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Out of harm's way: keeping residents safe from falls and wandering can be a challenge.

Many nursing home administrators say the two greatest safety concerns facilities face involve problems with residents falling down or wandering.

Of all injury-related accidents that send folder people to the emergency room, falls fare the biggest culprit. More than three-fifths of injury-related visits by older adults to emergency rooms are due to falls, according to the Centers for Disease Control in Atlanta, Ga. Of the 2.7 million elderly people sent to the emergency room for falls each year, 373,000 people are hospitalized and 11,6000 people die.

There is no sure-fire way to prevent a fall or to keep someone from wandering, but nursing home administrators are coming up with more innovative ways to minimize risks by using new technology, paying attention to detail and just general out-of-the box thinking.

Understanding why some falls occur can be a helpful start. Medication is often a big issue. A patient might be on a medication for behavioral or health reasons that causes dizziness or fatigue, according to Kim Ellis, director of administration from The Sweet Life at Rosehill in Shawnee, Kan.

There can be a fine line between whether a patient needs a particular medication or if it poses a greater risk of falling. Involve the doctor, the facility staff and the family in a team approach to solve the problem, Ellis says. Family members and nurses can work together, for example, by ensuring sure someone walks with the patient to breakfast, lunch and dinner every day.

Another strategy is to anticipate a patient's needs before they come up. By realizing someone is thirsty or may want to read a book, a caregiver can reach for a pitcher of water or a book before the patient gets up, Ellis says.

Keeping them busy

One of the best ways to prevent a fall is to keep a resident occupied, although with an Alzheimer's patient this can be a big challenge, Ellis says.

A cognitive patient can tell you whether she wants to cross-stitch or watch a particular show on television. Someone with Alzheimer's might not be able to explain what they want to do, but they still need to keep busy and feel productive, Ellis says.

"We have one gentleman who kept getting up and moving around," Ellis says. "Then we found out that he liked to do things with his hands, using numbers and papers. So what we came up with was to have him write out his own reports for us. He does this in the mornings and it keeps him busy."

Other facilities encourage staff members to share some of their own hobbies with residents, such as "playing cards, cross-stitching, [or] clipping newspaper articles," says Bethany Alexander, RN, director of nursing for Ruxton Health Woodbridge in Woodbridge, Va.

"If we have a resident who has a high risk for falling and can't be mobile, we might put him in a nice recliner in the TV room or even in a recliner right near the nurse's desk where we'll turn the lights down and put the radio one' Alexander says. "This way we can keep an eye on him and keep him occupied."


The risk of falling rises when residents try to get up to use the bathroom. Again, a cognitive patient is likely to remember to press the call light for help if they've broken a hip, for example. But an Alzeheimer's patient is more likely to try moving on his own, Alexander says.

"We do bowel and bladder assessments on all new residents to gauge how capable they are of toileting themselves" Alexander says.

Nurses set up a toileting regiment for some residents and take them to the bathroom after each meal. For residents who need extra help and have less predictable toileting patterns, nurses may check on them every two hours.

A safe physical environment

Dim or improper lighting in facilities can be hazardous to all residents in a facility. Alzheimer's patients need an entirely different set of physical criteria to prevent falls, says Daniel Kuhn, director of education for Mather Institute on Aging, Evanston, Ill.

Alzheimer's patients perceive flat surfaces differently than most people do, Kuhn says.

"Their depth of perception is impaired," Kuhn says. "So if you have a light colored floor and a dark printed pattern in the middle, people with dementia will misperceive the dark spots as holes and try to step around them."

Dementia patients also have a difficult time distinguishing where walls end and floors begin. "This is why it's important to have a sharp contrast between the color of the wall and the color of the floor, so that Alzheimer's patients don't get confused about where they're going," Kuhn says.

Solid colored floors without patterns also help Alzheimer's patients with their balance, Kuhn says.

Facilities also need to tailor their furniture to fit their resident's ergonomic needs. Although the soft, a low, deep chairs and sofas at many facilities may be comfortable for visitors and some residents, this type of furniture can also cause falls, Kuhn says.

Furniture should be firm, higher off the ground and easier for residents to sit and get up from, Kuhn says.

Beds should also be easy to get in and out of, says George Oommen, director of nursing at Brunswick General Hospital in Amityville, N.Y.

"We have very low beds that are easy to get out of. When a patient swings his legs over the railing, his feet are already touching the floor," Oommen says.

The Ruxton facility puts mattresses on the floor in addition to low beds, because in Virginia bed rails are considered a restraint, Alexander says.

Within a resident's private room, facilities can take other safety precautions, Ellis says.

"We encourage families to make the rooms look more homelike, (but) often rooms get jammed to the hilt, which is something we want to avoid," Ellis says. "We need to keep the path from the bathroom to the bed clear. We also want to be careful to avoid throw rugs and extension cords that residents can trip over."

Keeping a close watch

Despite all the precautions, residents are still going to fall occasionally. That's why Oommen has a one-to-one, nursing-to-patient ratio for his most at risk patients. It's expensive, he says, but not as expensive as a lawsuit.

Since implementing its staffing policy, patient falls at Brunswick have decreased from about 10 to six falls a month, Oommen says.

Brunswick's policy of conducting a full medical diagnosis on all incoming patients within 24 hours is another factor that prevents falls, Oommen says.

Brunswick houses a geriatric unit in psychiatry, a general hospital and a nursing home under one roof to make a diagnosis easier and faster. "Our team members can discuss any changes to treatment plans and exchange information freely without breaking any privacy policies," Oommen says.

On the watch

Wandering is another challenge. Many nursing homes use alarm systems to prevent Alzheimer's patients from wandering and leaving the facility.

Residents at the Minnesota Veterans Home, Fergusfalls, Minn., wear transmitters around their ankles, according to Maintenance Supervisor John Lehn. When the resident gets close to an outside door, an antennae senses the activity and magnetically locks the door

"If a fire alarm goes off, the door's released. Otherwise, the door stays locked as long as the resident is by the door," Lehn says. "If a patient does somehow get out, it sets off an alarm to let the nurses know which door a patient is leaving from." I

Since the Veterans Home has five different wings and hundreds of rooms, an alarm alone may not be enough to locate residents inside the building or courtyard, Lehn says. A mobile transmitter is necessary.

"One time we were looking for patient who we just couldn't find anywhere. We got a real strong signal from the courtyard, but we still didn't see him," Lehn says. "Then we pointed the transmitter toward the maintenance room in the courtyard and found him inside."

A mobile transmitter can also be used to locate a resident quickly, Lehn says.

It's important to find out what prompts the resident to wander, according to Alexander of the Ruxton facility.

"If they're traveling (or wandering), we try to give them diversional activities to keep them occupied," Alexander says. "Sometimes they're willing to participate, sometimes they refuse."

Once, a resident insisted on leaving the building because she thought her son was coming to visit.

"This little lady was so fixated on seeing her son, she kept holding onto the door, and didn't want to go upstairs. We sat there with her and brought her a cup of hot tea," Alexander says.

The nurses called the resident's son at work, who later came to visit. Until he arrived, the nurses took turns sitting with her.

"We really had to try to ascertain her drive to be outside on that particular day," Alexander says. "It could have been because it was a beautiful day. Or there was something going on upstairs, some particular noise or smell that made her want to go outside. Or it could have been that she was just missing her son that day."
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Title Annotation:Protecting Your Residents
Author:Lieberman, Lisa
Publication:Contemporary Long Term Care
Date:Feb 1, 2004
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