Quality Improvement in Long Term Care Program Falls Prevention.
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Transcript of Quality Improvement in Long Term Care Program Falls Prevention.
Quality Quality Improvement in Improvement in Long Term Care Long Term Care
Program Program FallsFalls PreventionPrevention
Falls Management Falls Management ProgramProgram
The purpose of a falls management The purpose of a falls management program is to assess each resident program is to assess each resident fall risk. To assess each resident’s fall risk. To assess each resident’s fall risk, ensure the resident’s fall risk, ensure the resident’s immediate safety and to ensure immediate safety and to ensure further safety and further safety and fall preventionfall prevention through a multidisciplinary through a multidisciplinary approach.approach.
FIRST STEPSFIRST STEPS
We determined the We determined the need for an initiative need for an initiative by reviewing and by reviewing and analyzing the Quality analyzing the Quality Assurance data Assurance data collected each month. collected each month.
Review current Review current resident falls resident falls assessment from pre-assessment from pre-admission information admission information to current data.to current data.
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SCREENINGSCREENING Review resident applications, many are high-Review resident applications, many are high-
lighted for fall risk.lighted for fall risk. On admission (and quarterly) a FALL RISK On admission (and quarterly) a FALL RISK
ASSESSMENT is completed:ASSESSMENT is completed: Identifies history of fallsIdentifies history of falls Medication usedMedication used Diagnosis and vital signsDiagnosis and vital signs Memory and orientationMemory and orientation Vision and hearing abilityVision and hearing ability Continence levelContinence level Mobility status, including gait analysisMobility status, including gait analysis Related behavioursRelated behaviours
RESIDENT CARE PLANRESIDENT CARE PLANWhen a resident is high/medium risk a care plan is When a resident is high/medium risk a care plan is
developed to identify the risk.developed to identify the risk. FOCUSFOCUS
Potential/ high risk for Falls related to ….. Potential/ high risk for Falls related to ….. GOALGOAL
Prevention of falls.Prevention of falls. INTERVENTIONSINTERVENTIONS
Place wheelchair in tilted back position to prevent exit Place wheelchair in tilted back position to prevent exit from chair and improve positioning.from chair and improve positioning.
Check q1h to ensure safety.Check q1h to ensure safety. Have commonly used articles within easy reach.(papers, Have commonly used articles within easy reach.(papers,
pen, Kleenx)pen, Kleenx) Transfer and Change positions slowly.Transfer and Change positions slowly. Reinforce need to call for assistance, check with resident Reinforce need to call for assistance, check with resident
every 1/2 hour to see if she needs assitanceevery 1/2 hour to see if she needs assitance Put 2 siderails up at all times / when in bed for safety.Put 2 siderails up at all times / when in bed for safety. Seat belt is for safety purposes only. Resident is able to Seat belt is for safety purposes only. Resident is able to
removeremove Call bell with in reach when in bedCall bell with in reach when in bed
POST FALL POST FALL ASSESSMENTASSESSMENT Date, time, locationDate, time, location Head to toe assessment, ROMHead to toe assessment, ROM
ROM, changes to extremitiesROM, changes to extremities Skin condition: abrasions, redness (location, Skin condition: abrasions, redness (location,
size and colour of injury)size and colour of injury) PainPain Head injuryHead injury
Vital signsVital signs Blood pressure : lying and standing (if Blood pressure : lying and standing (if
possible)possible) Pulse, respirationsPulse, respirations
Notify physician and familyNotify physician and family
ENVIRONMENTAL ENVIRONMENTAL FACTORSFACTORS
LightingLighting Call bell within reachCall bell within reach Flooring: wet or cluttered, carpetingFlooring: wet or cluttered, carpeting FootwearFootwear Restrictive clothingRestrictive clothing Glasses/hearing aide within reachGlasses/hearing aide within reach Use of assistive devicesUse of assistive devices
THREE TEARED THREE TEARED DOCUMENTDOCUMENT
1 st 1 st FallFall
2nd 2nd FallFall
3rd 3rd FallFall
Reminders to use call bell Reminders to use call bell
Physio. assessment requested Physio. assessment requested
Toileting routine reviewed Toileting routine reviewed
Initiate q1/2 hour safety Initiate q1/2 hour safety check check
Floor pad placed at bedside Floor pad placed at bedside
Safety alarm in use when in Safety alarm in use when in bed bed
Medical assessment Medical assessment
Hip protectors Hip protectors
Upgraded footwear Upgraded footwear
Installed night light Installed night light
DOCUMENTATIONDOCUMENTATION
Incident report / line listingIncident report / line listing Incidental charting (each shift x 3 days Incidental charting (each shift x 3 days
or 9 shifts)or 9 shifts) Present a clear account of incidentPresent a clear account of incident Factual, precise, descriptive language Factual, precise, descriptive language
recording observationsrecording observations Action taken, MD directiveAction taken, MD directive Vital signsVital signs Family member / SDM: who was notified Family member / SDM: who was notified
Document on shift reportDocument on shift report
REFERRALSREFERRALS PharmacistPharmacist
Pharmacological reviewPharmacological review Makes recommendations to MDMakes recommendations to MD EducationEducation
PhysiotherapistPhysiotherapist Assess balance (gait) and mobilityAssess balance (gait) and mobility Strength and balance trainingStrength and balance training Needs for physio. / rehab / restorative / assistive Needs for physio. / rehab / restorative / assistive
devicesdevices Transfer adviceTransfer advice educationeducation
PREVENTIONPREVENTION Care Plans will be reviewed and updated, Care Plans will be reviewed and updated,
review toileting routines, transferring needs review toileting routines, transferring needs and mobilityand mobility
Prevention strategies will also identify safety Prevention strategies will also identify safety equipment such as mattresses on the floor, equipment such as mattresses on the floor, safety monitors/alarms for chair and bed, hip safety monitors/alarms for chair and bed, hip protectors.protectors.
A multidisciplinary team meeting including the A multidisciplinary team meeting including the resident (if resident (if appropriate) and their family appropriate) and their family will be held will be held following the assessment following the assessment process to problem solve and draw an process to problem solve and draw an
action plan for falls prevention.action plan for falls prevention.
Falls DrillsFalls Drills
On the scheduled date, a staff member will be On the scheduled date, a staff member will be assigned the role of “fallen person”. A case assigned the role of “fallen person”. A case study scenario will be given to this staff study scenario will be given to this staff member outlining their diagnosis, any injuries member outlining their diagnosis, any injuries and the circumstances surrounding the “fall”.and the circumstances surrounding the “fall”.
Once the team discovers the “fallen person”, Once the team discovers the “fallen person”, they will proceed to care for them according they will proceed to care for them according to policy and procedure for falls management.to policy and procedure for falls management.
The Falls Drill Report is completed by care The Falls Drill Report is completed by care team and submitted to the Director of Care. A team and submitted to the Director of Care. A debriefing meeting will be held following the debriefing meeting will be held following the drill to review the procedure and education as drill to review the procedure and education as needed.needed.
EVALUATION OF EVALUATION OF PROGRAMPROGRAM
2005 = total falls 7992005 = total falls 799 2006 = total falls 5262006 = total falls 526 2007 = total falls 4502007 = total falls 450 2008 to present, focus on 2008 to present, focus on
sustainabilitysustainability
Setting up a Falls Prevention Setting up a Falls Prevention ProgramProgram
Start small – set goalsStart small – set goals Introduce the initiative to the Leadership Introduce the initiative to the Leadership
team, then departmental teams (get buy-in)team, then departmental teams (get buy-in) Select one unit (the most interested team) to Select one unit (the most interested team) to
trial the program trial the program Get input and evaluate the program as you Get input and evaluate the program as you
go, be open to new ideasgo, be open to new ideas Embrace challengesEmbrace challenges Celebrate successesCelebrate successes Maintain the commitment to be Maintain the commitment to be Resident Resident
FocusedFocused
Falls CommitteeFalls Committee In September 2009 we resumed our falls In September 2009 we resumed our falls
committeecommittee Consisting of RN’s, RPN’s, PSW’s, a Consisting of RN’s, RPN’s, PSW’s, a
Restorative Care Assistant, our Dietician, Restorative Care Assistant, our Dietician, the Physiotherapist and the Safety & the Physiotherapist and the Safety & Wellness Wellness
Co-ordinatorCo-ordinator Each discipline brings a unique Each discipline brings a unique
perspective on how to prevent fallsperspective on how to prevent falls A “Frequent Fall Assessment” was created A “Frequent Fall Assessment” was created
and are reviewed at meetingsand are reviewed at meetings
Frequent Fall Frequent Fall AssessmentAssessment
AgeAge Device (transfer pole, trapeze)Device (transfer pole, trapeze) Aide (wheelchair, walker or Aide (wheelchair, walker or
cane)cane) Medical ConditionsMedical Conditions DementiaDementia PainPain
Physiotherapy Physiotherapy AssessmentAssessment
Tenetti and/or Berg ScoreTenetti and/or Berg Score Identified GaitIdentified Gait BalanceBalance Range of MotionRange of Motion WeaknessWeakness TransfersTransfers
MedicationsMedications
Antianxiety Antianxiety AntidepressantsAntidepressants Treatment of Osteoporosis Treatment of Osteoporosis
(specifically Vitamin D)(specifically Vitamin D) AnalgesicsAnalgesics Was there a medication Was there a medication
change?change?
RestraintsRestraints
Review the use of restraint Review the use of restraint with the staff, the resident, the with the staff, the resident, the family or SDM and the family or SDM and the Occupational TherapistOccupational Therapist
Did the restraint contribute to Did the restraint contribute to the fall?the fall?
Can the restraint be removed?Can the restraint be removed?
Post Fall AssessmentPost Fall Assessment
Review the Post Fall AssessmentReview the Post Fall Assessment EnvironmentEnvironment TimeTime LocationLocation BehaviourBehaviour FootwearFootwear Vital SignsVital Signs
DocumentationDocumentationReview the ChartReview the Chart What were they doing before the What were they doing before the
fall?fall? Laboratory Results?Laboratory Results? Infections?Infections? Bath day?Bath day? Were they ill?Were they ill? Any behaviours?Any behaviours?
Pattern and CausePattern and Cause
Consider all factors and Consider all factors and opinions to opinions to identify any identify any pattern and probable cause!pattern and probable cause!
What interventions have What interventions have already been tried? Were already been tried? Were they effective?they effective?
SuggestionsSuggestions
ReferralsReferrals Pharmacist ReviewPharmacist Review OT ReferralOT Referral Physician ReviewPhysician Review PT ReferralPT Referral Responsive Responsive
Behaviour TeamBehaviour Team Dietician ReviewDietician Review
ActionsActions Safety ChecksSafety Checks Increase ActivitiesIncrease Activities Increase ExerciseIncrease Exercise Restraint Restraint
AlternativesAlternatives Modify EnvironmentModify Environment New footwearNew footwear Other……Other……
Review with The Review with The Resident Resident
and Their Familyand Their Family Discuss the Fall(s) and Review Discuss the Fall(s) and Review
findingsfindings Present SuggestionsPresent Suggestions ListenListen Respect their viewsRespect their views Establish a common goal!Establish a common goal!
EvaluateEvaluate
Evaluate effectiveness of Evaluate effectiveness of individual cases at Falls individual cases at Falls CommitteeCommittee
Monitor Falls Prevention Monitor Falls Prevention Program with Quality and Program with Quality and Risk Management CommitteeRisk Management Committee
‘‘Frequent Faller’ case Frequent Faller’ case reviewreview Mr. and Mrs. W. are a very pleasant couple
who have been married for 60 years. Each have their own room in a nursing home but have chosen to push both beds together in one room and use the other room down the hall, as a sitting area. Both residents have moderate dementia. Mr. W has noticeable weakness, walks stooped over, has difficulties balancing while standing and refuses to use his walker or even to grasp hand rails in hall.
Case Review ContinuedCase Review Continued
Mr. W. has had 3 falls at different times Mr. W. has had 3 falls at different times of day, all in his room while his wife was of day, all in his room while his wife was assisting him to stand to go to the assisting him to stand to go to the washroom. Both have call bells within washroom. Both have call bells within reach, neither remember to use them.reach, neither remember to use them.
Mr. W. has a diagnosis of Osteoporosis Mr. W. has a diagnosis of Osteoporosis and during his last fall, he obtained a and during his last fall, he obtained a compression fracture. The physician has compression fracture. The physician has prescribed Fentanyl Patch and Tylenol prescribed Fentanyl Patch and Tylenol #3 prn.#3 prn.
Mr. And Mrs. WMr. And Mrs. W
One daughter, wants One daughter, wants the residents the residents separated, the other separated, the other three children want three children want their parents to their parents to remain together. Mr. remain together. Mr. and Mrs. W. don’t and Mrs. W. don’t want to be separated. want to be separated. All agree to adjoining All agree to adjoining rooms which are not rooms which are not available at this time.available at this time.
Pattern Pattern InterventionsInterventions The pattern is easy The pattern is easy
in this case.in this case. For the past 60 For the past 60
years, Mrs. W. has years, Mrs. W. has cared for her cared for her husband.husband.
It would be It would be unrealistic to unrealistic to expect that to expect that to change.change.
Safety checks Safety checks were initiatedwere initiated
Both resident Both resident were reminded to were reminded to call for assistancecall for assistance
Mr W. has been Mr W. has been co-operative co-operative with exercises with exercises suggested by PTsuggested by PT
Some SuggestionsSome Suggestions Pharmacist review of treatment of Pharmacist review of treatment of
Osteoporosis and Pain ControlOsteoporosis and Pain Control OT referral for transferring device (if a OT referral for transferring device (if a
pole is there he might use it)pole is there he might use it) PT referral for strengthening exercise PT referral for strengthening exercise
and safe transfersand safe transfers Adjoining room when availableAdjoining room when available Review and modify toileting scheduleReview and modify toileting schedule Continue Safety ChecksContinue Safety Checks
Looking to the FutureLooking to the Future The committee will The committee will
Identify those at Identify those at risk using the risk using the “Falls RAP Key” “Falls RAP Key”
Increase exercise Increase exercise through restorative through restorative care initiativescare initiatives
Explore risks and Explore risks and treatment of treatment of OsteoporosisOsteoporosis
Questions?