Center for Nursing and Rehabilitation

1
Center for Nursing and Rehabilitation

• Enhancing Resident Safety via a Fall Reduction
  Initiative
• Speakers
• Dr. Saka Kazeem, MD, CMD Dr. Phyllis
  Quinlan, RN-Bc, PhD

2
SPEAKER DISCLOSURE

• None of the speakers for the
• Center of Nursing Rehabilitation have any
  relevant financial relationship with any vendors
  of products or programs mentioned in this
  presentation.

3
OBJECTIVES

• At the end of the presentation the participants
  will be
• able to
• Outline an approach for reviewing a Facilitys
  current Fall Management Program so as to identify
  opportunities for improvement
• Identify two approaches to reducing falls in the
  subacute resident population
• Identify 3 approaches to reducing falls in the
  cognitively challenged resident population
• Explain the value of an Interdisciplinary
  approach to resident safety

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Introduction

• The Center for Nursing Rehabilitation, located
  in the Prospect Heights section of Brooklyn, New
  York, is a 320 bed not-for-profit facility and a
  member of the Center Light Health System.
• The Facility has a dedicated 40 bed CARF
  accredited Subacute Care Unit, 40 beds allocated
  for medically complex residents and the remaining
  240 beds serve the needs of resident with a
  variety of physical co-morbidities and cognitive
  challenges.

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Background

• Data October 1 through December 31, 2010
• Total of 73 falls
• 66 un-witnessed
• 6 witnessed
• 1 lowering the resident to the floor
• Time of peak incident was 700pm and 900pm (38)
• Peak location as the residents room
• 25 falls occurred on the subacute rehabilitation
  unit
• 9 on the medically complex unit
• Remainder occurred on those units with cognitive
  challenges residents

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Background

• A Fall Management Program was in existence
• Screening tool
• Supporting policy and procedure
• Availability of low beds
• Floor mattresses
• Bed/chair alarms
• Four (4) residents had least restrictive
  restraints
• Objective
• Improve resident safety and quality of care by
  reducing the incident of resident falls by 25
  over the calendar year October 2010 through
  October 2011

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Background

• Reviewed current assessment tools,
  policy/procedures, internal occurrence
  investigation tool methods used for
  investigating fall events.
• Goal Ensure current practice is comprehensive,
  aligns with a best practice approach and is in
  compliance with the LTC Code of Federal
  Regulations for Accidents Restraints .
• Fall Risk Screen/Assessment Tool risk screening
  elements were adequate for determining a risk for
  falling however the tool did not quantify the
  risk with a numerical value such as, less than 4
  low risk greater than 10 high risk
• The tool revised to include an assigned numerical
  value that would highlight the severity of the
  residents risk and drive critical thinking and
  the need for immediate action.

• Once the resident was screened to be at risk for
  a fall, the tool/procedure did not lead the
  nurse to interventions to facilitate quick and
  easy initiation of a fall management plan of
  care.
• 26 Nursing Interventions for Fall Management and
  15 Nursing Interventions for Safe Resident
  Transfer developed by the Interdisciplinary Team
  and added to the back of the tool as an immediate
  resource and for user convenience.
• The policy/ procedure for Fall Management updated
  to include these management approaches.
• Ten Steps to Follow when a resident experiences a
  fall were also added to the procedure to
  standardized the staffs response to a fall
  event.

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Cycle One

• Falls in the subacute care unit were linked to
  rehab residents resisting need to call for
  assistance when they needed to use the toilet.
• Black toilet seats were installed in the unit as
  an out-of-the-box-approach to reducing the risk
  of falls in the bathrooms.
• Goal enhance the depth perception for resident
  by providing visual contrast between the white
  toilet fixture and the neutral bathroom flooring.

• The staff in-serviced in concepts of falls
  management and trained in revised documentation
  tools, policy and procedures
• A review of the internal occurrence investigation
  tool and methods used for investigating fall
  events did not reveal a need to modify current
  practice

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Cycle Two

• Data January through March 31, 2011
• Total of 76 falls
• 73 unwitnessed
• 2 witnessed
• 1 lowering the resident to the floor
• Peak incident hours of 700pm and 900pm
• Peak location as the residents room 40
• 13 falls occurred on the subacute rehabilitation
  unit
• The remainder occurred on those units with
  cognitive challenged residents
• The Facility was improving its fall management
  with subacute rehabilitation patients but the
  challenge of addressing this safety issue
  effectively in the cognitively challenged
  residents went largely unanswered

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Cycle Three

• A back to basics approach to fall management in
  the cognitively challenged resident was adopted
• Toileting patterns were reassessed and revised
• An overlay mattress with built-in side guards was
  trialed with success in managing those residents
  compelled to try to get out of bed unassisted
• Overlay mattress was not a restraint, had an exit
• Signaled bed boundaries slowed ability to get
  OOB offered additional time to respond to bed
  alarms
• Overlay mattress adopted throughout Facility as
  need identified
• Residents were re-evaluated for restorative
  rehabilitation
• Requisitions focused on need for evaluation of
  physical functional deficits, balance and
  transfer abilities with emphasis on bed to
  wheelchair and toilet transfer skills

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Cycle Three

• Review of several cognitively challenged
  residents who had a history of falls raised a
  question about adequate pain management in those
  residents with behavioral components to their
  presentation
• The Facilitys pain assessment tool and procedure
  were reviewed and revised to include the PainAD
  (advanced dementia) pain scale. Each cognitively
  challenged residents was then reassessed for
  pain using the PainAD scale
• Pain management in this population was enhanced
  and, in several cases, the use of psychotropic
  medications was reduced or discontinued
• The staff of the Therapeutic Recreation Team was
  challenged with enhancing the programs offered to
  this population during the peak fall event hour
  of 700pm to 900pm
• Resident care plans were revised to include all
  revised interventions

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Cycle Four

• Data April 1 through June 30, 2011
• Total 48 falls
• 45 unwitnessed
• 3 witnessed
• Peak incident was hours of 700pm and 900pm
• Peak location was the residents room 14
• Clearly success had been achieved in managing
  fall events in the cognitively challenged
  resident
• Challenge sustain this achievement

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Cycle Five

• Data July 1 through September 30, 2011
• Total of 34 falls
• 32 unwitnessed
• 2 witnessed
• Peak incident shifted to the day shift (28) with
  the peak location remaining as the residents
  room
• 6 occurred on the subacute rehabilitation unit
  remainder occurring on units with cognitively
  challenged residents
• 5 residents had least restrictive restrains in
  place to manage the residents inability to
  recognize their safety needs.
• Every effort was made to ensure that the key
  elements of these approaches to fall management
  were maintained as the Facility transitioned into
  using an electronic medical record 

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Cycle Five
15
Feasibility

• The feasibility of this Initiative was high. It
  required an interdisciplinary review of the
  Facilitys current practice in managing resident
  falls and collaborative thinking.

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GENERALIZABILITY The approaches outlined in this
Initiative can easily be implemented by any other
Long Term Care facility

• Review of current risk screening/assessment tool
• Revise policy/procedure to align with identified
  revisions
• Review current internal investigation tools and
  methods
• In-service the staff in fall management concepts
  and revised approaches
• Review new products available to maintain
  resident safety that can best address your
  facilitys identified areas of need.
• Review the residents toileting patterns and
  revise as necessary

• Age-related depth perceptions changes can be a
  factor in maintaining safety
• Review pain management assessment approaches in
  those residents with cognitive challenges and
  identified behavioral issues to ensure that pain
  is not misaddressed as an ongoing behavioral
  issue
• Therapeutic Recreation team is a vital component
  in addressing resident safety during off hours
• Review policies and procedures addressing
  restraints to ensure best practice and compliance
  
• Share the results of your efforts

Celebrate your success!!
17
Outcomes

• Our objective was to decrease resident falls by
  25 over the calendar year October 2010 through
  October 2011..
• Peak fall incidents 76 occurred during January 1,
  through March 31, 2011.
• By June 30, 2011, the quarterly incident of falls
  was reduced to 48.
• This equates to a 37 rate reduction.
• By September 30, 2011 the quarterly incident of
  falls was reduced to 36.
• This achievement equates to a 53 reduction.

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Outcomes

• The Center for Nursing and Rehabilitation employs
  the Resident Centered Approach as its care
  delivery model
• The staff had a high sense of commitment to
  maintaining resident safety by decreasing the
  rate of resident fall occurrence as demonstrated
  by our outstanding outcomes
• Conventional and creative approaches were
  utilized by the Interdisciplinary Team
• The cost of the black toilet seat was 29.45 per
  seat. Eighteen (18) seats were changed for a
  total cost of 530.10.
• The cost of the overlay mattress was 234.99. A
  total of 76 mattresses were ordered from the end
  of 2010 through September 30, 2011 for a total
  cost over 10 months of 17,859.24.
• These purchases did not present any additional
  cost to the Facility. Administration collaborated
  with Nursing and Housekeeping to reallocate
  existing identified monies to allow for the
  purchase of adequate numbers of black toilet
  seats and overlay mattresses to address resident
  needs

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The impact on the quality of care and service at
CNR was improved as outlined in the following

• Staff knowledge base and skills were enhanced on
  the subject of fall management and restraints.
• Staff knowledge base and skills were enhanced in
  the area of pain assessment in residents with
  cognitive challenges and behavioral management
  issues.
• User friendly screen/assessment tools were
  developed.
• The concept of an Interdisciplinary approach to
  Resident Centered Care was anchored.
• There was a 53 reduction in the quarterly number
  of falls over a one year period.
• Pain management for all residents was enhanced.
  (CFR 483.20)
• There were no citations for resident safety in
  the 2011 Annual State Survey
• Satisfaction surveys demonstrated a
  resident/family satisfaction rate over 90.

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References

• 1. AMDA Clinical Practice Guideline, 1998
  (revised 2003). Falls and Fall Risk. Available
  at http// www.amda.com.
• 2. Bonner, A. RN, GNP, FAANP. (2006). Falling
  into Place A Practical Approach to
  Interdisciplinary Education on Falls Prevention
  in Long-Term Care. Annals of Long Term Care.
  Volume 14, Number 6. An online article retrieved
  from Google on the World Wide Web
  http//www.annalsoflongtermcare.com/attachments/57
  78.
• 3. Burland, E. (2008). Improving Care at the
  Front Lines An Evaluation of a Fall Management
  Program in a Personal Care Home Population. An
  online article retrieved from Google on the World
  Wide Web http//www.longwoods.com/content/19663
• 4. Feinsod, F. MD, Capezuti, E. PhD, RN, Felix,
  V. BS, PT. (2008). Reducing Fall Risk in
  Long-Term Care Residents Through the
  Interdisciplinary Approach. An online article
  retrieved from Google on the World Wide Web
  http//www.annalsoflongtermcare.com/article/4365
• 5. Herr, K. PhD, RN, FAAN, Bjoro, K. RN, PhDc,
  Decker, S. PhD, APRN-BC. (2006). Tools for
  Assessment of Pain in Nonverbal Older Adults with
  Dementia A State-of-the-Science Review. Journal
  of Pain and Symptom Management Volume31, Issue
  2. An online article retrieved from Google on the
  World Wide Webhttp//www.sciencedirect.com/science
  /article/pii/S0885392405006111
• 6. Warden, V. RN, Hurley, A, RN, DNSc, FAAN,
  Volicer, L MD, PhD, FAAN. (2003). Development and
  Psychometric Evaluation of the Pain Assessment in
  Advanced Dementia (PAINAD) Scale. Journal of
  American Medical Directors Association Volume 4,
  Issue 1. An online article retrieved from Google
  on the World Wide Web http//www.sciencedirect.com
  /science/article/pii/S1525861004702583