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FA L L S : F R O MP R E A D M I S S I O N T O

D I S C H A R G EM E L O DY S C H R O C K , R N , B S N , R A C - C T

Q I P M O C L I N I C A L E D U C ATO R

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OBJECTIVES

• By the end of the webinar, registrants will be able to answer the following points.. - Define what constitutes a fall- Discuss interventions for fall prevention/safety- Identify how falls can impact Quality Measures/5-Star Reporting

F689: ACCIDENTS

• §483.25(d) Accidents.

• The facility must ensure that –

• §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

• §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

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INTENTINTENT: §483.25(d)

• The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:

– Identifying hazard(s) and risk(s);

– Evaluating and analyzing hazard(s) and risk(s);

– Implementing interventions to reduce hazard(s) and risk(s); and

– Monitoring for effectiveness and modifying interventions when necessary.

D E F I N I T I O N S

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FALL: SOM• Refers to unintentionally coming to rest on the ground, floor, or other lower

level, but not as a result of an overwhelming external force (e.g., resident pushes another resident).

• An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall.

• A fall without injury is still a fall.

• Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred (refer to Resident Assessment Instrument User’s Manual. Version 3.0, Chapter 3, page J-27). (SEE NEXT PAGE)

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FALL: RAI• FALL - Unintentional change in position coming to rest on the ground, floor or onto the

next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident).

• An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person – this is still considered a fall.

CMS understands that challenging a resident’s balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls.

FA L L S : B R E A K I N G I T…

… D O W N

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SOME STATISTICS

• Muscle weakness and gait problems account for about 24% of nursing home falls (SOM)

• Environmental hazards cause16% to 27% of falls for residents. (SOM)

• Falls are the second leading cause of accidental or unintentional injury deaths worldwide. (WHO)

• Adults older than 60 years of age suffer the greatest number of fatal falls.(WHO)

• Prevention strategies should emphasize education, training, creating safer environments, prioritizing fall-related research and establishing effective policies to reduce risk.

FACILITY RESPONSIBILITY

• Provide care in a manner that promotes quality of life.

–Rights to privacy

–Dignity

–Self determination

–Right to make choices about aspects of their life in the facility

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A CULTURE OF SAFETY

• Acknowledges the high-risk nature of its population and setting;

• Develops effective communication, including a reporting system that does not place blame on the staff member for reporting resident risks and environmental hazards;

• Engages ALL staff, residents and families in training on safety, and promotes ongoing discussions about safety with input from staff at all levels of the organization, as well as residents and families; (QAPI)

• Encourages the use of data to identify potential hazards, risks, and solutions related to specific safety issues that arise; (how do you analyze data?-What data do you collect?)

• Directs resources to address safety concerns; and

• Demonstrates a commitment to safety at all levels of the organization.

Processes in a facility’s interdisciplinary systematic approach may include:

1. Identification of hazards, including inadequate supervision, and a resident’s risks of potentially avoidable accidents in the resident environment;

2. Evaluation and analysis of hazards and risks;

3. Implementation of individualized, resident-centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment; and

4. Monitoring for effectiveness and modification of interventions when necessary.

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W H AT’ S T H ER I S K ?

IDENTIFICATION OF HAZARDS & RISKS

Involves ALL staff from ALL departments: Social Services, Environmental services, Maintenance, Dietary, Laundry, Nursing

• Consider unique characteristics and abilities of each resident:

– Diagnosis

– Physical abilities

– Cognition

– Strengths

– weaknesses

• Make reasonable effort to identify hazards and risks of EACH resident

– INDIVIDUAL basis: just because in building does not automatically mean high risk

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IDENTIFICATION OF HAZARDS & RISKS

Sources• Quality Assessment and Assurance Activities

• Environmental rounds

• MDS/CAAs Data

• Medical history and physical exam

• Risk assessments

• Facility assessment (F838)

• Individual observation

• Preadmission screenings

RISKS AND ENVIRONMENTAL HAZARDS

• Physical Plant, Devices, Equipment:

– May not be hazards… but when you add a vulnerable resident the risk becomes evident.

• Resident Vulnerability:

– Functional status

– Medical condition

– Cognitive abilities

– Mood

– Health treatments

– Medications

– ONGOING- Changing

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RISKS AND ENVIRONMENTAL HAZARDS

Plant hazards:

– Propped fire doors, Disabled locks or latches

– Nonfunctioning alarms: doors, personal, etc.

– Buckled or torn carpet or flooring

– Cords on floor: O2, electric beds, televisions, lamps, air mattresses, air pumps

– Irregular walking surfaces/Colored or patterned carpet

– Ill fitting equipment

• Chairs, beds, walkers

– Poor lighting: too dim, too bright, glares

I N T E R V E N T I O N S

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PRE-ADMISSION RISK AND INTERVENTIONS

• Who does the talking?

– Social services: tour -

• What does family report? Falls at home? Medications? Compliance? Stubborn?

– DON: Hospital admission paperwork

• Medications? Past procedures? Diagnosis?

– Family: set up room prior to arrival

• Familiar items: bedspread? Pillows? Pictures?

• Similar set up to home

– Maintenance: routine maintenance and checks of bed/wc brakes, checking equipment

– Rehab: education of new staff to lifts

– Laundry: checking lift slings as they come through for laundering

AFTER ADMISSION & THROUGHOUT STAY

• Rehab: Eval and Tx- go to the home early, review what is needed so family has plenty of time to get a fix in place if goal is to go home.

• Social services: resources for preparing home if needed (they take time!)

• Nursing: so MANY interventions

• Maintenance: adding assistive devices, entrapment assessments

• EVERYONE: keeps an eye on safety and behaviors

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SUPERVISION• Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to

provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident’s assessed needs, and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Devices such as position change alarms may help to monitor a resident’s movement temporarily, but do not eliminate the need for adequate supervision. The resident environment may contain temporary hazards (e.g., construction, painting, housekeeping activities, etc.) that warrant additional supervision or alternative measures such as barriers to prevent access to affected areas of the resident environment.

• Adequate supervision to prevent accidents is enhanced when the facility:

– Accurately assesses a resident and/or the resident environment to determine whether supervision to avoid an accident is necessary; and/or

– Determines that supervision of the resident was necessary and provides supervision based on the individual resident’s assessed needs and the risks identified in the environment.

RESIDENT INTERVENTIONS• Therapy: PT/OT/ST/Restorative

• Social cervices, psychologist/psychiatrist

• Toilet, TOILET, Toilet!

• Hydration

• Feet:

– Footwear, nonslip socks

– Check no slip surfaces

– Shuffling gate?

– Cognitive impairment? Moccasins or nonslip socks

• Pain?

• Glasses: are they clean? Contacts?

• Belongings in reach (the nest)

• Orthostatic issues

• Anticipate needs

• Avoid Sensory overload

• Environment changes

• rest periods

• Activities

• Exercise

• Exercise pedals

• Distractions while waiting

• Wii

• Dance music therapy

• Daily ambulation program (group/individual)

• Hip protectors, knee/elbow pads

• Cues/reminder signs

• Large number clocks/calendars

• Reminiscence/life review

• Tapes of loved ones and friends (family videos or albums)

• Spiritual support

• Intergenerational cultural, pet programs

• Remove objects that my trigger (i.e., coat hat)

• Limit caffeine

• HONOR THEIR ROUTINE

• Involve in choices and plan

• Safety contract

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FAMILY INTERVENTIONS

• Education: if falling at home… likely to fall again.

• Involve in planning care

– Predicted course of illness

– Anticipated behavior/cognitive changes

• Patient history: habits and customs

• Coping mechanisms/triggers (dates, smells, color, person)

• Encourage use of family/sitters to stay with high risk: (Essential caregivers)

• Recording of reassuring messages

• Family scrap book or photo box, memorable event/objects of affection

ENVIRONMENTAL INTERVENTION• Personalize rooms, familiar objects

• Room relocation

• Call light system

• Bedside commode

• Bed height

• Trapeze, bed handle, transfer pole

• Body pillows

• Bolsters

• Nest

• Bedside table

• Clutter free

• Frequent rest areas

• Position bed to accommodate weakness

• Reduce noise

• Floor mats

• Padding

• Carpeted surfaces or nonslip wax, low buff to reduce glare

• Nonskid on floor in front of sink, toilet, bed

• Exit doors (keep exit door closed, stop signs,

• higher seated lounge chairs and toilets

• Appropriate size equipment

• Visual cues/signage

• Memory trigger

• Minimized hall equipment

• Adequate lighting

• Light and color, high contrast/avoid busy patterns

• Property fencing

• Establish a wandering path/ courtyard

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STAFF INTERVENTIONS• Everyone is responsible

• Fall prevention team with direct care staff

• “mama's rules”

– clean up spills immediately

– Pick up/move items

– Rough flooring/carpet

– Light not working

– Eyeglasses dirty

– Pants to long

• Determine reason for and relieve discomfort

• All Eyes Open/frequent rounding

• Color coded re: risk, magnet,

• Address call light promptly

• Permission before touching, moving, hugging

• Move slowly around ambulatory residents/avoid abrupt changes or rushing

• Calm approach

• Avoid confrontation

• Consistent caregivers

• Actively listening/validate feelings

• Structured activities

• Assess sleep pattern

• Assistive devices

• Medication review/changes

IMPLEMENTATION OF INTERVENTIONS

• Implementation refers to using specific interventions to try to reduce a resident’s risks from hazards in the environment. The process includes:

• Communicating the interventions to all relevant staff, assigning responsibility, providing training as needed, documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident), and ensuring that the interventions are put into action.

• Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with professional standards, including evidence-based practice.

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IMPLEMENTATION OF INTERVENTIONS, CONT.

• Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully.

• Facility-based interventions may include, but are not limited to, educating staff, repairing the device/equipment, and developing or revising policies and procedures.

• Resident-directed approaches may include implementing specific interventions as part of the plan of care, supervising staff and residents, etc.

• Facility records document the implementation of these interventions.

MONITORING AND MODIFICATION• Monitoring is the process of evaluating the effectiveness of care

plan interventions.

• Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks.

• Monitoring and modification processes include:

– Ensuring that interventions are implemented correctly and consistently;

– Evaluating the effectiveness of interventions;

– Modifying or replacing interventions as needed and

– Evaluating the effectiveness of new interventions.

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PRE-DISCHARGE

• Another home eval: have recommendations been followed through?

• Overnight LOA?

• Cooking?

• Cleaning?

• Home Exercises

DISCHARGE INTERVENTIONS

• Post DC call to resident

• Post DC call to responsible party or family contact

• Deliver flowers/gift basket to home (personally check on resident)

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W E H AV E FA L LS… W H AT N O W?

REVIEW THE FINDINGS

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WHY DO THEY FALL?• Environmental hazards, such as wet floors,

poor lighting, incorrect bed height and/or width, or improperly fitted or maintained wheelchairs;

• Unsafe or absent footwear;

• Underlying chronic medical conditions, such as arthritis, heart failure, anemia and neurological disorders;

• Acute change in condition such as fever, infection, delirium;

• Medication side effects;

• Orthostatic hypotension;

• Lower extremity weakness;

• Balance disorders;

• Poor grip strength;

• Functional impairments (difficulty rising from a chair, getting on or off toilet, etc.);

• Gait disorders;

• Cognitive impairment;

• Visual deficits: cataracts, glaucoma, transitional zones between light and dark spaces, supplemental light near beds for tasks during times of low light;

• Pain; and

• Incontinence.

POST FALL INTERVENTION

• Fall huddle: include all on the hall (housekeeper, dietary, nursing, etc)– What was seen?

– How were they found?

– Environmental check? Call light? Floors? cords/tubing?

– Witnessed?

• Fall investigation

• Root cause analysis

• Fall tracking and logging

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VISUAL AIDES/CHARTS

• Facility blueprint/smart board– Indicate where, what shift, who was working

– Examine trends: common employees, locations, times

– Where are trends? Common staff? Location? Time?

• Line/pie charts

HOW TO CALCULATE FALL RATE

• Count the number of falls in the month.

• Figure out how many beds were occupied each day.

• Add up the total occupied beds each day for the month (patient bed days).

• Divide the number of falls by the number of patient bed days for the month.

• Multiply the results by 1,000 to get the fall rate per 1,000 patient bed days.

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FALL RATE CALCULATION EXAMPLE

Directions Example

Count number of falls in April. 3 falls in April

Count occupied beds each day in April. 26 on April 1, 28 on April 2, …

Add up the total occupied beds each day for April (patient bed days).

879 occupied beds

Divide the number of falls by the number of patient bed days in April.

3/879 = 0.0034

Multiply by 1,000. 0.0034 x 1,000 = 3.4 falls per 1,000 patient bed days

USE OF DATA

• Examine the rates for trends over time.– Graph data in a run chart to visually examine.

– Are rates getting better or worse?

– Can you relate changes in rates to changes in practice?

– Rates are probably quite different by patient unit.

– Focus on trends over time. There will be fluctuations. Don’t overreact.

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FALL RATE DATA

When you first start tracking, you may notice increased fall rates. This is not necessarily due to worse care. Instead, unit staff members are becoming better at reporting falls that were missed in the past.

W HAT P RACTICES S HOULD B E M EASURED?

Initially, look at two practices:1. Performance of fall risk factor assessment within 24 hours of

admission2. Performance of care planning that addresses each risk

factor identified during fall risk factor assessment

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AFTER A FALL

• Proper actions following a fall include: – Ascertaining if there were injuries, and providing treatment as necessary;

– Determining what may have caused or contributed to the fall, including ascertaining what the resident was trying to do before he or she fell;

– Addressing the risk factors for the fall such as the resident’s medical conditions(s), facility environment issues, or staffing issues; and

– Revising the resident’s plan of care and/or facility practices, as needed, to reduce the likelihood of another fall.

NOTE: A fall by a resident does not necessarily indicate a deficient practice because not every fall can be avoided.

ASSISTIVE DEVICES & FALLSThree primary factors that may be associated with an increased accident risk related to the use of assistive devices include:

1. Resident Condition. Lower extremity weakness, gait disturbances, decreased range of motion, and poor balance may affect some residents. These conditions combined with cognitive impairment can increase the accident risks of using mobility devices. Unsafe behavior, such as failure to lock wheelchair brakes and trying to stand or transfer from a wheelchair unsafely, can result in falls and related injuries;

2. Personal Fit and Device Condition. Devices can pose a hazard if not fitted and/or maintained properly.26 Personal fit, or how well the assistive device meets the individual needs of the resident, may influence the likelihood of an avoidable accident; and

3. Staff Practices. Mobility devices that a resident cannot readily reach may create a hazardous situation. Unsafe transfer technique used by staff may result in an accident. Inadequate supervision by staff of a resident during the initial trial period of assistive device use or after a change in the resident’s functional status can increase the risk of falls and/or injury. Additionally, staff needs to ensure assistive devises properly fit the resident and the resident has received proper training in the use of the assistive device.

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ASSISTIVE DEVICES/EQUIPMENT HAZARDS

• Assistive devices can:– Help prevent accidents

– Help residents move with increased independence

– Transfer with greater comfort

– Feel physically more secure

• BUT ALSO: – Give false security

– Increase risk if wrong size

– Misplaced optimism

ASSISTIVE DEVICES

MUST BE MAINTAINED

• Training of Staff, residents, family members, volunteers

• Communicate approaches in care plan to all staff: agency, temporary, PRN

• Competencies/Policies

– Mechanical lifts

• Weight limitations

• Policies

• Manufacturer’s guidelines

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TRANSFER DEVICES& FALL RISKS

• Mechanical assistive devices for transfer include, but are not limited to, portable and stationary total body lifts, sit-to-stand devices, and transfer or gait belts

• The resident assessment helps to determine the resident’s degree of mobility and physical impairment and the proper transfer method; for example, whether one or more caregivers or a mechanical device is needed for a safe transfer. Residents who become frightened during transfer in a mechanical lift may exhibit resistance movements that can result in avoidable accidents. Communicating with the resident and addressing the resident’s fear may reduce the risk.

TRANSFER FACTORS

• Staff availability

• Resident abilities

• Staff training and competency

• Resident communication abilities

• Physical limitations

• Transfer bars/side rails/assist bars– May add entrapment risks

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Q U A L I T Y M E A S U R E, FA L L R AT E S, & 5 - S TA R

WHAT TRIGGERS?

J1800: Has the resident had any fall since admission, entry, or reentry, or the prior assessment (OBRA or Scheduled PPS), whichever is more recent?

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PERCENTAGE OF RESIDENTS EXPERIENCINGONE OR MORE FALLS WITH MAJOR INJURY

• This measure reports the percentage of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period (one full calendar year).

MOST COMMON QUESTION: HOW LONG DOES IT STAY ON THE REPORT?

• Based on your report date it captures a look back scan. – What is a look back scan?

• Last assessment then 275 days prior to that (can be over a year dependent on MDS schedule)

• Looks at all assessments in that range

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STEPS TO TAKE

• Ensure the MDS was coded correctly – Was it really a fall? Miscoded?

• Evaluate:– What is the fall problem?

– What is the prevention strategy for fall risk reduction, versus an intervention after a fall has occurred?

– Are you proactive or reactive? Are you are waiting for the quality measure report to see improvements? Or Doing internal data/tracking?

CARE PLANNING ASSESSMENT

• All risk factors identified on the fall risk factor assessment need to be addressed in the care plans.

• Next, act on the care plans.

– Critical thinking by staff

– Tailored approach to each patient, based on the patient’s risk factors

• Ensure that care plans address all areas of risk.

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5-STAR AND QUALITY MEASURES

Quality Measures - Measures based on MDS and claims-based quality measures (QMs): Ratings for the quality measures are based on performance on 15 of the QMs that are currently posted on the Care Compare website. These include nine long-stay measures and six short-stay measures. Note that not all of the quality measures that are reported on Care Compare are included in the rating calculations. In addition to an overall quality of resident care rating, separate ratings for the quality of resident care for short-stay residents and long-stay residents are also reported.

SCORING RULES

For long-stay pressure ulcer, long-stay catheter, long-stay urinary tract infections, long-stay falls, short-stay pressure ulcer/pressure injury, and short-stay antipsychotic medication: nursing homes are grouped into quintiles based on the national distribution of the QM. The quintiles are assigned 20 points for the lowest performing quintile, 100 points for the highest performing quintile, and 40, 60 or 80 points for the second, third and fourth quintiles respectively.

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RANGES FOR POINT VALUES FOR QUALIT YMEASURES, USING FOUR QUARTER AVERAGE

DISTRIBUTIONS

WHEN WILL IT CHANGE?

Quality Measure rating changes: Data for the MDS-based QMs and the claims-based hospitalization and ED visit measures are updated quarterly, and the QM rating is updated at the same time. The updates typically occur in January, April, July, and October at the time of the Care Compare website refresh. Changes in the quality measures may change the star ratings.

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C R I T I C A L E L E M E N TPAT H WAY

ACCIDENTS: CRITICAL ELEMENT PATHWAY

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ACCIDENTS: CRITICAL ELEMENT PATHWAY

ACCIDENTS: CRITICAL ELEMENT PATHWAY

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ACCIDENTS: CRITICAL ELEMENT PATHWAY

ACCIDENTS: CRITICAL ELEMENT PATHWAY

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ACCIDENTS: CRITICAL ELEMENT PATHWAY

ACCIDENTS: CRITICAL ELEMENT PATHWAY

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ACCIDENTS: CRITICAL ELEMENT PATHWAY

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Q U E S T I O N S?

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M E L O DY S C H RO C K , R N , B S N , R AC - C TQ I P M O C L I N I C A L E D U C ATO R

4 1 7 - 2 9 8 - 2 9 6 3

S C H R O C K M @ M I S S O U R I . E D U

REFERENCES

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf

• https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-Pathways.zip

• https://www.who.int/news-room/fact-sheets/detail/falls

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf

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