Preventing Falls: It s Easy to Miss. Objectives. Background & Process 4/21/2014. Linda M. Shell RN, BSN, MA May 8, 2014 Lindashell.

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1 Preventing Falls: It s Easy to Miss What You re Not Looking For Leading Age Iowa Linda M. Shell RN, BSN, MA May 8, 2014 Lindashell.com Objectives Provide a overview of an evidenced based falls program. Describe the process of root cause analysis for use in reducing falls. List evidenced based interventions for managing falls. Identify specific tools that are effective in eliminating alarms, conducting root cause analysis and enhancing fall prevention. Background & Process Empira: Consortium for 10 years, 27 SNFs / 5 companies Empira awarded 3 year MN DHS PIPP grant, began 10/1/08 ~ Goal: Reduce Measured CMS QIs; Falls, Depression & Anxiety, Decline in LL ADL, Decline in movement Program built on benchmarking, research, evidenced based practices, and best practices. Achieved 20% reduction in falls over three years! 1

2 What is the key to the fall prevention program? Root Cause(s) Analysis (RCA) What is root cause analysis? RCA is a process to find out what happened, why it happened, and to determine what can be done to prevent it from happening again. Getting to the Root Cause 2

3 Have you ever had a fall? Why did you fall? What was different when you fell that time? What did you change after you fell? RCA begins with Observation Root Cause Analysis: A Layered Process Immediate encounter: triage 10 Questions Fall Scene Investigation report Multidisciplinary Team 3

4 Hurdles & Challenges RCA skill set competency: Root Cause Analysis vs. Just Tell Me What To Do Scatter gun approach to interventions vs. matching interventions to root cause of fall Staff resistant to change e.g. alarms, balance, staffing times Sustainability: building redundancies OSHA s Safe Patient Handing Cost: reduction in resident independence Tools to determine RCA 10 Questions direct the collection of clues leading to the root cause analysis of the fall FSI Report (Fall Scene Investigation Form) Post Fall Investigation Summary Report Fall Summary Pre admission/ At admission assessment: Sleep & toileting habits, personal interests Alarm Tracking = for diagnostic purposes only Post fall huddle 4Ps = Customer Service Hourly Rounds 4

5 Challenges to a successful Fall Prevention Program: old way versus new way More comfortable in holding onto the known Takes time Lack of knowledge Traditions Step 1: Gather clues, evidence, data Observation skills are critical! It s easy to miss something you re not looking for Gather the clues: Look, listen, smell, touch Note placement of resident and surrounding area Protect the area around the incident/fall: Secure the room/equipment Don t disturb the fall scene the clues are there! Observation and recording begins immediately while things are still fresh! A Picture is Worth a Thousand Words Room: window, door, bed, head & foot of bed, chair, wheelchair, nightstand Position of Resident: how close to furniture, head & feet, position (sitting, lying) Equipment: call light, oxygen, tubing, catheter, commode, walker, cane Personal items: phone, glasses FSI Tool 5

6 Fall Huddle Occurs immediately after a fall happens Charge nurse has all staff, working in the area of the fall, meet together to determine RCA 10 Questions will be asked of staff Staff will be asked (be prepared to answer): Who has seen or has had contact with this resident within the last few hours? What was the resident doing? How did they appear? How did they behave? Re enact or Show & Tell The persons involved in the fall or incident are asked to re create what happened do exactly what you did when the fall happened the first time Use the same people, same equipment, same room, same time of day Causes: Intrinsic Untreated or undertreated pain Sleep disturbance Apnea Restless leg syndrome Decline in ADLs Medication side effects Excessive diuresis 6

7 PAINAD Scale Evidenced based tool used for assessing pain in cognitively impaired Measures five domains: Breathing, negative vocalizations, facial expression, body language and consolability. Observe resident for 5 minutes. Medications Contribute to Falls New medications Change in meds Diuretics water pills Laxatives bowel movement Anti psychotics Anti depressants Do you know which of your residents are taking these meds and when they were last given? 7

8 Protect Sleep At admission, obtain information on usual sleep/awake patterns when at home. What is their normal bedtime routines? Gentle control of fluids Trade naps for activities Quiet on the hall! Reassess turning and repositioning and incontinent care Education of staff, residents, and families Causes: Extrinsic Environmental Noise: alarms, TVs, talking, phones Environmental contrasts Bed heights Room / bed assignment Placement of furniture & personal items Floor surfaces, mats Lighting Footwear / clothing Assistive devices Alarm Reduction & Elimination Evidence based studies for the reduction and elimination of alarms to reduce: Falls, depression, skin breakdown, incontinence, inappropriate behaviors Results from alarm reduction: Get rid of alarms! Use alarm tracker 8

9 Place of fall: Environmental Clues At bedside 5 feet away > 15 feet Loss of blood Lost balance Strength, tired to the brain Root Cause Analysis Fall Occurs No Care Plan Yes Assessments and/or Interventions Employee and/or Systems Alterations from Resident s Baseline Alterations in Environment Causes: Systemic Time of day Shift change Break times Day of week Location of fall Type of fall Staffing, staff assignments Routines of services 9

10 Common Root Causes of Falls Sleep Deprivation Napping Turning and Repositioning Noise Lighting Pain Medications side effects Inconsistent staffing Lack of supervision/accountability Alarm use Incorrect bed height Lack of follow up and monitoring of high risk fallers Failure to conduct root cause analysis How can YOU encourage balance? Count to 4, stay off the floor. Reach for it. Stand tall, sit tall. Stand at the sink Pause during the transfer Allow standing for a moment Interventions to Prevent Falls Root Cause Analysis Fall Huddle/10 Questions Hourly Rounding 4Ps Reduce Noise Alarm Elimination Correct Beds Heights Medication Reduction Consistent Staffing Improve sleep 10

11 Hourly Rounding or the 4 Ps Positioning: Does the resident look comfortable? Ask the resident, Would you like to move or be repositioned? Ask the resident, Are you where you want to be? Report to the nurse. Personal needs: Ask the resident, Do you need to use the bathroom? Ask if they d like help to the toilet or commode. Report to the nurse. Pain: Does the resident appear in to be in pain or uncomfortable? Ask the resident, How are you in pain or uncomfortable? Ask them what you can do to make them comfortable. Report to the nurse. Placement: Is the bed at the correct height? Is the phone, call light, remote, walker, trash can, water, urinal, tissues, all near the resident? Place them all within easy reach. Note: Staff should ask the resident Is there anything else I can do for you, I have time? Weekly Falls Meeting Review new falls Review previous falls to ensure interventions are working Review fall summary Conduct analysis of trends, timing, staffing, etc. Utilize Quality Measures to support RCA Root Cause Analysis: Root cause analysis (RCA) transforms an old culture that reacts to problems, into a new culture that solves problems before they escalate. Aiming performance improvement operations at root causes is more effective than merely treating the symptoms of problems. Problems are best solved by eliminating and correcting the root causes, as opposed to merely addressing the obvious symptoms with "scatter gun approaches" to solutions. 11

12 Nutrition Physical Activity Sunlight Sleep Florence Nightingale I did then what I knew then, when I knew better, I did better. ~ Maya Angelou Resources Lord, Stephen., Falls & Balance Group at Neuroscience Research Australia, University of New South Wales: and balance research group Morand, Molly, Fall Management: The next step... Moving Beyond Alarms & Low Beds, AANAC Conference 10/2008. Napier, R., McDaniel, R., Measuring What Matters, Davis Black Pub., Nelson, A., Algase, D., Evidence Based Protocols for Managing Wandering Behaviors, Springer Pub., Power, M.D., G. Allen, Dementia Beyond Drugs, HPP Press., Sheridan, Dan, Investigation of Accidents & Falls, AANAC Conferences 10/2008 & 4/2009. Teri, Linda, Behavioral Treatment for Depressed Mood: A Pleasant Events Intervention for Seniors, University of Washington, & 2010 Annual Conferences Transforming Fall Management Practices, Department of Veterans Affairs Annual Conference Pioneer Network Annual Conference and Pre conference Intensive, Eliminating Restraints Including Alarms, Pioneer Network. 2008, 2009, 2010 Annual Conferences Gerontological Nursing. 12

13 Take out: Type of Alarm (Bed, chair, mat, wheelchair, etc.) Date (alarm went off) Alarm Tracking Form Time (alarm went off) What was the resident trying to do or wanted to do, when the alarm went off? IDT Analysis of Data (patterns, times, reasons alarm went off): Action Plan: Date of Review: Signatures of IDT: Resident Name: MR# Rm# 10 Questions at the time a resident falls: (link) 1. Ask resident: Are you ok? 2. Ask resident: What were you trying to do? 3. Ask resident or determine: What was different this time? 4. Position of Resident? a. Did they fall near a bed, toilet or chair? How far away? b. On their back, front, L side, or R side? c. Position of their arms & legs? 5. What was the surrounding area like? a. Noisy? Busy? Cluttered? b. If in bathroom, contents of toilet? c. Poor lighting visibility? d. Position of furniture & equipment? Bed height correct? 6. What was the floor like? a. Wet floor? Urine on floor? Uneven floor? Shiny floor? b. Carpet or tile? 7. What was the resident s apparel? a. Shoes, socks (non-skid?) slippers, bare feet? b. Poorly fitting clothes? 8. Was the resident using an assistive device? a. Walker, cane, wheelchair, merry walker, other 9. Did the resident have glasses and/or hearing aides on? 10. Who was in the area when the resident fell? Skilled Facility Fall Summary June Fall Incidents Fall Location Type of Fall Time Room :59AM Resident 90.9% During Ambulation % % Dining Room % During Self Transfer % 7-7: % Other Area % Other % 8-8: % Activity Room % From W/C or Geri Chair % 9-9: % Hallway % From Bed % 10-10: % Bathroom % During Staff Asst % 11-11: % Shower/TB Room % Shower/Toilet Chair % 12-12:59PM % Outside % 1-1: % 2-2: % Type Footwear Day Week 3-3: % of of Socks : % Gripper 0.00% Sunday 18.18% Shoes % Monday % 5-5: % Barefeet % Tuesday % 6-6: % Off load boots % Wednesday % 7-7: % Socks % Thursday % 8-8: % Slippers % Friday % 9-9: % Amputee % Saturday % 10-10: % 11-11: % Unit/Wing Residents Devices 12-12:59AM % of Assistive Hall % None % 1-1: % #Falls Has & use % 2-2: % was in Memory Care % Has, but not in use % 3-3: % # Falls 4-4: % TCU % Recurrent Fallers 5-5: % # Falls RV - 3 falls 13

14 Draw a picture of the area and position resident was found. Remember to include: was the resident face down, on their back, on R or L side, position of their arms and legs, placement of the furniture, equipment and devices, indicate head & foot of bed, location of any doors and hallway. How far from bed, chair or toilet Nursing Assistant assigned to resident at time of fall: Must complete questions 1-6. (And other questions as appropriate.) 1. The last time you saw resident before they fell? Time: am/pm Location: 2. Does this resident have some kind of personal alarm? N/A Yes No If yes, was it sounding? Yes No 3. Was the resident in bed just before the fall? Yes No Bed at correct height? Yes/No If Yes, were the positioning rails up? Yes/No Was the call light on? Yes/No 4. Was the resident walking when they fell? Yes/No If Yes, were they using an assistive device? Y/N What were they using to walk? walker, cane, railing, nothing, something else? 5. Does this resident need help using the bathroom per careplan? Yes/No If Yes, when was the last time you toileted or offered a urinal to the resident? AM/PM. Is this resident usually incontinent per careplan? Yes/No If Yes, when did you last check the resident s brief? AM/PM. Did you toilet them after the fall? Yes/No Did they void or have a BM? Yes/ No( circle which one) 6. Describe the resident s day. Include anything about eating, drinking, behavior, ability to do tasks, complaints of pain or illness, sleeping more or less, environment different. Revised 7/