Preventing Falls in the Nursing Home
Q: Are all falls in the nursing home preventable?
A: According to the Centers for Medicare & Medicaid Services (CMS), a fall is defined as failure to maintain an appropriate lying, sitting, or standing position, resulting in an individual’s abrupt, undesired relocation to a lower level. An episode in which a resident lost his/her balance and would have fallen, were it not for staff interventions, is also considered a fall. Both the incidence of falls and fall-related injuries increase steadily in the elderly. Incidence rate for falls in nursing home residents is two to three times greater than that in community-dwelling elderly (about 1.7 falls per bed annually). Ten to 25% of falls among institutionalized elderly result in a fracture, laceration, or need for hospital care.1
A fall in a nursing home resident is a possible cause of citation by long-term care regulatory agencies. The long-term care facility may be cited under one or more regulatory F-tags (Table I).2 Falls and related injuries are also a frequent cause of litigation in the long-term care setting.
While the majority of falls in long-term care settings should be preventable, it is not feasible to prevent all falls, even when the best possible care is provided.3 Preventing falls constitutes a significant challenge in nursing home settings and requires a substantial interdisciplinary team effort. Every facility should have a fall prevention program that, at the minimum, addresses the following three elements:3
• Assessing residents for risk of falling
• Identifying and implementing interventions to minimize risk of falling
• Identifying and implementing interventions to minimize risk of sustaining an injury as a result of a fall
ASSESSING FALL RISK
Regulatory guidelines require that a comprehensive patient assessment, the Minimum Data Set (MDS), be completed within 14 days of admission to a nursing home. Certain items on the MDS will indicate that a resident is at risk of falling (Table II). When the MDS is completed, a resident who has one or more of these items (also known as triggers) will trigger a falls Resident Assessment Protocol (RAP). Assessment instruments such as the RAP may provide clues to possible causes of falls. The assessment by the MDS and associated RAP may be too late for some residents who are at increased risk for falling from the time of admission.
In addition to the MDS, many facilities use fall assessment tools that are completed by nursing staff within 24 hours of admission, and regularly afterwards (quarterly or annually, at any time a resident has fallen, and with any significant change in resident condition). Most of these tools are composed of items that have been linked to increased risk of falling (Table III).4-7 Such tools may help identify possible causes for falls. The Morse Fall Scale8 is an example of such tools that can be easily administered by nursing staff. The Morse Fall Scale is used in Veterans Administration long-term care units and in some community nursing homes. The scale is composed of six items that address history of falling, secondary diagnosis, ambulatory aids, presence of IV/heparin lock, gait/transferring, and mental status. On the Morse Fall Scale, a score of 0-24 indicates no fall risk, a score of 25-50 indicates low risk for falling, and a score of 51 or higher indicates high risk for falling.
The Tinetti Balance and Gait Evaluation instrument9 is a validated assessment tool that may be used to evaluate fall risk. Using this tool, individuals who scored 19 or less out of 28 had 5.7 times increased risk of falling. The Tinetti Balance and Gait Evaluation instrument is a valuable tool that can help practitioners and therapists to assess fall risk in their patients. The tool, however, may not be practical for routine implementation by nursing home staff.
Comprehensive post-fall assessment can reveal many correctable problems and may lead to decreased future falls and related morbidity.10 After a fall, each resident should be carefully assessed for the presence of injury by nursing staff, and the practitioner and family should be promptly notified. Nursing staff should complete a fall incident report that carefully describes the fall incidence. In addition, the fall assessment tool should also be completed after each fall. The resident care plan should be updated by the interdisciplinary team, and a new MDS should be completed if the fall represents a change of condition.
Members (or a dedicated member) of the fall interdisciplinary team should assess each resident who falls in a timely fashion. This assessment should include evaluation for possible injury, risk factors for falls, and fall-related injuries. Careful and thorough medication review is an important component of evaluating the risk for initial or recurrent falls. Simple clinical tests such as Timed Get Up and Go test and evaluation for possible orthostatic hypotension should be utilized when appropriate. Medical conditions (eg, urinary tract infection, pneumonia, dehydration, stroke, Parkinson’s disease), use of new medications, or change in dosing of current medications should be considered when evaluating a resident with a fall.
THE FALL CARE PLAN
The care plan is a vital communication tool used by the interdisciplinary team to help the resident attain/maintain the highest practicable level of function. It must include measurable goals and plans/approaches necessary to attain the goals. The care plan for a resident at increased risk of falling should address interventions to minimize fall risk (Table IV),3,11 as well as interventions to minimize injuries as a result of a fall (Table V).5,12 Examples of such interventions include pharmacy evaluation of medications, environmental modifications (eg, improve lighting, keep hallways and rooms clear of clutter), use of a sitter, and use of bed and chair alarms. Appropriate communication with families of residents with fall risk is important to help minimize litigation risk.
Most falls do not have a single cause but result from the interaction of several risk factors. Subsequently, multifactorial interventions are often required while managing residents at increased risk of falling. In one study, the implementation of an interdisciplinary program that included staff education, environmental modification, exercise programs, supplying aids, reviewing drug regimens, providing free hip protectors, and having post-fall problem-solving conferences significantly decreased the risk of falls and hip fractures among institutionalized elderly.13 Similar findings were reported by other investigators.10,14
Residents at high risk of falling should be evaluated by an interdisciplinary team. Many facilities have established a fall committee for this purpose. The interdisciplinary team members often meet monthly to perform an analysis of potential risk factors for falls and to identify possible interventions to minimize the risk of falling and fall-related injuries. In addition, the team performs ongoing systemic evaluation to determine the effectiveness of the fall prevention program, and monitor and document resident response to implemented interventions. If a resident continues to fall, the interdisciplinary team should re-evaluate current interventions and amend the care plan accordingly. The nursing facility should regularly conduct quality improvement activities related to falls. This should help track falls by time and location, and identify categories of causes.
There is no evidence to support the use of restraints for fall prevention. Indeed, restraint use could contribute to serious injuries as a result of a fall.11 Federal regulations state that the resident has the right to be free from any physical or chemical restraint imposed for purpose of discipline or convenience, and not required to treat the resident’s medical symptom (Tag F222). The regulation defines medical symptoms as an indication or characteristic of a physical or psychological condition. Before a resident is restrained, the facility should determine the presence of a specific medical symptom that would require the use of restraints, and how the use of restraints would treat the medical symptom. There are instances where, after assessment and care planning, a least restrictive restraint may be deemed appropriate for an individual to attain or maintain his or her highest practicable physical and psychological well-being. In such incidents, the facility has the responsibility to assess care plan restraint use on an ongoing basis, and should engage in a systematic and gradual process toward reducing restraints.
Nursing home residents at risk of falling should be assessed for risk factors for osteoporosis. Bone density assessments should be obtained when possible in individuals at risk of osteoporosis.12 Calcium and vitamin D intake in nursing home residents is often inadequate, and supplementation is often required.15 The current availability of bisphosphonates that can be given weekly (alendronate and risedronate), monthly (ibandronate), or every 3 months (intravenous ibandronate) should make it easier to treat nursing home residents with osteoporosis. Hip protectors should be offered to nursing home residents at risk of sustaining a hip fracture.11
While it is not possible to prevent all falls in the nursing home, with appropriate care it is often possible to significantly reduce the frequency of falls and the severity of related injuries. Any fall prevention program should include measures to assess fall risk, and to implement interventions to decrease fall risk and the risk of sustaining an injury as a result of fall. The author reports no relevant financial relationships.