Preventing falls through environmental assessment.

How to "discover the obvious" before the event

Sooner or later, 40% of nursing home residents fall, making falls the nursing home's single greatest exposure to medical malpractice litigation. The MDS mandated by OBRA lays the groundwork for identifying the medical problems that may contribute to falls. But too often, we tend to stop there, when in fact, two-thirds of falls in the nursing home can be attributed to multiple causes not always neatly summarized by the MDS. For this reason, the effective, proactive fall prevention program must be multi-faceted, including medical, psychosocial, quality management, and environmental approaches.

A safe, supportive environment is essential to keeping residents safe from falling -- but the environmental aspects are frequently neglected. Successful environmental fall prevention consists of orienting residents to their surroundings and minimizing their potential for falls by creating a resident-friendly environment.

Resident Orientation

Because the vast majority of falls occur during the first week after admission, allowing residents to remain unfamiliar with their environment for any period of time is an invitation to a fall. Residents should be oriented to the nursing home not only at admission, but after a room change, a significant illness, hospitalization or any other potentially disorienting event. Walking the resident through their new environment takes about 30 minutes, but that half-hour is time well spent. In the first 24 hours after a fall, nursing homes report spending an average of 2 1/2 to 6 1/2 hours dealing with the aftermath.

The orientation not only helps to familiarize the resident with their new surroundings, but also provides the opportunity to ensure that the resident's personal space (room and bathroom) is tailored to his or her individual needs. Ideally, the orientation is conducted by the admitting nurse with support from the rehabilitation therapy department, and includes the following:

1. Walk the resident through their room, pointing out light switches and call buttons. Watch the resident get in and out of bed, noting where they place their feet when getting up. Adhesive strips on the floor near the bed may be needed to improve footing if the resident is stiff or the resident's feet tend to slide.

2. Show the resident the bathroom, pointing out the light switch and call light. Watch the resident simulate getting on and off the toilet, washing their hands, turning to exit, etc. The physical therapist should be involved in evaluating the resident's transferring ability and use of assistive devices, such as canes or walkers, in what may be closer quarters than their bathroom at home. Note the height and location of grab bars. A bar installed on the right side of the toilet to accommodate a previous resident will be of no use to the resident who requires left-sided support.

3. Walk residents through hallways, into the dining and activity rooms and through other public areas. Point out the nearest nursing station, bathrooms, any changes in flooring (such as carpet to linoleum) and guardrails. Many new residents may be unaware that rails on hallway walls are there to assist them.

4. Familiarize the resident with any stairways or elevators in the facility.

5. If residents will have access to an outdoor area, orient them to the exits and entrances and point out any changes in ground surfaces, such as curbs, pavement and grass.

6. The physical therapist should make certain that assistive devices are appropriate for the individual and in good repair. The resident should be instructed in their use. Remember, too, that well-meaning family members may bring in a device that ultimately causes falls rather than maintaining mobility, because of inappropriate height, missing rubber tips or a failure to instruct the resident in its use.

7. The physical therapist should also evaluate the resident's footwear for fit and sole structure. A good walking shoe is safer than the tennis or running shoes that family may bring in. Residents may have to be convinced that wearing heals, sandals, or some slippers may place them at risk for falling.

Facility Evaluation

Performing what amounts to an environmental audit of the nursing home requires that we look at the facility through the residents' eyes. The following areas should be assessed on a routine basis and after any event (construction, major repairs) that alters the environment:

* Ground Surfaces: Avoid carpeting with bold patterns which are disorienting to residents with limited depth perception. Make certain that surface changes (such as carpeting to linoleum) are clearly distinguished. The glare from highly waxed surfaces can be extremely disorienting. Ironically, floors waxed to a high gloss to improve the appearance of the facility pose one of the greatest fall-related risks in the nursing home.

* Lighting: Light switches should be accessible (within reach and workable with arthritic fingers) and visible. Bright-colored contrasting tape placed around switch plates will keep light switches from blending into the wall. Accessibility is especially important in the bathroom, since residents unable to locate the light switch may attempt to use the bathroom in the dark. In hallways where sunlight streams in and reflects off the floors, shades, blinds or curtains help to prevent falls that occur when glare makes floors appear wet.

* Bathrooms: Grab bars in private and common bathrooms should be accessible and in good repair. Because residents may reach for the sink with wet hands, sink edges should be covered with an adhesive strip to create a non-slip surface. Floors must be kept clean and dry.

* Doors/Doorways: Lever-type handles are much easier to grasp than the door knobs found in many older facilities. Doorways should be at least 32 inches wide to accommodate assistive devices. Thresholds should be clearly marked, and the difference in height between the two surfaces should be no greater than 1/4 inch. Make certain any locks on bathroom doors can be opened from the outside. Ideally, the bathroom door should open out into the resident's room. The doors to both the bathroom and the resident's room should open completely to provide ample room.

* Stairs: Stairways must be clearly marked and adequately illuminated. If stairs are carpeted, use a plain, unpatterned carpet kept in good repair. Contrasting adhesive strips will clearly define step edges. Hand rails should be installed on both sides of the stairway and should extend at least 12 inches beyond the bottom step.

* Elevators: All elevators should be equipped with automatic balancing mechanisms to make the floor of the facility and elevator even when the door opens. Elevators should close on a delayed response to give residents sufficient time to get in and out.

* Chairs and sofas: Residents find it difficult to get into and out of chairs and sofas that are excessively low or have no arms for support. A love seat is a better choice than a larger sofa that leaves the person in the middle with no means of support. Because furniture cannot be individualized in common areas, the following rule of thumb is helpful with respect to furniture height: approximately 14 to 16 inches between floor and seat, to accommodate the average adult leg length; space between the thigh and chair cushion indicates the seat is too low. Avoid chairs with cross rails at the base, since the rails will make standing difficult for residents who get up by "pushing off" with one foot behind the other.

* Beds: Beds should be tailored to the individual, with the resident's height considered. In general, manual beds can usually be lowered further than electronic beds and may serve a greater number of residents. Half-siderails serve as effective aids in getting in and out of bed. Full rails may not be easily lowered by residents, who may fall in an attempt to climb out of bed.

* Shelves: Shelving in closets or elsewhere in the residents' rooms and common areas should be low enough for all residents to reach without stretching. Shelf edges should be rounded.

* Tables: Avoid tables with highly polished wood or glass surfaces. As with floors, reflections off high-gloss surfaces can be disorienting and deceptive. Table edges should be rolled and corners rounded.

* Facility exterior: The nursing home exterior can pose risks to residents and visitors alike. Parking lot surfaces should be clearly marked, and asphalt surfacing is far preferable to gravel or other loose material. Steps and ramps must be kept in good repair and receive constant attention during weather changes. Exterior lighting is critical. Many falls occur in areas such as those bordered by curbs, where elevation changes. Fluorescent paint helps to make these problem areas more readily visible.

The facility exterior -- and, for that matter, interior as well -- is of special concern when residents tend to wander. A variety of personal and facility wander alarms are available to alert the staff when residents attempt to leave the building, their rooms, or even their beds and chairs, unaccompanied. Such devices, appropriately used, can eliminate many mishaps.

Restraint Reduction

A thorough environmental audit should include an assessment of the nursing home's policy regarding the use of restraints. The trend toward reducing or eliminating restraints remains a common source of concern for many nursing home administrators and managers who fear that fewer restraints will mean more falls. Despite a possible initial slight increase, implementing a restraint reduction program will not increase, and will likely decrease the incidence of falls if the program is a progressive, comprehensive one that includes strong support from rehabilitation therapy staff, with daily ambulation and transfer retraining. In fact, restraint reduction and fall prevention have proven to be fully compatible.

Wander alarm devices play a significant role in attaining both goals. These devices are potentially beneficial for residents with Alzheimer's disease and other dementias, as well as other conditions that impair the resident's ability to perceive or remember simple instructions.

When Falls Occur

Unfortunately, falls will occur despite our best efforts. They require a well-planned response. Once the resident is checked for injuries and treated appropriately, the observable causes of the fall should be identified and carefully documented. However, the key to preventing a similar incident in the future is to resist the temptation to stop looking when a single cause is found. For example, if a resident is found in a pool of urine, continue to assess the surroundings and situation. Was the light bulb in the resident's bathroom burned out? Was the call light within reach? Why wasn't the resident toileted?

The staff member who discovers the resident should fill out the incident report or be present when the report is made by the charge nurse. The report is then reviewed by the administrator, DON, medical director and other safety committee members. More is needed, however: The nursing home that is truly committed to reducing the number of falls in their facility will go beyond merely summarizing the incident reports in general. Submitting those reports to tracking, trending and analysis will help to pinpoint the factors contributing to falls and go a long way toward making the nursing home environment safer.

Joy S. Howe is Director of Long-Term Care Services at Cigna Property and Casualty Insurance, based in Philadelphia, PA. Ms. Howe has 18 years of experience in long-term care as a nursing home administrator, DON and retirement center executive director. She has served as a marketing and development consultant for nursing homes and retirement centers.