Minimizing risk in the nursing home.

Accidents among nursing home residents can cause a variety of problems, ranging from the obvious adverse effects on the emotional and physical well-being of the resident, to negative publicity that ends up reducing nursing home morale and even advmissions. Invariably, they lead to added costs, as well. Fortunately, most accidents are preventable, or can be reduced dramatically, through a sound risk management program. The key is in knowing which situations pose greatest risk in nursing homes, and what to do about them.

Falls While Assisted

Falls cause the majority of injuries in the united States and are, by far, the greatest risk for health-care facility residents. Falls accuont for two-thirds of all large claims against nursing homes.

It is often thought that resident injuries from falls take place when the resident is alone. Such is not always the case. Many injuries occur while residents are being cared for by the staff.

In many cases, defective equipment can cause the problem. A wheelchair with defective brakes, for example, can cause an injury as the resident is being moved to or from the bed and to or from the wheelchair. Periodic checks on the proper operation of equipment is vital to any preventative program.

Bath water temperature is another potential trouble area. Valves that are supposed to keep water temperature below 105[degrees]F are known to fail. Bath water must be checked by the staff regularly to make certain that a dangerously high temperature does not exist.

Lifting a resident is another major source of trouble. Even with mechanical lifts, or the so-called hoyer lift, problems can occur. Residents may slip out of the device if safety straps are not properly used. Residents should be lifted by more than one staff member. Even when using a hoyer lift, two or even three staff members should be present.

The condition of the resident should always be taken into consideration. Some residents require more assistance than others and this should be indicated clearly on their chart. A sound in-service program on this phase of the nursing home's operation is an important part of any risk management program.

Physical therapists tell us that residents should not be lifted under their arms. A gait belt should therefore be used whenever possible, especially when lifting the resident on and off a toilet seat where space is cramped and options for holding the resident are limited. Staff should be instructed on when and how to operate there useful devices.

The shower is another potential, and proven, hazard for falls. Often staff forget to provide safety straps when the resident is in the shower chair.

Preventing Falls

In general, your staff must be alerted to all the potential dangers facing residents and should be trained in proper procedures when handling their charges. Further steps can be taken to reduce the risk of falls.

Certain persons--namely those individuals who use assistive devices, such as wheelchairs, walkers or canes--are the most prone to falls. Also, some residents who are on a number of medications are more prone to fall. Therefore, one of the key risk management tools is to establish a fall profile program that identifies the 10 percent to 15 percent of the residents who are most fall-prone and that directs major attention to these individuals. For example:

1) Upon admission, all residents are given a fall profile assessment and should be reassessed on a regular basis during team meetings.

2) Those individuals in the high-risk category for falling ar eplaced in a falls prevention program.

3) A current list of all residents in the program is posted at the nurse's station.

When a resident is placed in the fall prevention program, identification reminders should be initiated to improve the staff's awareness of the resident. The reminder could include many of the following:

1) A special colored ID bracelet placed on the resident's arm.

or

2) A star or dot placed...

* on the outside door frame of the resident's room.

* above the bed.

* at the call light at the nurse's station.

* on the spine of the resident's medical chart.

* on the nurses aides' worksheets.

3) Room assignment aimed at keeping the resident near the nurse's station for easier observation and, if possible, obtaining a cooperative roommate.

4) Medication reassessment, with a physician or pharmacist as consultant.

5) Scrutiny of footwear.

Visitor Falls

The risk of falling is not limited to residents. Visitors, delivery people and even staff are potential victims of falls that can result in claims against the facility. Some common claims faced by nursing homes include those due to delivery men going up a slippery ramp, a visitor's chair collapsing, a pot hole in the parking lot or a visitor being bumped by an automatic door.

The only way to prevent such problems is through a program that increases the sensitivity of the entire staff to the potential for accidents within and around the facility. Each employee must play a part in noticing, reporting and reducing potential hazards.

In addition, the safety committee should regularly inspect the premises and promptly correct and sources of trouble. If an accident does occur, an efficient response system should be in place, including specific plans to make certain the accident does not recur.

Wandering and Elopement 

A resident's initial week or two are the most critical for assessing this type of nursing home risk. Naturally, the resident is unfamiliar with the layout of the facility, all the new people and the new lifestyle. These sudden changes can easily cause disorientation, depression, withdrawal and restlessness, all of which contribute to increased wandering and attempts to elope or escape.

It is interesting to note that a significant number of falls also transpire during these first two weeks of a resident's stay in a nursing home.

One can usually identify those residents prone to wandering and elopement, and every effort should be made to do so upon admittance. Prime candidates for problems are residents who are mobile, residents with a history of wandering or attempted elopement, or residents who are either slow or resistant in adjusting to admission.

Having an alert staff to provide close supervision is one vital approach. But, since no one can be watched 24 hours a day, other lines of defense need to be set up.

Exist alarms are one of these defenses. Having alarms on all exit doors is an important safety precaution for several reasons. First, they they provide a level of security against intruders and, second, they can alert the staff to people leaving a floor or the preimses, as in the case of a wanderer or an eloper.

However, exit alarms are only a source of security when they are properly used. They have to be activated. Unfortunately, it is not uncommon for some of them to be deactivated during the day with the staff going between floors and not wanting to bother about the alarm. This may explain why at least one-third of elopements take place during the day.

Also, staff reaction to the alarm is an important factor. Staff often go about their business when an alarm sounds, figuring that it is an authorized use of the exit, and then often simply reset the control panel. Some alarms even stop ringing once the door is closed. This lack of response to the danger signal can result in tragic occurrences. A disoriented resident, even in a wheelchair, could push open the door and pitch down the stairs or be out in the street in a matter of seconds.

To minimize such happenings, nursing homes must have a firm and written policy regarding exit alarms. When a staff member hears an alarm, they must investigate immediately.

The most positive approach is to use an individual resident electronic elopement control device for all potential wanderers. These devices will allow visitors and others to exit through regular doors without an alarm, but the patient "eloper" when wearing the electronic device will trigger the exit alarm. All newly admitted residents should wear such a device until their potential for wandering can be established. The individual elopement device is the most practical alarm.

Conclusion

Vigilance is vital in the operation of a nursing home. A dedicated staff, alert management and a sound risk management program can reduce problems as well as the cost of operation. Risk mamagement is a continuous task. Be alert to the particular risk problems of the nursing home and head them off before they occur.

Leo Foxwell is associate director of Health Care Services in the casualty technical services unit of the loss control department at ITT Hartford Insurance Group.