Resident falls and elopement: costs and controls.

Recently I had the opportunity to visit a long-term care facility and perform a Workers' Compensation audit on resident and employee safety. This particular facility, like most, had a staircase that led to the lower level, which housed the maintenance office, housekeeping, and laundry. Access to the staircase was near a lobby area toward the back of the facility; the door had a key pad to unlock the door, but the door sometimes failed to close completely. The door was not alarmed. As a result, a resident could literally walk out the back door undetected. There was enough traffic near the stairwell to allow the resident to walk to the staircase area and, possibly, fall to the lower level.

My guess is this situation is not uncommon in nursing facilities. This may explain why falls are the number one problem in long-term care facilities and can not only cause great human suffering, but cost thousands of dollars in legal judgments, depending on the nature and severity of the accident.

Some elopement claims data that must be considered are: 1) 70% of elopement claims involve a resident death; 2) 45% of elopements occurred in the first 48 hours of admission; 3) 80% of elopements involved chronic wanderers.

In claims against nursing homes, the most frequently reported plaintiff contention is negligent supervision, and the most frequently reported injury is wrongful death. Overall awards range from a midpoint verdict of $180,000 to a verdict in the neighborhood of $1.5 million. As you can see, costs can be staggering.

What can be done to reduce this exposure? Let's consider a very important factor in elopement. We all remember our first day on the job and how it took awhile to orient ourselves to our new surroundings. Such is the case for new residents acclimating themselves to a totally new environment. These changes can cause curiosity, restlessness, and sometimes depression. The wandering that can result often leads to accidents, usually within the first 48 hours to 72 hours of a resident's stay.

Reducing this exposure demands careful attention. To begin with, during the resident's crucial first few days, the staff should make a point of developing an individual fall profile as part of the routine orientation program. A formal fall profile risk assessment program will not only address the facility's major concern, but will be consistent with the requirements of OBRA '87.

The assessment program should take at least four weeks. Some elements of a good fall assessment program would include:

* Reducing fall potentials:

* Providing resident and employee training in avoidance;

* Maintaining focus on the resident's primary care needs;

* Providing quarterly fall in-service training.

Staff should be oriented toward its own safety, as well. After all, resident falls can also lead to employee back injuries when they catch residents or lift them back to their chairs or beds.

When a resident is placed on the fall prevention program, the following questions should be addressed:

1. Is the resident's room clearly identified for relevant preventive measures and rapid response?

2. Has the resident's medication been assessed?

3. Can the room be observed from the nurses' station?

4. Is the resident wearing proper footwear?

5. Have regular room checks been established and documented?

6. Has the staff involved with this resident received yearly in-service training?

7. Have any past falls been investigated thoroughly?

It is also very important to closely supervise new residents and help them through their awkward period of adjustment. Procedures for close room checks in the first few days will be beneficial for both safety and liability reasons.

It is also important to be able to specifically identify and respond to potential wanderers. Since we cannot have observation 24 hours a day on each and every resident, we must have all doors alarmed for unauthorized exiting or have those residents who could possibly elope equipped with individual identification bands or anklets that will trigger a sensor when an eloper attempts to leave.

Use of such devices emphasizes the importance of training and education of the staff. In many cases, exit alarms are deactivated during the day. Even if an alarm does sound, staffs often go about doing business as usual. This attitude can lead to a serious injury or death, and obviously cannot be permitted to continue.

One of the key elements here is the resident's relationship with the staff. A good staff/resident relationship can boost not only attention to detail regarding resident wandering, but improve overall performance. In line with this, the staff should come to realize that it is unacceptable to not check out an alarm that has sounded or ignore the possibility that a resident has triggered the alarm.

From the standpoint of management, it is important to realize that the way administrators and supervisors treat their staff has a significant impact on facility safety and overall quality care. Facilities should strive to maintain a good working environment. Wages and benefits are important, but intangible support is even more fundamental to keeping satisfied employees and providing good, consistent care. Workers should be made to feel worthwhile and that their personal needs are of concern.

In fact, the basic formula for a safe facility is simple: a) workers know that management cares about them; b) they are encouraged to take personal initiative; c) they are reminded that residents' safety is in their hands; d) they are shown how to implement it.

John Rodriguez, ASP, is a senior loss control consultant with Willis Corroon Corporation, Nashville, TN, and a member of the firm's Health Care Concepts Committee. He also serves on the board of directors for the Tennessee Safety & Health Council.