Top 5 Ways to Prevent Falls

Top 5 Ways to Prevent Falls
HARMONY UNIVERSITY
The 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.
Disclosure
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
Copyright © 2013 All Rights Reserved 5

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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Harmony Healthcare International, Inc. 7
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/General
New?
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/HomeandRecreationa
lSafety/Falls/index.html
Oregon Patient Safety Commission:
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/

Questions/Answers
Harmony Healthcare Internationa
1 (800) 530 – 4413
ekelly@harmony-healthcare.com
jsadewicz@harmony-healthcare.com
Harmony Healthcare International, Inc. 6868Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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Harmony Healthcare International, Inc. 69Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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