Top 5 Ways to Prevent Falls

Top 5 Ways to Prevent Falls

HARMONY UNIVERSITYThe Provider Unit of Harmony Healthcare International, Inc.

Presented by:

Eileen Kelly, PT, RAC-CT

Regional Consultant

Joyce Sadewicz, PT, RAC-CT

Field Operations and Regional Consultant

Speaker Bio (Eileen Kelly)

Regional Consultant for Harmony Healthcare International, Inc, providing on-site auditing of the MDS and associated records for PPS and Case Mix purposes

Education

Physical Therapy degree from SUNY at Buffalo

Masters Degree in Applied Anatomy and Physiology from Boston University

MBA in Health Care Policy at Brandeis University

Experience

Adult Rehabilitation for NY State and MA Rehab Hospitals

Rehabilitation Program Manager for Skilled Nursing Facilities, responsible for transitioning Therapy Departments into Medicare’s Prospective Payment System

Considerable experience with DPH and JACHO Surveys

Devised and implemented Quality Improvement Programs and collaborated with nursing to develop a CNA Career Ladder Program

Extensive experience with third-party payment systems, including Medicare, Managed Care and Workers Compensation

Medicare Specialist working with provider groups regarding performance management for one of the country’s leading Medicare Advantage Plans

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

Speaker Bio (Joyce Sadewicz)

Field Operations and Regional Consultant for Harmony Healthcare International, Inc.

Education

Bachelor of Science in Physical Therapy from Russell Sage College and Albany Medical School

Extensive knowledge in reimbursement and management of patient care

Clinical Case Manager

MDS and reimbursement in a PPS environment

Knowledge of the RAI process in the Medicare PPS setting as well as the Case Mix setting

Experience

Over 15 years of experience in Physical Therapy, working with neurologically impaired children and adolescents

Invaluable Physical Therapy experience working in acute care a city hospital with an active inpatient and outpatient program as well as a regional burn center and trauma unit

Manager of the Physical and Occupational Therapy Departments

Manager of the Work Tolerance Center, an outpatient work-hardening program

Manager of 40 rehab personnel with a combined budget of $1.5 million in a 440 bed acute care setting with multiple outpatient sites

Rehabilitation Manager in a long-term care facility



Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose

Planners:

Elisa Bovee, MS, OTR/L

Diane Buckley, BSN, RN, RAC-CT

Beckie Dow, RN, RAC-MT

Keri Hart, MS CCC, SLP, RAC-CT

Kristen Mastrangelo, OTR/L, MBA, NHA

Christine Twombly, RNC, RAC-MT, LHRM

Presenters:

Eileen Kelly, PT, RAC-CT, Regional Consultant

Joyce Sadewicz, PT, RAC-CT, Field Operations and Regional Consultant


Harmony Healthcare International, Inc.

Top 5 Ways to Prevent FallsDisclosure

Speakers: Eileen Kelly, PT, RAC-CT, Regional Consultant

Joyce Sadewicz, PT, RAC-CT, Field Operations and Regional Consultant

The speakers have no relevant financial relationships to disclose

The speakers have no relevant nonfinancial relationships to disclose

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Harmony Healthcare International, Inc.


Criteria for Successful Completion

Complete Sign-in and Sign-Out on Attendance Form

Attendance for entire session

Completion and submission of speaker evaluation form

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Housekeeping

Sign In

Contact Hours Certificate

A Little About Us

Handouts

Contact Information for Questions

Copyright © 2013 All Rights Reserved

Objectives

The learner will be able to detail the

benefits of Root Cause Analysis

The learner will be able to discuss the

process of a Falls investigation

The learner will be able to verbalize the

benefit of interdisciplinary involvement and

follow-up


Falls in America


Falls in America

How big is the problem?

One in three adults age 65 and older falls

each year.

Less than half discuss with a healthcare

professional.

20% to 30% suffer moderate to severe

injuries that decrease mobility.


Falls in America

How big is the problem?

In 2009 ERs treated 2.4 million non-fatal fall

injuries among older adults.

More than 662,000 had to be hospitalized.

Among older adults, falls are the leading cause of

death related to injuries.

In 2010, the direct medical costs of falls, adjusted

for inflation was $30.0 billion.

By 2020, the annual direct and indirect cost of fall

injuries is expected to reach $54.9 billion.


Falls in Nursing Homes

In 2003, 1.5 million people 65 and older

lived in nursing homes. If the current rates

continue, by 2030, this will rise to about 3

million. More people than Chicago,

Houston, or Philadelphia.

Each year a typical nursing home with 100

beds reports 100 to 200 falls. Many falls go

unreported.


Falls in Nursing Homes

Between half and three-quarters of nursing

home residents fall each year

Twice the rate of falls for older adults living

in the community

Patients often fall more than once. The

average is 2.6 falls per person each year.

About 35% of fall injuries occur among

residents who cannot walk


How Serious Are These Falls?



About 1,800 people living in nursing homes

die each year from falls

About 10% to 20% of nursing home falls

cause serious injuries; 2% to 6% cause

fractures



Falls result in:

Disability

Functional decline

Reduced quality of life

Fear of falling

Loss of function

Depression

Feeling of helplessness

Social isolation


Why Are There More Falls In Nursing

Homes?

Other health problems

Generally more frail than older adults living

in the community

Older, with more chronic conditions

More difficulty walking

Thought or memory problems

Difficulties with ADLs

Need assistance with mobility


Common Causes of Falls in Nursing

Homes

Muscle weakness and gait difficulties (24%

of falls)

Environmental hazards (16% to 27%)

Medications

Other causes (Poor foot care, poorly fitting

shoes, improper use of walking aids.)

Low vision


What is the Cost of Doing Nothing?


What is the Cost of Doing Nothing?

A jury has awarded $1.1 billion in damages to

the family of a Florida woman who received

poor nursing home care prior to her death in

2007.

The family alleged that she often fell, and

received inadequate supervision.

The jury took an hour to deliberate and

awarded $110 million in compensatory

damages and $1 billion in punitive damages.


What is Your Current Fall Risk Picture?

Know your fall statistics

Analyze the data

Use scatter analysis to help identify

trends


5 Steps to an Effective Fall

Management Program

Development of the Interdisciplinary

Team

Assess, Assess, Assess

Root Cause Analysis

Falls CSI

Follow-up


Interdisciplinary Team



Team Leader

CNAs

Administration

Nursing

Rehabilitation

Activities

Dietary

Housekeeping

Maintenance



Team Leader

Task

Goals

Decision making

Training

Maintain standards



Team Leader

Relational

Coaching

Collaborating

Manage conflict

Build commitment



Team Leader

Environmental

Share Information

Buffering

Assessing

Advocating



Why CNAs?

They spend more time with patients than anyone else

They know more about the patients than you think

They need to be empowered to report problems and suggest solutions



Administration

Support the program

Support the team

Filter down the importance of the program and results. Talk the talk, walk the walk!

Share information with the team

Quality Assurance, Performance Improvement



Nursing

Patient assessment

Care Planning

Medications

Vision

Follow Through



Rehabilitation

Patient Assessment

Screening vs. Treatment

Visual Assessment

Environmental Assessment

Assess for proper footwear

Care Planning

Follow Through



Activities

Patient Assessment

Provide meaningful diversional activities

Assist with identification of fall trends and solutions

Exercise classes



Dietary

Patient Assessment

Identify patients at risk for fractures

Maintenance of strong bones through diet

Identify patients at risk for dehydration



Maintenance

Environmental Hazards

Lighting

Environmental Aids

Preventative Maintenance Program for beds, wheelchairs, and walking aids



Housekeeping

Environmental hazards

Placement of furniture

Location of bed linens


Resident Assessment

Who assesses the resident?

When are the residents assessed?

How are the results communicated to the staff?

How are the results used to develop a fall program for the resident?

Which patients should have a fall program?


Resident Assessment

The 30-Second Chair Stand Test

The Timed Up and Go (TUG) Test

The 4-Stage Balance Test

Orthostatic Blood Pressure


OK, I have a patient on the floor!


Now What?

“Most people see what they want to, or at least what

they expect to.”

-Martha Grimes


Falls CSI


CSI of Falls

Why draw a picture or take a photo?

Someone else may find a contributing factor to the fall that was unseen by the first responder

Eye witness memory is not reliable

Memory can be affected by stress or mood


Kitchen Test


How good is your visual memory?

Is the child a boy or girl?

What color is the child’s shirt?

What is dripping from the refrigerator?

Name all items on the floor?

How many eggs are on the refrigerator door?


Root Cause Analysis

Traditional Models of looking at adverse events have focused on holding an individual responsible

Root Cause Analysis (RCA) guides you to look at systems and what made it possible for the adverse event to happen


Root Cause Analysis

Gather and document initial information

Fill in the gaps

Analyze (The 5 Whys)

Develop an Action Plan (SMARTS)

Evaluate Effectiveness (PDSA)


Root Cause Analysis

Gather and Document Initial Information

Interview staff and others closely involved

What do you think happened?

Use open ended questions, “Tell me about…”

Make a diagram of the scene at the time of discovery

Draw a stick figure to indicate where the resident was found/fell (label as face up or face down)


Root Cause Analysis

Fill in the Gaps, Review Findings

Identify any gaps and gather any missing information (review record, fall history, interview/re-interview, plan of care)

Outline the sequence of events leading up to the fall

List possible contributing factors


Root Cause Analysis

Identify Contributing Factors

Possible contributing factors to consider:

Environment and equipment related

Medication related

Communication related

Identified fall prevention/risk interventions in place?

Care plan appropriate, updated and followed?

Use the 5 Whys to uncover root causes


Root Cause Analysis

The 5 Whys

This is a question asking method used to uncover the underlying cause of an event

Uncovering the root cause(s) leads to action plans that are more likely to prevent the event from happening again


Root Cause Analysis

Why•Resident fell in room

Why•She tripped over a chair

Why•She didn’t see the chair

Why

•The room was dark, no nightlight

Why

•Nightlight was not part of the Care Plan

Why

•Resident assessed as NOT at risk for falling


Plan: Remove or move the chair

Plan: Put nightlights in all patient rooms

Plan: Review fall risk assessment process; update if needed

Root Cause Analysis

Environmental Factors/General

Lighting

Flooring (wet, shiny, contrast, uneven)

Furniture placement

Room to move freely in the turn radius

Others present, residents, staff visitors?


Root Cause Analysis

Environmental Factors/Equipment

Defective/nonworking equipment

Equipment design

Use specified in Care Plan?

Appropriate for resident?

Correct placement?

Entrapment/safety risk?


Root Cause Analysis

Medications/GeneralNew?

Changes? (Dose, time)

When was last dose given?

Has there been a medication error in the last 24 hours?

Side effects (weakness, dizziness, acute delirium)

Interactions (drug-drug, drug-food, drug-herb)


Root Cause Analysis

Communication Factors

MD or NP

Hand off or shift report

Resident transfer

Available information

Between departments

Between healthcare professionals and family

Other organizations

HARD TO READ HANDWRITING/FAXES


Root Cause Analysis

Evaluation of Effectiveness

Test the plan

Plan

Do

Study

Act


Root Cause Analysis


Root Cause Analysis

Implement the plan and assess for effectiveness

Track and trend data over time

Share results with Safety and Quality committees

Update Care Plan and communicate to team members and all staff


Follow Up - Model for Improvement

Two Step Process

Three fundamental questions can be asked in any order

The Plan-Do-Study-Act Cycle to test and implement change


Three Questions

What are we trying to accomplish?

The aim should be time-specific and measureable

Use SMARTS goals to help set your aim


Three Questions

How will we know that a change is an improvement?

Establish measures

Quantitative measures will help you determine that a specific change leads to an improvement

Track and trend your data over time


Scatter Analysis


0

5

10

15

20

25

30

35

40

0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48 19:12 21:36 0:00

Number of Falls in 6 months

Number of Falls in 6 months

Three

What change can we make that will result in an improvement?

Identify the change that will most likely lead to an improvement

Start small, perhaps with one nursing unit at a time


Plan-Do-Study-Act

Study or Check:

Assess the change for a specific period of time to determine if the change was effective

Have team members report back to the team on the effectiveness of the change


Plan-Do-Study-Act

Act:

Implement the action plan or start the process over again

Celebrate success

Return to the process if the plan has not worked

Track and trend data over time using graphs and charts


What Works?

Staff Education

Vision Awareness

Frequent rounding by nursing/CNA staff

Same staff, same patient

Eliminating wheelchairs

Meaningful activities


References

CDC: http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html

Oregon Patient Safety Commission:

http://oregonpatientsafety.org/healthcare-professionals/nursing-homes/long-term-care-falls-investigation-toolkit/284/


http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html

http://oregonpatientsafety.org/healthcare-professionals/nursing-homes/long-term-care-falls-investigation-toolkit/284/

References

Oregon Safety Commission

http://oregonpatientsafety.org/healthcare-professionals/nursing-homes/root-cause-analysis-materials-for-long-term-care-facilities/283/


http://oregonpatientsafety.org/healthcare-professionals/nursing-homes/root-cause-analysis-materials-for-long-term-care-facilities/283/

Questions/Answers

Harmony Healthcare International

1 (800) 530 – 4413

[email protected]

[email protected]

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