Falling Leaves Protect Falling Residents.

How one SNF cut resident falls in half over a two-year period

Successes are meant to be celebrated and shared. Although we are not the first to be successful in significantly reducing falls, we feel that our "successes" can be easily replicated. We feel that there are steps that can be taken immediately to start the process.

Comparing the January to October period of 1998 with the same period in 2000, we found that the number of resident falls had decreased from 214 to 105. We thought that our more than 50% decrease in falls was significant and worthy of comment. Others in the industry have inspired us, and we would like to encourage other facilities that are struggling in this area.

Although we had always believed our facility provided good basic care, we had to come to the sobering realization that we were "falling flat" when it came to fall prevention. Administration knew that the best way to solve this problem was to create a team and hold its members accountable for an action plan. Even though administration initiated the wake-up call, we knew that success would never come until a team of players took full ownership of the process. Thus was born a quality improvement (QI) plan, overseen by our QI coordinator.

A prerequisite for successful analysis of the problem was data collection. The QI coordinator compiled the data in different formats so that analysis became easier. For instance, if we wanted to find out when the falls were happening, we had a chart that broke the time frame down into 24 one-hour segments. Showing the statistics by week and by month gave us still another perspective, as did using a calendar to chart frequency of falls.

Another study clearly identified which residents were falling most frequently; this enabled the administrator to follow up on whether we were responding appropriately to "frequent fallers." Along with an Incident/Accident log, we had a report that showed, within a progressive daily format, time of fall, shift on duty, name of resident, description of occurrence, the type of injury (if there was an injury), where the fall occurred and whether or not there was a fracture.

After the team members (director of nursing, activities director, QI coordinator) were appointed to start devising an action plan, the QI staff coordinator clearly took on the leadership role. Two new committees were set up: One was to act immediately on identified problem areas and to focus on the "individual," i.e., if an individual had fallen, the critical areas were looked at immediately. The second committee, which met regularly but with less frequency, looked at systemic issues and reviewed and discussed outcomes. The two committees over lapped in composition and complemented each other nicely in looking at both the short and long term.

A visual symbol of falling leaves was adopted. Everyone who lives in the northern area of the country can relate to the visual of falling leaves. Thus, leaves hanging outside the doors of those who were at high risk became a visual alert to all staff. Everyone seeing these leaves knew the necessity of making frequent visual checks of these high-risk residents. And all staff, not just nursing, were to respond to these residents' needs.

Committee members were encouraged to attend training sessions outside the facility, to visit other facilities that had successfully implemented programs, to read related journal articles and to study other organizations' procedures. Education and training were always key to the process.

A program such as ours has other keys to success. For example, commitment from administration needs to be unwavering; this communicates the serious ness of the mission. Even more important, however, than administration sup port, team players working on the problem need to take full ownership. There needs to be, in particular, a "hands-on" staff member who is vigilant in resident assessment and followup, providing consistency within the program. Our staff members identified our restorative care nurse as a "hands-on expert." With one of her main responsibilities being to maintain and improve resident mobility, the restorative care nurse became responsible for overseeing, analyzing and creating approaches that would both eliminate falls and increase awareness of them.

The immediate response to accidents is also critical to successful outcomes. An "Immediate Need Care Plan" is used whenever an accident/injury/fall occurs. We realize that the window of opportunity for finding the reason for a fall is, in fact, immediately after the fall. The fall is the symptom. If you don't find out "why" on the first fall, the resident will fall again. After taking immediate action, physical therapy and occupational therapy are asked to perform screening assessments of the resident after the incident. The care plan team chairperson is notified so that "fine-tuning" of the "immediate" plan can be accomplished. Making sure that staff know of the plan at shift changes is extremely important. If frontline staff members aren't made aware of the is sues, changes and plans, then all assessment and planning are worthless.

Restorative nursing collaborates with therapy staff to identify residents who are considered "high risk for falls." Tools used to make this determination consist of therapy admissions screens, fall assessments, fall task force written recommendations and quarterly PT screens. Qualifying factors for being considered "high risk" designation are:

1. scores of 10 or above on our fall as sessment tool;

2. two or more falls in a one-month

period;

3. a history of falls;

4. a medical condition which directly impacts on equilibrium and/or vestibular awareness, i.e., hypertensive disorders, ambulation dysfunctions, balance disorders, etc.

These are the residents who have brightly colored decorative leaves placed above their door frames. All employees who pass by the identified room(s) automatically perform a quick, nonintrusive visual check of the resident and surround ings for safety issues, i.e., resident sliding out of chair, moist or cluttered floor, and safety devices in place. All employees who find unsafe conditions are expected to correct them immediately when possible and report directly to charge nurse(s). If a repair is required to ensure safety, the employee will complete and submit a maintenance request form.

A resident can be discharged from our "Falling Leaves Program" if she or he meets these criteria:

* The resident is no longer considered "at high risk for falls" by demonstrating an increase in functional mobility status, balance and/or safety awareness that has been documented in therapy records.

* There is a change in the resident's medical status that prevents functional mobility.

* There is no report of the resident falling in a 90-day time period (although the resident might be kept in the program longer if the physical therapist or fall prevention task force deem it necessary).

* Fall committee, restorative care nurse and PT document that the resident is no longer considered at risk.

* Fall assessment tool declines below a score of 10.

An obvious factor in fall prevention is employing sufficient staff. With high-risk "fallers" who tend to wander, staff from different departments have to "tag team" to directly supervise the residents and help prevent injury. If the resident is unwilling to participate in or, at the very least, be distracted by activities programming--another very important component to fall prevention, by the way--staff from other departments might walk with him or her for a period of time.

It is also very important for the fall prevention task force not to beat itself up over perceived failures, but rather to analyze them and move on. It is also important for everyone to realize that this is not "administration's problem," but requires a coalition of different departments working together to manage it.

The Falling Leaves Program is explained to every employee. What's more, we have an employee safety committee, which helps increase staff awareness and participation in The Falling Leaves Program. Without a keen sense of awareness on everybody's part, positive outcomes will never be realized.

Quality improvement is never done, and neither are we. Recent careful analysis of our data leads us to believe that we can improve even more by focusing on "troubled times" and unsafe areas, and that is what we are doing.

Jonathan Doty is the administrator of Chapel Pointe at Carlisle, a skilled nursing facility in Carlisle, Pennsylvania.