Reduction of Risk for Falls Program: Adapted from a 2002 OPTIMA Award entry by Evangelical Manor, Philadelphia. (Feature Article).

For more than a century, Evangelical Manor has served the Philadelphia community by providing residential living accommodations and independent living, assisted living and licensed nursing care for persons of retirement age.

The facility's Health Center has 120 beds--a 60-bed unit for skilled nursing and long-term care, and another 60-bed special-care unit for residents with dementia. The retirement living facility is licensed for 50 personal-care beds out of 174 residential apartments.

In an effort to self-evaluate resident care and services, facility administration embarked on several endeavors to promote improvement. One of the resident care areas focused upon was the transition from quality-assurance to quality-improvement programs. The Reduction of Risk for Falls Program, a result of this process, began in October 1999 and continues to this day.

Readers might recall that in 1999, facility quality-indicator (QI) reports were promulgated by the then Health Care Financing Administration. The impetus for establishing the Reduction of Risk for Falls Program arose when the facility began analyzing its Facility Quality-Indicator Profile (FQIP), comparing it with various QIs of other facilities in the state. One of the rules is that any percentile ranking of 70 or more for problems warrants investigation for improvement. Evangelical Manor's FQIP report showed a percentile rank for falls of more than 70% for seven of nine months reported.

The facility's QI data on "Accidents--Incidence of New Fractures" and "Prevalence of Falls" are shown in Table 1.

Although the clinical staff acknowledged the facility's problem with resident falls, discussing this during Care Plan conferences had no impact on resident falls during the remainder of 1999. The clinical team had not previously focused attention on falls, the interventions that might reduce their incidence or how to prevent serious fall-related injuries. The QI reports, though, clearly necessitated an immediate response.

A Quality-Indicator Review (QIR) Committee was established in late 1999 under the leadership of the new assistant director of nursing. Its initial meetings included representatives from nursing (nurses and aides) on all three shifts, an occupational therapist, a social worker, a registered nurse assessment coordinator, a restorative nurse, the director of nursing, the administrator and a healthcare consultant we had retained to assist with the QI process. The "Prevalence of Falls" QI was identified as a priority area.

Trending of falls data showed great fluctuations in the facility's monthly percentile rank. The QIR Committee did not understand why these statistics varied so, but agreed to investigate the variance as part of the process. The committee set as its goal an improvement in the percentile rank for falls of 10% annually, starting with the 1999 annualized rate of 78%.

After deliberation, the QIR Committee decided to establish a structured program, which included creating an indepth "risk for falls" assessment with its own scoring methodology, a plan-of-action process to develop recommendations for the Care Plan Team, improved documentation practices, and computerized tracking and trending of falls data.

The structured Reduction of Risk for Falls Program started with the identification of audit criteria--factors that could contribute to resident accidents, including new fractures resulting from falls. The committee discussed and fine-tuned a list of criteria for use in a baseline Falls Audit, and committee members were trained on audit procedures, which included resident sampling, maintaining resident information confidentiality and performing chart reviews.

The initial audit criteria were:

1. Is section J4 of each resident's MDS coded for falls?

2. Is the resident using psychotropic medication or blood pressure medication, and are related diagnoses noted?

3. What time of day was the fall recorded?

4. What are the resident's ambulation status, locomotion level; use of walker, cane, wheelchair; and needed transfer methods?

5. Does the resident use fall-preventive devices (e.g., motion monitor, side-rails)?

6. Has a PT/OT consult for gait and ambulation been completed?

7. Does the resident have a history of falls?

8. How is the resident's vision?

9. Any physical or sensory impairment?

10. Any cognitive impairments leading to poor judgment?

Of the nine residents in the initial fall sample, five had received an OT/PT evaluation within a relatively recent period; all nine had vision impairments; six had physical/sensory impairments; and seven had cognitive impairments. However, the audit team found inconsistencies in data collection and suggested that the criteria be revised. The revised criteria were as follows.

1. Are there predisposing conditions or diseases present that might contribute to falls?

2. History of falls?

3. Impaired vision?

4. Any perceptual disturbances?

5. Problems in communicating needs?

6. Any physical or sensory impairments?

7. Any cognitive impairments?

8. Did any falls occur within a month after admission to the facility? Any falls after 31 to 180 days?

9. Any use of blood pressure or psychoactive medications? What are the diagnoses?

10. Time of day of the fall?

11. Resident's ambulation level prior to the fall?

12. Resident transfer needs prior to the fall?

13. Are protective or assistive devices used?

14. Has a PT/OT consult been done in last 3 months? What type?

15. Did the resident sustain a fracture as a result of the fall?

16. Was a fall risk assessment completed, dated and noted on the Care Plan?

For this baseline audit, samples were varied from 4 to 12 residents, depending on the monthly FQIP report. Audits were completed monthly for the first three months and repeated quarterly thereafter. New residents at risk for falls were added or deleted monthly. Audit findings were obtained from the incident reports and medical record entries in the physician history and physical, physician orders, MDS, nurses' notes, mood and behavior tracking forms, restorative nurses' notes, dietary notes, medication administration notes, blood pressure log, therapy notes, consultant notes and walking rounds reports.

The committee developed a Plan of Action form, with a section of recommendations to the Care Plan Team. The Plan of Action also included recommendations for revision and creation of new clinical forms (Table 2) and policies related to falls activities.

A Falls Alert Program was developed using large pink dot stickers to be placed on room nameplates of residents assessed to be at risk for falls. The pink dots also were placed on the spine of the resident's medical record, on the Care Plan as displayed on the chart and in the room, and on the resident's wristband. Staff, residents, families and visitors were instructed about preventing falls through observation and use of multiple interventions.

Below are several sample measures used in prompting investigation of contributing factors to falls:

Predisposing diseases. Staff reviewed residents who triggered on the FQIPs with diagnoses that might have contributed to the residents' risk for falls. Interventions were noted in the residents' Care Plans.

History of falls. Residents with a history of falls had their Care Plans reviewed and updated to include additional approaches, such as monitoring awake time location with supervision. Staff also monitored residents for whom falls had recurred in the previous 30 and 180 days.

Mental status. Staff reviewed residents' pattern of falls by shift and time to determine their relation to periodic or general confusion when residents were tired or waiting to get into bed. Siderails as enablers were requested by residents or ordered by the physician to assist in positioning, and to serve as a reminder of boundary limitations and a measure of safety during bed mobility. Evangelical Manor's goal is to remain as restraint-free as possible.

Vision status. The program alerted staff, the resident, family and visitors about the resident's need for glasses. Residents who demonstrated vision problems received eye examinations, glasses or lens changes.

Gait stability. Staff reviewed physician orders, MDSs, nurses' notes, restorative nurses' notes and therapy notes to determine residents' gait problems and/or use of assistive devices when ambulating and transferring. Therapists screened residents who had noticeable gait problems.

Elimination status. Staff reviewed physician orders, MDSs, nurses' notes, dietary notes and medical consults to determine residents' level of continence and bowel/bladder patterns. CNAs were reminded about the importance of timeliness in assisting residents to the bathroom.

Hydration status. Staff reviewed residents' intake of liquids and food. This review was screened by the dietary manager, who determined whether medication caused dehydration, dizziness or disorientation. A hydration program was developed by the nursing and dietary departments for all residents. Nursing monitored residents' daily fluid intake.

Medications. Staff reviewed physician orders, MDSs, medication administration records (MARs) and nurses' notes for residents' use of and response to medications. Stafflooked for drug-drug interactions, use of nine or more medications, and drug-induced side effects. Findings were discussed with the pharmacist, physicians, nurse practitioner and medical director. Medication orders were changed accordingly.

Systolic blood pressure. Staff reviewed diagnoses, physician orders and MDSs, and monitored blood pressure records to determine if residents had experienced dizziness resulting from a drop in blood pressure. Nursing staff were alerted to observe for potential episodes of dizziness when getting residents up from bed or a chair. Medication adjustments were made, as necessary.

To enhance our data collection related to falls, the QIR Committee recommended the development of a computerized falls-data-tracking and -trending system, using Microsoft Access; our information management department developed the program in Microsoft Excel format for easier data entry and graphic report generation. The information obtained with this program is analyzed to better understand the causes of falls. Monthly falls outcome data and graphs are presented at the monthly Quality-of-Life meeting.

The falls data from the FQIPs for 2000, after modifications to the Reduction of Risk for Falls Program, continued to show trending fluctuations. The committee learned by analyzing QI data (Table 3) that the fluctuations involved some, but not all, of the contributing factors. Principal contributors included changes to census, with higher acuity caused by multiple debilitating conditions; residents aging in place and becoming frail; an increase in the number of residents with dementia diagnoses; decline in ADL functional abilities; impairments resulting from cognitive changes; alterations in behavior and mood; the number of residents who did not seek staff assistance when needed; uninformed new employees who lacked knowledge about falls prevention; and turnover among nursing management personnel.

It should also be noted that, despite the many interventions considered, no one intervention worked exclusively to prevent falls. Even with continual supervision and half-hour status checks, a resident attempting to transfer or ambulate with staff standing beside the resident still could--and did--slide to the floor or fall independently.

The program attempted to reduce these fluctuations through a variety of "mini" in-services, both formal and informal, on such topics as:

* Completion of "risk for falls" assessment and checklist

* Orientation of new residents to their rooms and environment

* Completion of visual and gait stability checks on at-risk residents

* Completion of interdisciplinary environmental unit rounds to remove hazards from the environment

* Instruction of residents, families and visitors to ask staff for assistance with residents, as needed, when ambulating, transferring, etc.

* Instruction of residents on use of ambulation devices when ordered

* Inspection of ambulation devices for safety by CNAs, restorative aides and maintenance staff

* Audit of falls-prevention interventions in residents' Care Plans

* Continuing implementation of the Falls Alert Program, with its pink-sticker identification approach

* Documentation of possible contributing factors, as prompted by the I&O Report

* Documentation of shift, time, type and location of falls, including any witnesses, on I&O Report

* Avoiding hallway clutter (furniture, equipment on nursing unit

* Cleaning up floor spills promptly

* Checking motion monitors for good operation

* Checking residents' shoes and slippers for proper fit and nonskid soles

* Checking for shiny floors or carpet patterns that could cause confusion for residents with dementia

* Reviewing appropriate siderail use

* Continuing consultations with physicians, psychiatrist, nurse practitioner and pharmacist regarding medication utilization, and discontinuing meds when possible

* Purchasing low beds, positioning devices and cushions, etc., to minimize residents' falls from bed

Outcomes

The QIR Committee's analysis of data from the computerized tracking and trending software, along with their evaluation of resident outcomes, captured the following list of outcomes (representing 80 fields of data gathered monthly):

* The highest number of recorded falls were not witnessed (e.g., reported as "resident found on floor").

* The second highest number of recorded falls were "resident slid to floor" while standing beside staff

* The frequency of falls was greatest during the 7 a.m. to 3 p.m. shift, followed by the 3 p.m. to 11 p.m. shift.

Significant falls also occurred:

* on the unit "Health Center II," where the majority of residents have a diagnosis of dementia and/or cognitive, mood and behavior problems;

* during wheelchair transfer or while walking in the room;

* among residents with limited ADL functioning;

* among residents who are "ambulatory with assistance," followed in incidence by residents with independent ambulation;

* among residents noted as having altered mental status;

* among residents who are prescribed (in descending order) antidepressants, antipsychotics and antianxiety medications;

* among residents using a wheelchair, followed by residents using a rolling walker;

* among residents with a history of falls; and

* among residents who did not use their call bell to summon staff assistance.

An Ongoing Challenge

Since 1999, when the Reduction of Risk for Falls Program was initiated, the QIR Committee leadership and members have continued to experience frustration over the fluctuations in the "Accidents--Incidence of New Fractures" and "Prevalence of Falls" statistics (although it has been determined that many of the new fractures were not associated with falls and required other approaches to staff training and operations--perhaps the subject of another article). The QI data for the first five months of 2002 are shown in Table 4.

Overall, the annualized percentages for falls were 78% in 1999, 40% in 2000, 69% in 2001 and, currently, 84%. These data reflect an increase in the documentation of the incidents of "resident found on floor" as a result of a slide or fall. Post-fall data showed fewer residents being sent to the ER and fewer serious injuries resulting from a fall. This documented, in short, an important change in resident outcomes that can be attributed to the many facets of the Reduction of Risk for Falls Program.

Management continues to support the QIR Committee's and clinical staff's efforts to reduce the risk of falls, knowing that to do less or nothing would lead to even higher occurrences of falls with serious injuries. The committee remains focused and determined to meet the challenges involved.

As a further encouragement, during both the state survey in April 2002 and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) survey in May, the QIR Committee presented the quality-indicators facility program, highlighting the Reduction of Risk for Falls Program. The nursing facility and the personal care program were deficiency-free and received full JCAHO accreditation.

The process is ongoing, with success measured in both reduction of serious injuries--including those from fractures--and reduction of ER visits or hospitalizations as a result of falls. The clinical team is committed to improving these results, and will continue all efforts to achieve positive outcomes and improve residents' quality of life.

Table 1

Quality Indicators for Accidents and Falls, 1999.

Date   New fractures  New fractures:     Falls       Falls:
          (No. of     QI percentile     (No. of   QI percentile
         residents)        rank       residents)      rank

1/31         0              0             12          100
2/28         1             86              6           71
3/31         0              0              8           77
4/30         0              0              8           77
5/31         0              0              4           44
6/30         0              0             11          100
7/31         1             73              5           35
8/31         0              0              8           83
9/30         0              0             10           92
10/31        0              0              8           79
11/30        0              0              7           81
12/31        0              0             10           92

Table 2

Recommendations for Forms and Policies.

Form                   Revision          New


Resident Nursing       Add functional
Assessment             section that
                       triggers
                       all residents
                       for a full
                       Falls Assessment

Falls prevention--                       Outline questions the nurse
resident review                          asks to gather data about
checklist                                the potential for falls

Plan of Action                           Create an outline to
                                         identify the problem and
                                         make recommendations to
                                         the Care Plan Team about
                                         falls prevention

Incident and           Expand report to
Occurrence Report      include more
(I&O)                  information on
                       data related to
                       falls

Clinical Review                          Use Incident Report Audit
Committee--                              data to follow up on
Accidents/Falls                          potential causes of falls

Falls Risk Assessment                    Use the latest Falls
                                         Audit criteria to score
                                         a resident's degree of
                                         risk for falls

Restorative Nursing                      Expand functional ADLs to
Assessment                               include interventions to
                                         maintain or improve
                                         resident mobility,
                                         transferring and use of
                                         supportive equipment

Low-Rehab/Nursing                        Complete by therapist
Restorative Referral                     after a nursing resident
Instructions                             referral for screening of
                                         potential decline in
                                         ADLs involving risk
                                         of falling

Falls Tracking and                       Develop an Access
Trending Computerized                    software program to
Program                                  trak and graphically
                                         trend data from I&O
                                         Investigative Report

Table 3

Quality Indicators for Accidents and Falls, 2000.

Date   New fractures   New fractures:    Falls         Falls:
          (No. of            QI         (No. of          QI
         residents)   percentile rank  residents)  percentile rank

1/31         0                0            4             23
2/28         3              100            8             74
3/31         0                0            6             71
4/30         1               84            6             79
5/31         1               95            1              8
6/30         3               99            5             78
7/31         0                0            3             22
8/31         1               80            5             60
9/30         0                0            0              0
10/31        1               77            4             29
11/30        0                0            2             18
12/31        0                0            2             21

Table 4

Quality Indicators for Accidents and Falls, 2002. *

Date  New fractures  New fractures:     Falls         Falls:
         (No. of           QI          (No. of          QI

        residents)   percentile rank  residents)  percentile rank
1/31        1              83             9             91
2/28        1              87             7             82
3/31        1              93             5             82
4/30        0               0            15             86
5/31        0               0             8             79

* First five months

Barbara Hacker, RN, MEd, NHA, is a healthcare consultant for Evangelical Manor. Contributing to this article was Patricia Sebold, RN, assistant director of nursing and quality-improvement coordinator for Evangelical Manor. For further information, phone [phone]. For more information on the OPTIMA Awards, visit www.nursinghomesmagazine.com. To comment on this article, please send e-mail to [e-mail].