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Reduction of Risk for Falls Program

November 1, 2002
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Adapted from a 2002 OPTIMA Award entry by Evangelical Manor, Philadelphia By Barbara Hacker, RN, MEd, NHA
Reduction of Risk for Falls Program Adapted from a 2002 OPTIMA Award entry by Evangelical Manor, Philadelphia

By Barbara Hacker, RN, MEd, NHA For more than a century, Evangelical Manor has served the Philadelphia community by providing residential living accommodations and independent living, assisted living and licensed nursing care for persons of retirement age. The facility's Health Center has 120 beds-a 60-bed unit for skilled nursing and long-term care, and another 60-bed special-care unit for residents with dementia. The retirement living facility is licensed for 50 personal-care beds out of 174 residential apartments.

In an effort to self-evaluate resident care and services, facility administration embarked on several endeavors to promote improvement. One of the resident care areas focused upon was the transition from quality-assurance to quality-improvement programs. The Reduction of Risk for Falls Program, a result of this process, began in October 1999 and continues to this day.

Readers might recall that in 1999, facility quality-indicator (QI) reports were promulgated by the then Health Care Financing Administration. The impetus for establishing the Reduction of Risk for Falls Program arose when the facility began analyzing its Facility Quality-Indicator Profile (FQIP), comparing it with various QIs of other facilities in the state. One of the rules is that any percentile ranking of 70 or more for problems warrants investigation for improvement. Evangelical Manor's FQIP report showed a percentile rank for falls of more than 70% for seven of nine months reported.

The facility's QI data on "Accidents-Incidence of New Fractures" and "Prevalence of Falls" are shown in Table 1. Although the clinical staff acknowledged the facility's problem with resident falls, discussing this during Care Plan conferences had no impact on resident falls during the remainder of 1999. The clinical team had not previously focused attention on falls, the interventions that might reduce their incidence or how to prevent serious fall-related injuries. The QI reports, though, clearly necessitated an immediate response.

A Quality-Indicator Review (QIR) Committee was established in late 1999 under the leadership of the new assistant director of nursing. Its initial meetings included representatives from nursing (nurses and aides) on all three shifts, an occupational therapist, a social worker, a registered nurse assessment coordinator, a restorative nurse, the director of nursing, the administrator and a health-care consultant we had retained to assist with the QI process. The "Prevalence of Falls" QI was identified as a priority area.

Trending of falls data showed great fluctuations in the facility's monthly percentile rank. The QIR Committee did not understand why these statistics varied so, but agreed to investigate the variance as part of the process. The committee set as its goal an improvement in the percentile rank for falls of 10% annually, starting with the 1999 annualized rate of 78%.

After deliberation, the QIR Committee decided to establish a structured program, which included creating an in-depth "risk for falls" assessment with its own scoring methodology, a plan-of- action process to develop recommendations for the Care Plan Team, improved documentation practices, and computerized tracking and trending of falls data.

The structured Reduction of Risk for Falls Program started with the identification of audit criteria-factors that could contribute to resident accidents, including new fractures resulting from falls. The committee discussed and fine-tuned a list of criteria for use in a baseline Falls Audit, and committee members were trained on audit procedures, which included resident sampling, maintaining resident information confidentiality and performing chart reviews.

The initial audit criteria were:

1.Is section J4 of each resident's MDS coded for falls?
2.Is the resident using psychotropic medication or blood pressure medication, and are related diagnoses noted?
3.What time of day was the fall recorded?
4.What are the resident's ambulation status, locomotion level; use of walker, cane, wheelchair; and needed transfer methods?
5.Does the resident use fall-preventive devices (e.g., motion monitor, side-rails)?
6.Has a PT/OT consult for gait and ambulation been completed?
7.Does the resident have a history of falls?
8.How is the resident's vision?
9.Any physical or sensory impairment?
10.Any cognitive impairments leading to poor judgment?

Of the nine residents in the initial fall sample, five had received an OT/PT evaluation within a relatively recent period; all nine had vision impairments; six had physical/sensory impairments; and seven had cognitive impairments. However, the audit team found inconsistencies in data collection and suggested that the criteria be revised. The revised criteria were as follows.

1.Are there predisposing conditions or diseases present that might contribute to falls?
2.History of falls?
3.Impaired vision?
4.Any perceptual disturbances?
5.Problems in communicating needs?
6.Any physical or sensory impairments?
7.Any cognitive impairments?
8.Did any falls occur within a month after admission to the facility? Any falls after 31 to 180 days?
9.Any use of blood pressure or psychoactive medications? What are the diagnoses?
10.Time of day of the fall?
11.Resident's ambulation level prior to the fall?