Kunin-Lunenfeld Applied Research Unit Falls in Ontario LTC Settings: Laura M. Wagner, PhD, RN Nursing Scientist Kunin-Lunenfeld Applied Research Unit at.

Kunin-Lunenfeld Applied Research Unit

Falls in Ontario LTC Settings:Falls in Ontario LTC Settings:

Laura M. Wagner, PhD, RNNursing Scientist

Kunin-Lunenfeld Applied Research Unit at Baycrest



Acknowledgments and FundingAcknowledgments and FundingCanadian Patient Safety InstituteOntario LTC Association:

Krista Robinson-Holt, RN, MN (Co-I)Jennifer LangstonOLTCA Applied Research Committee

Family representative: Ms. Krystyna SchmidtParticipating LTC FacilitiesResearch Team:

Nina Mafrici, Julie Andrassy, Joanna Dionne, Hannah Gao, Xiao Jin Chen, Yannie Aass

Thecla Damianakis, PhD, MSW


BackgroundBackground Falls are the most frequently reported adverse incident

in LTC settings

Approximately 50% of residents fall each year

Numerous studies have addressed falls in LTC, very few have focused on the processes of identification, implementation, and communication regarding the management of falls


Research QuestionsResearch Questions1) What fall risk factors are identified by nursing staff and

which factors result in associated interventions documented on the fall risk care plan?

2) What fall prevention strategies are listed in the fall risk care plan and are these interventions correctly implemented into actual practice?

3) How is care plan information regarding falls communicated and implemented to the health care team?


MethodologyMethodology Descriptive correlational design in 8 randomly selected homes in

and around central Ontario (>100 beds) Range 120-170 avg. monthly census

Data collection:

– Monthly incident report review

– Medical record review

– Quarterly rounds to examine care plan interventions

– Focus groups


Resident DemographicsResident Demographics N= 635 Average age: 82.27years (10.22SD) Average Length of stay: 28 months Female: 67% Risk factors:

– Fall history 66% Dizziness 14%– Wandering 26% Anxiolytic 32%– Antidepressants 44% Restraint 6%


Falls

• 1901 Total Reported Falls among the 8 facilities over 1 year period

• Average 20 falls per facility/per month

– Range 6 - 37• Average 3 falls per faller/per year

– Range 1 - 35


Care Plan/Medical Record ReviewCare Plan/Medical Record Review

•Risk Factor•Medical Problems•Mobility Problems•Footcare Problems•Urinary/Bowel Incontinence•Vision Problems•Unsafe Behaviours•Psychological condition•Environmental/external hazard•Medications

• Example• Stroke/TIA• Gait dysfunction• Neuropathy• Nocturia• Glaucoma• Combativeness• Depression• Cluttered room

• Antidepressant


Results: Medical Record ReviewResults: Medical Record Review

•Risk Factor•Medical Problems•Mobility Problems•Footcare Problems•Urinary/Bowel Incontinence•Vision Problems•Unsafe Behaviours•Psychological Condition•Environmental•Medications

•% Identified / % Follow-up•86% / 41%•88% / 73%•11% / 54%•74% / 15%•51% / 14%•43% / 60%•76% / 58%•3% / 21%•67% / 6%


Quarterly Environmental RoundsQuarterly Environmental Rounds

N= 1517 observationsObservations focused on risk factors

• Mobility, unsafe behaviours, vision, environment, incontinence, etc.

Overall: 66% adherence to care plan interventions


Rounds AdherenceRounds Adherence Mobility (e.g., proper footwear): 64% Unsafe behaviours (e.g., bed alarm, call bell, bed

in lowest position): 57% Vision (e.g., glasses clean and on while out of

bed): 60% Environmental (e.g., common items within

reach): 80% No Falls Risk Care Plan: n=104


Facility PoliciesFacility Policies•Admission policy (n=6 facilities)•Risk level (e.g., high) (n=2)•Staff education (n=3)•Prevention program reviews (n=3)•Medication reviews (n=6)•Interdisciplinary participation/communication (n=3)

•Post fall policy (n=8)•Immediate evaluation (n=8) •Contact family member (n=7)•Facility fall committee (n=5)•Explicit QI Program (n=2)


Fall Risk AssessmentFall Risk Assessment• Fall history (n=8)• Secondary diagnosis (n=7)• Ambulatory aid (n=4)• Gait/Balance (n=8)• Mental status (n=6)• Medications (n=7)• Continence (n=6)• Sensory impairment (n=5)• Orthostasis (n=1)


Focus Group: Focus Group: Design & SelectionDesign & Selection8 focus groups in 4 randomly selected LTC facilities

1 RN/RPN and 1 PSW/HCA group per facility

21 RN’s and RPN’s

21 PSW’s & HCA’s

Purposive sampling

Inclusion criteria

Informed consent


Method: Method: Focus Group DemographicsFocus Group DemographicsSex:

• 35 female; 5 male

Ages:

• 17% 26-35 years

• 17% 36-45 years

• 24% 46-55 years

• 12% > 56 years

• 30% Preferred not to respond

Type of Position:

• 11 (27%) Registered Nurses (RNs)

• 9 (22%) Registered Practical Nurses (RPNs)

• 21 (51%) Personal Support Workers (PSWs)

Time Working in Current Job:

•15% < 1 year

•34% 1 to 5 years

•20% 6 to 10 years

•10% 11 to 15 years

•5% 16 to 20 years

•16% 21 years or >

Highest Level of Education:

•20% High school diploma

•39% Associate degree/diploma in nursing

•32% Some college or university

•9% Preferred not to respond


Method: Method: Data CollectionData CollectionSemi-Structured Interview Format:

30 min per focus group

Audiotaped; Transcribed

Facilitator and Recorder

Interview Guide:

Falls Risk Identification: Assessing “High Risk” Residents

Post Fall Reporting Procedures

Communication Processes

Falls Quality Improvement and Prevention Strategies


Method: Method: Data AnalysisData AnalysisData Analysis:

Open and hierarchical codingWithin and cross-case analysisThematic analysisObservational recordingsInterrater reliability of coding and analysis with

research team; triangulation; thick description


OVERALL PerceptionsOVERALL Perceptions

Falls monitoring and incident reporting good overall

Good communication: RN’s & PSW’s

Teamwork is important

Staff shortages

Multiple barriers


Fall Risk Identification: Fall Risk Identification: “High Risk Resident”“High Risk Resident”

Variation in meaning of “High Risk Resident” across locations and sample groups

Some falls considered non-preventable (inevitable) and others preventable

Prioritize: Seriousness of Falls


RN’sRN’s PSW’sPSW’s CCAC report Visual Physiotherapy Nurses Identifiers:

• bracelets; bed alarms, signs

Information from families

RN Report(s)• primarily verbal

Visual Physiotherapy Identifiers:

• bracelets; bed alarms, signs

Assessing “High Risk” ResidentsAssessing “High Risk” Residents


Falls Risk Identification: Falls Risk Identification: How do you know which of your residents are at How do you know which of your residents are at

high risk for falling?high risk for falling? RN: sometimes we have some information from

the previous place, but it’s not always correct and we can’t rely on that, so the best thing is to have our own assessment.

PSW: I believe…we have new metal id bracelets…some of them are colour coded…red, blue, green, blah, blah, blah…but I can’t remember the one that’s “has a history of falls”.


Post Fall Reporting ProceduresPost Fall Reporting Procedures

Limitations Noted:

Lack of communication b/w licensed and non-licensed staff contributes to poor incident reporting

Lack of knowledge of inexperienced staff


Post Fall Reporting Procedures:Post Fall Reporting Procedures: How are you informed that the fall has occurred, and How are you informed that the fall has occurred, and how is this information communicated to other staff how is this information communicated to other staff

members working on the following shift?members working on the following shift?

RN: I do a report…a written report at the end of the shift, and that report goes down to management….And then we report at the end of the shift to the next shift coming on.

RN: Pretty good here. They (PSW’s) let us know whatever they discover, anything…if there is anything new with the resident….anything unusual…their walking patterns, or if they get drowsy or something…they let us know.


Post Fall Reporting Procedures:Post Fall Reporting Procedures: How is the fall incident communicated toHow is the fall incident communicated to

family members? family members?

PSW: Whomever is in charge on the floor. Automatically…it doesn’t matter what time of day.

RN: Usually the person whose filling out the report, or the registered staff….always registered staff.

RN: It depends on when they fall too…if it’s late at night they put it on the report for the next shift….the day shift to call the family.


Post Fall Reporting Procedures:Post Fall Reporting Procedures: How are you informed of any changes in the How are you informed of any changes in the

resident’s Care Plan following his/her fall?resident’s Care Plan following his/her fall? RN: Well, they (PSW’s) read the care plan.

- F: And how often do they read it? - RNC: They don’t (with a chuckle)

RN: … you go to the person right away, the person who is taking care of the person, like the PSW whose taking care of them, and you let them know the changes; and it’s in the daily report as well.


Post Fall Reporting Procedures:Post Fall Reporting Procedures: Do you have any concerns when it comes to Do you have any concerns when it comes to reporting when a fall occurs on your unit?reporting when a fall occurs on your unit?

RN: I’d like them in a more timely manner not three hours after the fall… don’t tell me at like 11 o’clock when I’m trying to close my shift off, that “oh, so-and-so fell at 7 o’clock” and I wasn’t even aware of it to do the incident report.(in a mocking voice): “oh I forgot to tell you three hours ago that the person fell, and they might have hit their head even?!”

PSW: It comes back to the same thing about the knowledge…you go to report it and the nurse…uh…whatever…the nurse will turn around and say: “oh well, you know, you should have done this, you should have done that…you should have known”…But if the knowledge isn’t there, then how would’ve know? So she’s getting upset because a certain person isn’t doing something right, but they weren’t taught the right way, so if they don’t have the knowledge, we’re still going to have falls.

PSW: I think, [in] general, the staff in this facility take a lot to prevent falls from happening on the units.


Registered StaffRegistered Staff

Personal SupportPersonal SupportWorkersWorkers

FamiliesFamilies

Health Care-InterdisciplinaryProfessionals

AdministratorsDirectors of Care

Communication ProcessesCommunication Processes


Communication ProcessesCommunication Processes

At Risk Identification & Post Fall Recording:

Direct and indirect

Verbal and written

Quality of relationship important: non-punitive; trusting; safe


Communication GapsCommunication GapsPost-Fall Reporting

Not witnessed; resident gets up on their ownNot reported at the time; but reported afterwards if there

are visible signs (e.g., bruising)

“Like if we are washing [the residents]…then we have to look…if we locate anything or see anything, we have to…it gets documented right away” (PSW)

Near-misses: not identified


Barriers: Preventing Falls or Barriers: Preventing Falls or Implementing InterventionsImplementing Interventions

Staff (RN’s and PSW’s) acknowledge multiple factors which contribute to falls

Despite lack of both formal and informal discussion on falls, seen as important

Discrepancy in falls quality improvement actions among units at the facilities

Interventions toward fall quality improvement tend toward retroactive not preventative strategies

Infrequent in-service training


What barriers do you face in preventing falls or What barriers do you face in preventing falls or

carrying out specific interventions on your unit?carrying out specific interventions on your unit? PSW: …I think knowledge…not to say that we don’t have the knowledge,

but we could always use more knowledge. Because falls is not something…we talk about all the time unless it happens.

RN: …the PSW has eight or ten residents to look after, and when they are busy with one, of course, anything can happen with another, and they can’t be there every single minute.

PSW: …some of the barrier, I think would be the family members.

PSW: It’s like too long…sometimes they need [a] proper wheelchair…waiting for months…Oh months! How long?!! Six months already and we never get it….


Do you have meetings to Do you have meetings to

discuss falls on your unit?discuss falls on your unit? PSW: We have one inservice two times a year…if residents are

falling.

PSW: So…I’ve never had one (referring to meeting about falls).. And I worked on there for a year, and we’ve never had one.

RN: …inservice, we had one last year, regarding falls and these similar…situations

RN: If there is an increase…in the number of falls [and] if a resident would have fallen…[we] discuss what’s going on, and what we can do.


Barriers to Falls PreventionBarriers to Falls Prevention1. Family Non-ComplianceResident footwear

2. Lack of Staff Staff-resident ratioLimited time to monitor

3. Lack of Resident StimulationLack & Quality of Planned ActivitiesResident Boredom

4. Cognitive ImpairmentInstability; Aggression

5. MedicationsAgitation, Weakness

Resident Falls


Barriers to Falls PreventionBarriers to Falls Prevention6. Lack of Education-Staff TrainingInfrequent in-service training

7. Restraint Policies Pose ethical tensions for staffSelf-determination vs. safetyFamilies lack of understanding

8. Proper EquipmentDelays in getting equipment

9. Environmental ConditionsPhysical-on floor obstructions

Resident Falls


Falls Quality Improvement: Falls Quality Improvement: What is the most pressing issue that needs to be What is the most pressing issue that needs to be

addressed when it comes to residents falling?addressed when it comes to residents falling? RN: Well, staffing issues because…right now…I think there is one lady

upstairs and she’s out of the chair six times an hour…and I’ve got two staff members and that’s been taking them away from their normal duties….and they’re getting stressed out.

PSW: …or guilt….because, you know, mom used to be up and down here and there, and you know, umm…they don’t want to have mom restrained…they don’t accept that mom is not as strong anymore…mom is weaker and potential for falls is there. So, they’re major…I find the major concern is the family members and falls

RN: ..when you have to prevent a fall, you have to put every nurse in every room…and this is twenty or thirty rooms…we have nobody. It is very difficult, especially at night.


DeliverablesDeliverables Website live in April 2007:

• www.fallsinltc.ca

OLTCA, ALTCA, Manitoba LTC Assn (Spring 2007)

LTC magazine article: June 2007• “Communicating with Families about Falls”


Key MessagesKey Messages

Implications for:Practice-Education-Management-Research- Policy-


Implications for Policy, Clinical Implications for Policy, Clinical Practice and ResearchPractice and Research

Policy & AdministrationNeed for more staff Increase in-service trainingFocus on prevention not only incident reporting

Encourage non-punitive reportingEnsure quality programming which facilitates resident N stimulation and activities; decreases boredomEstablish an interdisciplinary approach with families to provide education and facilitate understanding of care proceduresEnvironmental impact: “geriatricproof” to minimize impact of falls; provide frequent audits


Implications for Policy, Clinical Implications for Policy, Clinical Practice and Research (cont’d)Practice and Research (cont’d)

Clinical Training & Practice Standardized Assessment Tools In-service:

• Common meanings of ‘high-risk’ resident; • Restraint procedures, including policies (e.g., least

restraint)• Dealing with ethical challenges • Standardize knowledge across floors

Communication frameworks which focus on quality of interaction and promote teamworkIncludes families


Implications for Policy, Clinical Implications for Policy, Clinical Practice and Research (cont’d)Practice and Research (cont’d)

Future Research

Develop valid and reliable fall risk assessment tools

Point-of-care approaches to improve communication of

care plan interventions

Kunin-Lunenfeld Applied Research Unit Falls in Ontario LTC Settings: Laura M. Wagner, PhD, RN Nursing Scientist Kunin-Lunenfeld Applied Research Unit at.

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