaction and feelings of success--and, as a result of the decrease, they have fewer Accident/Incident forms and investigations to complete.

Conclusion

As a team we feel a great sense of pride and accomplishment. Evaluation of outcomes and discussion of collaborative efforts continue within the risk management teams and at each quarterly Safety Committee meeting. In addition, all performance-improvement project accomplishments and goals are discussed annually at the Performance-Improvement Committee meeting each January, as well as on an ad hoc basis at quarterly meetings throughout the year. Throughout the year meetings are held with all levels of staff to discuss the falls-prevention program and need for changes and/or enhancement.

The program's success has markedly improved resident and family well-being. There are fewer falls, thus fewer injuries, and an overall decrease in pain and functional decline. Added to this, residents' emotional well-being has improved. There appears to be a decline in residents' fear of falling, depression, feeling of helplessness, and sense of social isolation. Family well-being is heightened in turn.

We have developed a stronger team involvement in resident care because of this program. The team has expanded to include every department, including Housekeeping and Engineering. Every level of staff has now stated that they feel more involved with resident care and are "making a difference."

Through continued staff education on all aspects involved with resident falls, we were able to enhance and improve both the investigative process and accompanying documentation, increase staff awareness of factors that lead to and/or contribute to resident falls, and ultimately produce more individualized and improved quality plans of care. Formal in-services, as well as ongoing one-on-one in-services by the interdisciplinary team and the Risk management/Clinical Care Coordinator and presentations by administrative staff and outside speakers, enhanced our staff education at all levels.

Although not quantified at this time, financial benefits could become apparent in accounting for the reduced time spent by various disciplines, such as nursing, in caring for patients experiencing the results of falls.

We intend to strive for continuing improvement. Future goals include developing a safety/falls-prevention video specific to skilled nursing care and subacute facility clients, families, and staff education programs, and continuing to explore new devices and interventions to prevent falls and minimize injuries.

      JAN  FEB  MAR  APR  MAY  JUNE  JULY  AUG  SEPT  OCT  NOV  DEC

2002  95   81   112  104  98   110   119   103  103   88   97   106
2003  79   90    73   73  93    74    75    73   80   74   64    85

2002 -- Total 1,216
2003 -- Total 933

Figure 3. Monthly reports of resident falls, 2002 to 2003.

Table 1. Failure mode and effects analysis (excerpt)

Potential Failure Mode       Frequency  Effects                 Severity

1. Ineffective standardized  8          Resident may fall          5
   preventive interventions
2. Investigation conducted   8          1. Cause of fall not       5
   inconsistently, poorly,                 identified
   or incompletely                      2. Plan to prevent
                                           recurrence not
                                           initiated or
                                           specific to the
                                           resident
3. Appropriate staff         8          1. Limited input           5
   participation                        2. Less individualized
                                           plan of care
4. Review at risk            8          1. Device/plan not         5
   management                              individualized to
                                           meet resident's
                                           needs
                                        2. Routine requests
                                           for rehab
                                           evaluation
                                        3. Resident reviews
                                           missed
5. Ineffective resident      8          1. Resident                5
   education/reinforcement                 noncompliant
                                        2. Resident will not
                                           use device
                                        3. Resident may fall
6. Reevaluation of           8          1. Resident may fall       5
   effectiveness of revised                before scheduled
   care plan by                            interdisciplinary
   interdisciplinary team                  team reevaluation

                             Likelihood
Potential Failure Mode       of Detection  Potential Causes

1. Ineffective standardized       6        1. Unavoidable
   preventive interventions                2. Staff did not carry out
                                              plan appropriately
                                           3. Limited resources
                                           4. Lack of education
2. Investigation conducted        6        1. Lack of education
   inconsistently, poorly,                 2. Staff noncompliance
   or incompletely                         3. Lack of communication
                                           4. Risk management process
                                              not user-friendly
                                           5. Inaccurate/ incomplete
                                              information
3. Appropriate staff              5        1. Information not elicited
   participation                           2. Poor attendance/
                                              participation
                                           3. Staff noncompliance
4. Review at risk                 8        1. Lack of availability
   management                                 of alternate resources
                                           2. Implementation of generic
                                              plan
                                           3. Inadequate record keeping
5. Ineffective resident           5        1. Presence of impaired
   education/reinforcement                    cognition
                                           2. Lack of staff education
                                              reinforcement
                                           3. Lack of resident
                                              understanding of teaching
                                           4. Did not call/wait for
                                              assistance
6. Reevaluation of                8        1. Lack of timely follow-up
   effectiveness of revised                2. Lack of expertise in falls
   care plan by                               management
   interdisciplinary team

                              Risk Priority  Risk-Reduction
Potential Failure Mode        Number*        Strategy/System Redesign

1. Ineffective standardized   240            1. Staff education
   preventive interventions                  2. Increase availability of
                                                resources
2. Investigation conducted    240            1. Staff education
   inconsistently, poorly,                   2. Revision of
   or incompletely                              investigation on process
                                                (increase user-
                                                friendliness)
3. Appropriate staff          200            1. Reassign direct
   participation                                caregiver
                                             2. Mandatory attendance
                                                of interdisciplinary
                                                staff who work
                                                directly with the
                                                resident
4. Review at risk             320            1. Education
   management                                2. Increase availability
                                                of resources
                                             3. Development of team
                                                structure
5. Ineffective resident       200            1. Staff education
   education/reinforcement                   2. Reassess resident's
                                                cognitive status
                                             3. Assess/confirm
                                                resident's understanding
                                                of education
6. Reevaluation of            320            1. Reevaluation of revised
   effectiveness of revised                     care plan within 1 month
   care plan by                                 by risk management group
   interdisciplinary team                    2. Staff education

*Product of Frequency, Severity, and Likelihood of Detection.

Table 2. Kings Harbor Multicare Center's fall incidence rate* for
selected months

March 2002   11.0%                      March 2003   10.6%
June 2002    14.2%                      June 2003     9.0%
Sept. 2002   14.6%                      Sept. 2003    8.4%
Dec. 2002    10.5%                      Dec. 2003     8.4%

*Data for 2002 from the Center for Health Systems Research and Analysis
(CHSRA) at the University of Wisconsin--Madison indicate that New York
State long-term care facilities had 14.6% of their resident populations
experience a fall.

For further information, phone Toni Mooney, RN, Vice-President of Nursing/Performance Improvement at [phone]. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].

RELATED ARTICLE: FACILITY TEAM

Program Staff

Toni Mooney, RN, Vice-President Nursing/Performance Improvement

Randi Feigenbaum, RN, Director of Nursing

Alice Massa, Director of Rehabilitation

Hilary Rizzo, RN, Assistant Administrator

Roy Goldberg, MD, Medical Director

Marie Knapp, RN, Risk Management/Clinical Care Coordinator

Program Directors

Maxine Hall, RN (Manor Building)

Judy Henrys, RN (SNF Building)

Candace Spencer, RN (Subacute Units)

Vivienne Bartley, RN (Pavilion Building)

Juliette Clifford, RN (Evening Program Director)

Team Leaders

Rohinie Hereman, RN

Una Smith, RN

Mercena Mattis, RN

Therese Sigauke, RN

Kira Slipak, RN

Chandroutle Brijlall, RN

Team Liaisons

Lisa Boucher, PA; Lou Kaplan, PA; Pat Spatola (Chief Clinical Dietitian); Kathy Shea (Assistant Director of Social Services); Lillian Rodriguez (Director of Therapeutic Recreation); Carolyn Perito (Assistant Director of Therapeutic Recreation); Lorraine Bernardone (Director of Health Information); Jessica Gangi (Assistant Director of Social Services); Helaine Blye (Director of Speech and Language)

Staff Development

Wavenine Collymore, RN, and Hilma Moore, Staff Development Coordinators

Note: A successful program would not be possible without all staff from Dietary, Social Services, Rehabilitation, Nursing, Medical, Resident Assessment, Security, Case Management, Performance Improvement, Staff Development, Engineering, Housekeeping, and Admissions, who are involved with our residents and families on a daily basis.

We extend special thanks to Morris Tenenbaum, CEO, and Alexander Stern, Administrator, whose support and encouragement are invaluable in every project we undertake.

BY THE STAFF OF KINGS HARBOR MULTICARE CENTER, BRONX, NEW YORK