Event Title: Improving Nursing Home Resident Mobility Part II Event Date: August 31, 2017 Event Time: 11:00am 12:00pm EST Good morning and thank you for joining the nursing home quality care collaborative. My name is Sarah with the New England QIN-QIO, and this is Part II of our two-part webinar series on improving nursing home resident mobility. Before we begin today's program, I have a few housekeeping items to review. This webinar will be recorded, and the presentation will be available within a few business days. The phone lines will be on mute for the duration of the presentation. If you have any questions, please enter them in the chat log on the right of your screen. Make sure that you send your comments to All Participants. Doreen from the QIN-QIO in Connecticut will be monitoring and responding to questions and comments in the chat. Will also have plenty of time for questions at the end of the presentation, and we will open the lines backup. Leslie if you find this presentation, please use the plus or minus icon in the top right corner of the presentation window to adjust your screens accordingly. In Part 1 of this webinar series, we discussed how this might encourage endorsing nursing home mobility. We reviewed how to reduce falls and eliminate the use of bed and chair alarms. We also reviewed the nursing home Change Package and reviewed how to apply the strategy of the mobility bundle. On today's webinar we have presenters from Genesis Healthcare in Connecticut and Chelsea Soldiers Home in Massachusetts. For the second part of this webinar series on improving nursing home mobility patterns, you will hear from Florence Bolella, Debbie Antonelli, and Chad Morin. During the session, you will learn strategies on how to help your residents improve mobility and reduce falls, become an alarm free facility, overcome staff reactions, and sustain improvements. You will also learn how to develop a falls program that includes hourly rounds, post-fall assessment, and other resources. To kick off today's first presentation I want to introduce to you Debbie Antonelli who is the Director of Nursing Services at the Chelsea Soldiers Home in Chelsea, Massachusetts, along with Chad Morin who is a Compliance Officer. Debbie and Chad, I am turning it over to you. We are happy to present to you some research that we have and data that we have collected over the last 12 months on reducing fall rates within the Chelsea Soldiers Home. We were asked to be part of a national effort with State Veterans homes to work on best practices and reducing falls within the state. The results have been remarkable. We initiated a falls committee and took an interdisciplinary approach to this committee. As you can see by the slide, this committee involves a director, the medical director, compliance officer, nursing supervisor, occupational therapy, and physical therapy. We have nursing services and any other team members that wanted to be included in the fall initiative. Our focus was the entire facility which has 10 nursing units, five of which are skilled nurses and the other are long-term care nurses.
Our goal is to create a falls committee that could work on identifying the reasons for falls, whether it was environmental, acute-care processes, and critically look at our systems which contributed to the falls. Our falls committee meets twice per week. The slide you see here is a Decision Tree for Types of Falls that we obtained through the VA which, other than the initial intervention discussed when the staff respond to the medical staff on the unit to find out how the fall occurred and how we could intervene. This tool helps us to further develop an approach on the Tuesday and Thursday meeting, test questions that we have the answers to, and break it down to specific reasons. With each fall, the nursing staff automatically produces a [ Indiscernible ] for our PTO rehab assessment and completes a consult sheet and submits it to the rehab team. We take a multisystem approach to bowel and bladder, restorative, and psychotropic medicines, any behaviors, any need for updating policy and procedure as well as development of new assessment forms which we all know our teams love new assessment forms and work through consistent assignment of staff. We also worked on improving our dining program and realignment of staff during lunches and that enabled staff to monitor high-risk residents in the dining areas. We also introduced a post fall huddle sheet. We have a two-part goal. Our center was seeing as many as 75 falls per month. Our primary goal is to reduce the number of falls and our second goal is to work on reducing falls with major injury. I'm proud to say that we have reached the scope. We were averaging 35 falls per month. Right now our average is a low six per month, and the highest was 18 falls per month. This is a major reduction in minor and major injuries to our veterans. We have a fall assessment tool that we are going to share with you on an additional slide and that is working through all processes. The fall assessment tool is also utilized on the units during post-fall huddle. We have challenges to keep the staff engaged and focused on the need to continue critical intervention for patient safety. When all staff members see somebody trying to raise up out of a chair with a high-risk fall patient, the first thing we do is assess for pain, whether or not they need to go to the bathroom, we adjust for position, and determine if there are any possession items or obstacles in the way that might increase risk of fall. This is an example of what have posted on every unit. This slide is the first intervention at the bedside, dining area, or in activities. As you mentioned before, the fall committee meets twice a week after the initial intervention is in place and we do bring the residents charts and make additional changes to any care plans to make sure they are updated. There is a representative from the unit in which the resident lives to assist and add input on what will better help the resident going forward and how to prevent the risk of a fall. Another thing we do focus on is trying to eliminate repetition of the same resident falling. The post-fall huddle, which I will show you in the next slide, is utilized for each fall by the fall committee. We do have changes to processes and procedure which is updated as needed. An intentional rounding is another thing that we
implemented to have a more active approach to not only the high-risk followers but all residents residing in the unit to prevent anyone that is not considered a high-risk fall from having one. This is the post-fall huddle page which I and a compliance officer will view as part of my investigation to see why a patient fell and make sure we have appropriate interventions in place. When the medical team arrives, this form is brought to the scene of the fall which helps us to focus on specific information If you look at the second box down,t we go as far as what type of footwear, shoes, socks, barefoot, that they have, grips on the shoes, one sock on or one sock off, if they had their cane or walking device with them, and if there were any obstacles in place. Then this slide would be the intentional wanting form that we have which helps the staff to also have a safe check on where residents are. If you look on the right side of the slide, we have the abbreviations on how the staff person assigned during that hour when making their rounds with each resident, how they can code the resident s location or what they are doing, and that way we have an hour-by-hour approach to keep track of those high-risk followers which helps us tremendously reduce our number of falls from eight or nine or 10 major injuries among to now maybe one or two each month. That is the focus of our reduction in falls and as little injury as possible to our veterans. I just want to add to the intentional rounds. It is hard to have total team by and when you're asking them to do another documentation of actual hands-on rounding, so what we did here systematically is we had supervisors around the units to ensure that the direct care workers were documenting that they did check and to watch and see and evaluate the effectiveness of that round For our results, we've had six falls this month, three of them have resulted in injury, but it is a far cry from 74 or 75 falls per month. That is a work in progress and we are looking for ways to improve that, and I'm interested in hearing what people have to say about decreasing falls in the facility because that is our next step. What your team has done to prevent falls is impressive and proves that it really takes a team. Debbie and Chad will be available for questions and answers following our second presentation. At this point I will introduce Florence who is the clinical reimbursement coordinator at Kimberly Hall South, a Genesis health care facility in Windsor, Connecticut. Florence, I'm going to turn it over to you. Do you have the ball? Thank you very much for taking the second to write me to talk about alarm reduction. Back in 2012 Genesis gave the initiative to become alarm free, and this is where the tortoise and hare story comes in. I chose to do the tortoise group which honestly took me almost a year to remove all alarms. Some facilities did pick a date and then go alarm free with all the residents. I found that a bit to be overwhelming. Don't be afraid to take your time because ultimately it is reaching the goal of being alarm free that is important. Your first step is education. When we told our staff we were going to reduce and eliminate alarms, their response was, you are crazy. Education is very important, and you need to discuss the negative effect of the alarms. You need to bring it to your residents. We bought it to resident counseling, and they were excited and happy to hear that we were going to reduce alarms. What took me so long to remove all my
alarms is having one family that said you're not going to take that alarm away. That is sometimes what you have to encounter. You need to be proactive, not reactive, and that's what happens with alarms. In research we found that alarms create a lot of noise and fear and agitation and confusion in elderly residents. We don't really address the underlying need of why our resident might be standing up and sounding the alarm. Instead we'd say sit down. Alarms decrease overall mobility increasing the risk of fracture, and I don't think any of us would want to shift their position and have an alarm go off. Alarms can increase breakdown from immobilization. The residents are afraid to move because the alarm goes off. Loss of independent bowel and bladder function induces agitation, and often we found with our alarms that there were false-positive or false-negative events where our alarms did not sound. Sometimes our alarm sounded five or 10 minutes after the resident was removed off of the alarm. Before you begin your process of eliminating the alarms, make sure you have a good fall prevention program. If you have a restorative program to focus on strengthening, it is definitely an interdisciplinary approach to falls and the quality of life. We have weekly rounds, so we review every resident. It is a good opportunity to see if there are any changes in the resident and get therapy involved prior to, and then your CNAs can be cross-trained to provide recreational programs or activities on the unit, so that keeps our residents busy. Set a goal. For example, if you have 24 alarms in the facility and you want to take six months to reduce your alarms, reduced a few each month. You don't have to reduce a lot. Review each resident, look back at their history. Are there any patterns? Are they still mobile? Do they need a toileting plan? Look at the room. Is it cluttered (walker or wheelchair when they are in or out of bed)? Success with initial reductions will enforce the staff and is very important. If you are successful on the first few residents, then the staff, residents, and families are going to buy into reducing the alarms. Meet weekly with the team. Make sure everybody knows who is being reduced that week and how they are doing after the alarm is reduced, and then share your fall percentages prior to beginning, and what your goal percentage is. Initially we had significant falls, but afterwards and still five years later, our fall percentages are lower. In the end you are definitely going to have very peaceful and quiet units. You're going to decrease agitation in residents as well as roommates with listen to the alarms. You're going to increase staff satisfaction due to the elimination of alarms and experience a cost savings; but, most importantly, you will have reduction in falls and much happier residents. That is what I have. Thank you, Florence. We are going to open up the line for Q&A. As a reminder unmute your line with #6 or use the manual mute button on your phone to ask a question.
You can also ask a question in the chat box on the bottom right-hand corner of your screen. Has anyone joined the line to ask a question? Doreen, do we have any questions in the chat? I do not have any yet. Great. I do see that we have a comment or question in the chat from Dale. She says great program, intentional rounding challenges. Do you assign a CNA to rounds with their own residents, one CNA and around each hour? Do you involve nursing staff? Does anyone have any ideas that have helped with intentional rounds? As far as rounding, it is all staff member. Housekeepers, dietary aids, everyone needs to be on the lookout when they come down the hallway. The CNAs and nurses are in the rooms the most, so you can't just look at your own assignment. You need to look at every resident. Will your tools and poster be available to the audience? Would you be able to share those tools? You could send it over to me, and I could make sure that goes out in the thank you email that goes out the following day. Do we have anyone else that has joined the line? I just wanted to tell the audience what has really been effective here is it does take a whole team to monitor what is necessary to maintain a safe environment. However, we make one CNA in charge of the unit to do those rounds and the charge nurses responsible to check the flow sheets to show that the round is happening. Then we put it in a third buffer and for administration to see that the round is happening. With that we have had amazing success to the point where now when I do rounds on the unit, everybody wants to show me he had no fall. I think once they see it is effective, it is a positive outcome, and people are willing to participate. We have another question for you from Rosemary. Can you discuss further the post-fall huddle? I thought I assume that is all shifts and the interdisciplinary team when possible. Correct. Post-fall huddles happen in two phases. At the time of the event, no matter what the shift or what day of the week, nursing staff with other available staff and the nursing supervisor review the fall area, document where they were when the fall happened and what kind of barriers by using that fall and [ Indiscernible ]. On Tuesday morning to Thursday morning, the fall committee meets and reviews the statements, reviews the direct [ Indiscernible ] assessment of that fall and then looks at what the interdisciplinary approach is or something we matched and at that time we do a shot review, care plan review, and any CNA care card review to make sure that everybody is doing the exact same thing and mobility to the best maintenance possible of that veteran. Does that help?
We have a question from Jason. In terms of guidance for fall prevention team, should the overall philosophy be that all alarms are bad or are there appropriate times for use of an alarm? You have to look at all of your residents and look at your residents individually. We wanted an alarm free facility. It did take a while to become alarm free. We had some residents that were high risk fall patients that we kept towards the end of our goal. It is really up to the team and the residents who you decide to remove the alarms on and we decide to keep alarms on. It looks like we do not have any other questions. Thank you all for the great questions that you had and thank you to our speakers who were very informative, and I hope that it helped everyone out who joined us today. If you were not able to ask questions during today's session, you can reach out to your QIN-QIO state lead. We listed their contact information here on this slide. Don't forget to mark your calendars for upcoming collaborative events and educational opportunities. On September 14 we have a webinar with the Maine Veterans Home that will be sharing an antibiotic stewardship program. On September 21, we have an in-person event called, Getting to the Root Causes of Resident Falls. We have another in-person event in Massachusetts on September 26, Assessing and Managing Pain seminar with special guest speaker Carol Curtis. Check out our website for more information or to register. In addition the next CMS MLN call is scheduled for next Thursday, September 7, from 1:30 p.m. until 3 p.m. This will be an overview of the Nursing Home Facility Assessment tool and State Operations Manual Revisions call which will cover frequently asked question related to the revision of the State Manual for Phase 2 of the reform of the requirement for long-term care facility Final Rule. We will include a link to register for this call in a follow-up email of this webinar. We also have our winner from the Facebook contest from part one of this webinar series. Congratulations to Kathy DM. You have won tickets to the in-person event, Getting to the Root Causes of Resident Falls with Sue Ann Guildermann in Wallingford, Connecticut. If you would like to join, another contest and win free tickets, all you have to do is go on Facebook and follow us. If you're already following us, please go to Facebook and share the post about this contest. We are now giving away tickets for assessing and managing pain seminar, which takes place later next month. Between today and September 13, go to Facebook, like us, and follow us, or share that post, and you will be entered to win to free tickets to the pain conference. Following today's webinar you will be directed to a survey to provide feedback on the webinar. Your input really helps us to improve these educational sessions and provide us with meaningful programs in the future. Also within the next few business days, we will send out and email to everyone that today's presentation, the resources we mentioned earlier on today's presentation, and the recording of this webinar can be found on our website. Thank you all for attending today's webinar, and have a great day.