Keeping the Care and Caring Connected€¦ · and AARP Public Policy Institute 601 E St NW, Washington, DC 20049 202-434-3890; E-Mail: [email protected] 16 Factoids For Falls 2012 = $30

Direct Supply -- Ray Miller 10/12/2016

Copyright 2016-17 1

Senior Living success starts here.

Sustaining Quality:

The Dollars and SENSE of Reducing Falls Risk in LTC

Keeping the Care and Caring Connected

2

Fall and Culture

Keeping the CARE and the CARING Connected

… but (MY hands are) stretched still … Isaiah 9:12

4

Disclaimer

The materials, comments and other information

contained in this presentation are intended to provide

general information but not advice about certain

regulations and initiatives.

This information is not and not intended as legal or

other advice and each situation may vary depending

on the particular facts and circumstances.

You should not act upon this information without first

consulting with qualified legal counsel.

Thank You.


Copyright 2016-17 2

1. Introduction

2. Claims, Costs & Considerations

3. Assessments and Interventions

4. Technology, Strategies and People

5

Falls Session

Agenda

Sustaining Quality:

The Dollars and SENSE

of Reducing Falls Risk in LTC

> Has 35+ years in HC safety/risk (29+ years in post-acute care)

> Serves on the AHCA Professional Development Work Group

> Serves on the AHCA Emergency and Disaster Prep Committee

> Is a former corporate safety director for several LTC companies

> Spent his career developing risk & safety strategies, programs & solutions

> Is a founding member of the Direct Supply-sponsored Loss Prevention Forum

> Is a board member for University of Wisconsin Eau Claire, CHAASE (Center for

Health Administration and Aging Services Excellence)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 6

Ray Miller MSOSH, GP

Educator, Story-teller, Wanderer Direct Supply Dir. of Risk & Safety Solutions 414 405 0492; [email protected] 6767 N. Industrial Rd. Milwaukee WI 53223

6

ASSESSING: Your Perceptions

What is the one thing, if you could change it,

that would have the greatest impact on reducing falls?

8

1. 1-on-1

2. Lighting

3. Glasses

4. More staff

5. Assistance

6. More training

7. Reduce Clutter

8. Toileting / meals

9. Increased activity

1. … …

2. Associations

3. Vetter Health

4. Courtyard HC, IL

5. Glenview Terrace, IL

6. Harmony Health & Rehab, IL

10. Thank The Employees

11. Get to Know the people

12. Advocate for technology

13. Make steps more obvious

14. Remember to ask for HELP

15. Assist Devices (Walkers … )

16. Resident and Staff Education

17. If Staff KNEW the Resident’s life story

18. ASSESSMENT and Re-assessment (balance)

8

mailto:[email protected]


Copyright 2016-17 3

1. Introduction

2. Claims, Costs, Considerations



Falls Session

Agenda

9

Sustaining Quality:



Aging is not new but it is different

Life Expectancy

(78 vs. 72 --1960’s)

Where we live

How we live

Care and Services:

□ Access

□ Payment

□ Whose involved

The Power of Partnership: Using Data and Innovation to Target Falls and Reduce Re-Hospitalizations in AL; Allison Guthertz, VP

Quality Resident Services, Benchmark Senior Living and Liz Jensen, RN MSN, RN-BC, Clinical Director, Direct Supply, Inc.

What’s changed?

Expectations

Aging in place

10

11


Copyright 2016-17 4

What will disrupt our “Aging in Place” plans?

Trauma – e.g. Falls with injury □ AMI

□ CHF

□ COPD

□ Diabetes

□ Dementia

□ Depression

□ Pneumonia

□ Hypertension

Unmanaged Progressive Conditions or Trauma

Normal Process of Aging:

Not the cause BUT can exacerbate the condition

and make treatment more difficult

The Power of Partnership: Using Data and Innovation to Target Falls and Reduce Re-Hospitalizations in AL; Allison Guthertz, VP

Quality Resident Services, Benchmark Senior Living and Liz Jensen, RN MSN, RN-BC, Clinical Director, Direct Supply, Inc. 12

Frailty

Isolation

…

Consequences of Discharge to a Higher Level of Care

Quality

of life Choice

Independence

Cost of

Care

“UN-Merry" Go-Round

Increased risk of not regaining prior health or lifestyle 13

1. Muscle weakness & walking / gait problems

2. Environmental hazards (wet floors, poor lighting, incorrect bed height,

improperly fitted/maintained wheelchairs)

3. Drugs affecting CNS (sedatives and anti-anxiety drugs significantly

elevate risk of falls during the three days following these kinds of med. changes)

4. Poor foot care, poorly fitting shoes, improper or incorrect

use of walking aids

NOTE: Patients with dementia have a fall risk 2-3 times higher

than that of cognitively intact elders. Annual incidence is nearly

60 percent (+ much higher risk for serious injury)

Most common causes of Resident falls?

http://www.cdc.gov/homeandrecreationalsafety/falls/nursing.html

Helping Patients With Dementia Avoid Falls, Posted on: January 5, 2004, Vol. 15 •Issue 1 • Page 54, Subacute and Long-term

Care, By Bob Thomas, MS, PT, and Susan Staples, PT 14




Copyright 2016-17 5

What Does Your Analysis Reveal?

75 yrs.+ experience the highest number of falls

Majority of “our” falls occur at months 5-6 of residency*

75% of “our” falls occur during waking hours (7am-11pm)*

Frequencies, Patterns, Trends, Correlations, Causes,

Interventions …

IF Frailty + Assistance With ADLs,

THEN 3-4x’s more likely to fall

(muscle weakness and gait and/or balance disorders)

1. Rubenstein LZ., Preventing falls in the nursing home. Journal of the American Medical Association 1997;278(7):595-6.

2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Updated

February 29, 2012. Accessed on 7.25.2013 www.cdc.gov/homeandrecreational safety/Falls/data/cost-estimates-figures1-2.html

* AL Corporation’s Experience 15

Increasingly Fewer Differences

Assisted Living

70% are female

90% are over 65;

50% are 85+

37% require help with

3 or more ADLs (74%

require some ADL help)

42% have Alzheimer’s

or dementia

Assisted Living & Residential Care in

the United States in 2010; accessed on

www.ahcancal.org 2/1/2013

Skilled Nursing

82% are female

91% are over 65;

>50% are 85+

85% require help with

4-5 ADLs

50% have Alzheimer’s

or dementia

National Care Planning Council Tuesday, April 09, 2013

and AARP Public Policy Institute 601 E St NW, Washington,

DC 20049 202-434-3890; E-Mail: [email protected] 16

Factoids For Falls

2012 = $30 B*

65+ = 1 in 3 fall

20-30% < morbidity and mortality

65+ = Hospitalized 5x for falls than other causes

*Actual direct costs but not long term disabilities, lost wages, quality of life ’s

17

2012

CDC Stats

http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html

http://www.cdc.gov/homeandrecreational safety/Falls/data/cost-estimates-figures1-2.html







http://www.ahcancal.org/


Copyright 2016-17 6

What Do “Other’s”

Learned About

Falls Claims?

1. Most claims are settled

2. A large corporation’s experience:

a. $137K av. spent to “settle” falls claims

b. 41 claims settled 9/30/2011 to 8/31/2014

3. Residents that fall = 18% / month (National LTC av. ≈ 20%)

18

Current

Corporate

Perspectives

19

SIDEBAR: Annual Activities Budget

Activities: $.004 ppd.

Census: 94 residents

Daily Budget : $ .38

365 days/yr.

Annual Budget: $ 137

$137K av. Spent To Settle Falls Claims

A little math: $137,000 ÷ $137/yr. = ??

1 av. settled falls claim: 1,000 YEARS of Activities 10/12/2016

25

1. Professional DUTY owed to the resident Dignity, Safety, Standards of Care*

2. BREACH of that professional duty Elopement, Fall, Infection, Weight Loss

3. INJURY caused by the breach Malnutrition, Bedsore, Fracture, Death

4. Resulting DAMGES a. Noneconomic loss (pain, suffering)

b. Economic Loss (lost wages, related health care costs)

Copyright Status: Public domain information on the National Library of Medicine (NLM) Web pages may be freely distributed and copied.

Four

Elements The Plaintiff Must Prove:


Copyright 2016-17 7

What is another “NON-ECONOMIC damage”

that many Residents experience

with or without a lawsuit?

This is

a Test

26

Fear of Falling

All at once or a “Cycle of Fear”?

Restricts activity

Physical capabilities reduced

Restricts more activities

more impaired physical capabilities

Fear of falling

Fear of Falling Among Seniors: Needs Assessment and Intervention Strategies ; Susan L. Murphy

ScD, OTR; World Federation of Occupational Therapy Conference, June 2002, Stockholm Sweden

Is the “Cycle of Fear” reversible?

FALL(s)

28 28

Falls and the

Dignity of Risk

Was it worth it?

What Changed?

29 29


Copyright 2016-17 8

FUNDEMENTALS of “Risk”*

What we’re use to:

1. Risk

2. Risk Avoidance

3. Risk Assessment

4. Risk Management

Other concepts to ponder:

1. Risk Benefit

2. Risk Enablement

3. Risk Enablement Plans

‘Nothing Ventured, Nothing Gained’: Risk Guidance For People With Dementia 30

“… excess safety …”

Dr. Bill Thomas

Dr. Judah Ronch

30

1. Introduction




Falls Session

Agenda

Sustaining Quality:



31

SIDEBAR: Thinking of the Resident Holistically

Breathing

Caring For the

Whole Person

Circulation

Elimination

Orientation

Dignity

Self-Esteem

Hygiene

Skin Tissue

(Wound)

Nutrition

Copyright 2015-2016 Direct Supply, Inc. All rights reserved

USED WITH PERMISSION: by Karen L Bonn, President, Restorative Medical, Inc.; 270-422-5454; 800-793-5544; www.restorativemedical.com . Copyrighted

Mind and

Spirit

32


Copyright 2016-17 9

Breathing

Circulation

Elimination

Orientation

Dignity

Self-Esteem

Hygiene

Skin Tissue

(Wound)

Nutrition

SIDEBAR: Thinking of the Resident Holistically


USED WITH PERMISSION: by Karen L Bonn, President, Restorative Medical, Inc.; 270-422-5454; 800-793-5544; www.restorativemedical.com . Copyrighted

Mind and

Spirit

Caring For the

Whole Person

33

“Elinor Miller, 85 years old, talked herself out of a

speeding ticket by telling the young officer that she had

to get there before she forgot where she was going.”

SIDEBAR:

Assess

My Mom

34 34

ASSESSING: Your Residents 35 35


Copyright 2016-17 10

Jack at 73 Jack in his 90s

Jack LaLanne

33

73

93

10/12/2016 36

37

Reducing Risk for Frailty

Screen for frailty:

□ All persons 70+ yrs.

□ All residents upon move-in (involve therapy)

□ Chronic illness-related weight loss (5+% in past year)

□ CONSIDER: Ask for physician’s findings for frailty screen

Focus on managing frailty:

□ SUPPORT: Calories, protein, Vitamin D

□ EXERCISE: Resistance AND aerobic

□ REDUCE: Polypharmacy

Morley, J., Vellas, B., et al. Frailty Consensus: A Call to Action. Journal

of American Medical Directors Association. June 2013; 14(6): 392-397

“A multi-component exercise

program can reverse frailty

and improve: 1] function,

2] cognition, 3] emotional

and social networking”

1. ASSESSMENTS (Post-Fall): Identify risk factors and

underlying medical conditions

2. INTERVENTIONS: (Address risk factors and Treat underlying

medical conditions)

a. CATEGORIES: Treatment, Rehabilitation, Environmental

b. METHODS: Multi-factorial, Interdisciplinary

c. LEVELS: Organizational, Staff, Patient

3. EDUCATION: (Staff + WHO?)

a. Fall risk factors

b. Prevention strategies

How YOU prevent falls?


1. Assessments

2. Interventions

3. Education

4. Residents

5. Medications

6. Environment

40





4. RESIDENTS:

a. Exercise programs (balance, strength, walking ability,

physical functioning, ENGAGEMENT)

b. Teach residents (not cognitively impaired) behavioral

strategies to avoid potentially hazardous situations**

c. Hip pads, fall protection mats, walkers …

5. MEDICATIONS:

a. Assess potential risks vs. benefits

b. Minimize use

6. ENVIROMENT: Ensure easier and safer residents passage

(grab bars, adding raised toilet seats, lowering bed heights,

handrails, lighting, flooring …)

How can we prevent falls in nursing homes?

** A promising approach.23


1. Assessments

2. Interventions

3. Education

4. Residents

5. Medications

6. Environment

41

HOW ELSE?

Clinical & Care Needs

□ Pain medications

□ Bedside commode

□ Medication adjustments

□ Fewer wellness checks

□ Roommate compatibility

□ Toileting plan / Nighttime briefs

□ Extending time between turning

& repositioning

Comfort Interventions

□ Wider bed

□ Softer mattress

□ Blanket warmer

□ Temperature control

□ Comfortable pajamas & socks

□ Softer sheets, blankets, pillows

Calm & Quiet

□ Light dimmers, amber lighting

□ Aromatherapy

□ Reduce noise

□ Ear plugs

□ Massage

□ Music

Sleep Improvement Interventions

But How Do You Get to

These Interventions??

43

Learning Circle (LaVren Norton)

1. FOCUSED, small group (8-10) with a COMMON interest

a. Family, staff, community rep’s., advocates, educators,

researchers, others …

b. Flexible, peer-directed learning experiences

2. INTENDED:

a. Meet regularly, weeks / months, ground rules

b. Have targeted learning objectives

c. Lead to ACTION and OUTCOMES

d. Solve Problems / Make Decision

e. Open and honest discussion

f. Length depends on topic

INFORMATION COMPILED BY BILL KEANE AND USED WITH PERMISSION: Sources: Norton, LaVrene, “The Power of Circles: Using a Familiar Technique

to Promote Culture Change”, Culture Change in Long term Care, Audrey S. Weiner and Judah





44

QUESTIONS:

1. What facility activities are disruptive to a resident's good

night sleep?

2. What can you do differently to minimize disruptions?

Learning Circle:

http://aging.ohio.gov/ltcquality/nfs/choice/

A FEW OF THE POSSIBLE ANSWERES:

1. Talk to LOUD -- Implement “quiet voices”

2. Perform night time floor care – Create and follow a

different stripping routine. (Also, avoid equipment use

until after 9 am)

3. Fill water pitchers during the night – Schedule it during

on the evening shift

4. We wake up / retire residents at times convenient for us*

1. Talk to LOUD -- Implement “quiet voices”

2. Perform night time floor care – Create and follow a

different stripping routine. (Also, avoid equipment use until

after 9 am)

3. Fill water pitchers during the night – Schedule it during

the evening shift

4. We wake up / retire residents at times convenient for us*

Resident Choice and

Supporting Better Sleep (1 of 4)

45

“We wake up / retire residents at times convenient for us”

“Therefore, WHAT?”

1. Ask residents what time they prefer to wake up / retire

knowing that some may prefer to wake up on their own.

2. a] Such a change may affect medication administration

times. b] Obtain the facility's medical director's involvement

and buy-in. c] Adjust medication orders as necessary ("upon

rising" or “as per residents' choice”)

3. Their preferences will be reflected in the MDS & Care Plan.


…

Learning Circle: Resident Choice and


46

Resident

choice of

wake up and

retire time

Dietary (Enhanced Dining)

Clinical

(e.g. Med Pass,

Care Plan,

Physician)

Housekeeping

(Cross-Training)

Direct Care (Consistent

Assignment)

Activities

(Meaningful)

Supporting Better

Sleep Through

Resident Choice


(3 of 4)









48

APPLICATION:

Charter a “Sleep Improvement PIP” (staff and residents) … to

remove practices enterprise-wide that are disruptive to sleep.

CHANGE MANAGEMENT:

In your PIP, plan for a “Small Scale Test” and “Systemic

Action, and Enterprise-Wide Implementation”. The actual

implementation need not be everywhere and all at once.

Build on your successes. Ensure that resident

preferences are honored but don’t stop with a good night's

sleep.

What’s Next?


Learning Circle: Resident Choice and


Multi-factorial

Assessments

49

Outside Inside Bedside Person

49

1. Shade

2. Patios

3. Security

4. Vehicles

5. Sidewalks

OUTSIDE

50

Safe At Home

6. Parking lot

7. Way finding

8. Grassy areas

9. Weather-related

10. Seating and benches






Safe At Home

1. Lighting: Adequate, no glare

2. Walking: Areas clear of barriers

3. Equipment: Beds, w/c, footwear, grab bars

4. Furnishings: Design, function, color, height

5. Monitoring Systems: Nurse call, resident monitoring

6. Risks in specific spaces: Gym, dining room, bathrooms

INSIDE

51


Environmental

hazards cause

16-27% of falls in

nursing homes

What do you see?

52


52

Considerations with Strength

& Balance Concerns

INSIDE

Flooring

Entry mats

Transitions

Wax buildup

Transition points

Carpet pile height

Raised thresholds

Patterns (tile / laminate)

Furniture

Beds height

Chairs:

W/ arm rests

Firmer seats

Supportive back

Not too deep / too low

Avoid castors on chairs (and tables)

53

Safe At Home




Goals:

1. Minimize fall frequency and severity (Residents)

2. Improve resident and customer satisfaction (Metrics)

3. Increase referral strength through partnerships (Census)

Tactics: Minimize falls through:

1. Safety product installation (Towel & toilet paper grab bars)

2. Care Staffing Alignment (Appropriate coverage and Toilet scheduling)

3. Communication (Staff, Resident, Family; Care Plan, Consistent Assignment)

Falls Reduction Goals and Tactics?

“Intended” Consequence:

1. Increased length of stay

2. Culture of Safety

3. … 54

Beside -- Contributions of a Culture of Safety?

1. Compensates for the normal changes that occur with aging

2. Is adaptable to a resident’s changing needs

3. Serves the resident, staff and visitors

4. .

5. .

6. .

7. .

55

RESEARCH:

Resident

Assessments

and

Interventions

Anticipated

Physiologic Fall

Unanticipated

Physiologic Fall Accidental

Fall

Gait, Confusion, Balance, Hx. of Falls

Stroke, Seizure, Heart Attack, Orthostasis, Hypoglycemia

Spills, clutter, cords, Leaning on a curtain

Morse, JM. Preventing Patient Falls.

Thousand Oaks, CA: Sage; 1997

What “kind”

of a Fall?

56

Which should

be PREVENTABLE?

56



57 http://www.ahcancal.org/quality_improvement/QAPI/Documents/fall_reduction_PIP_algorithm.pdf

1. Specific

2. Measurable

3. Attainable

4. Relevant

5. Time-bound

SMART goal

developed

Element 3: Feedback, Data Systems and Monitoring Staff identifies a particular problem -- Unacceptable Resident Falls Frequency

Element 4: Performance Improvement Projects (PIPs)

Achieve a 25%

Resident Falls decrease

for the population with

2< falls in prior 90 days

58 http://www.ahcancal.org/quality_improvement/QAPI/Documents/fall_reduction_PIP_algorithm.pdf

PIP charted*

(Interdisciplinary + R

& F; Steering Cmte. )

PIP: (timeline,

budget, goals)

RCA / PDSA

PIP: Analysis

& Interventions

PIP: Selects

Focus Metrics

PIP: Monitors,

Analyzes,

Modifies

PIP: Reports

Findings / Plan

to Sustain

Steering Cmte:

Support &

Resources

Achieve a 25%

Resident Falls decrease

for the population with

2< falls in prior 90 days

Falls Reduction PIP

PIP: “Small

Scale Test”

(Implementation) Systemic Action –

Enterprise - Wide

(Communicate, Educate,

“Permenate”, Evaluate,

Celebrate)

Duties

Mission

Formalize

Accountable

Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls; Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D,

Rita S. How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; 2012. Available at www.IHI.org.

•Everyone is at RISK* •Of falling (Hx)

•Of related injury (smoking, steroids, alcohol, chemo,) (Osteoporosis, Frx, of bleeding)

FALLS RISK

ASSUMPTION

at time of

admission

63

Assessments

http://www.ihi.org/



64

ABCS of Injury Risk

Age > 85

Bones (osteoporosis, osteopenia, recent fracture)

Coagulation (currently on anticoagulant)

Post-op Surgery

Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D, Rita S. How-to Guide: Reducing Patient

Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; 2012. Available at: www.ihi.org.

Are there other high injury risk factors that should be considered?

A =

B =

C =

S =

65

Traumatic Fall Stratification

Low Fall Risk but

High Likelihood

of Trauma

High Traumatic

Fall Risk

Low Traumatic

Fall Risk

High Fall Risk but

Low Likelihood

of Trauma

Trauma

Likelihood • Anticoagulation

• Osteoporosis

Fall Likelihood • Balance & mobility concerns

• Cognition impaired

• Previous falls

Stefanacci, R., Stand by Me—preventing falls. Geriatric Nursing. 2012;33;2:134-136

Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls; Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D,

Rita S. How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; 2012. Available at www.IHI.org.

• In-depth

• Multifactorial

• COMMUNICATE: those “at risk” those “at risk”

• EDUCATE: R/F,/S residents, R/F,/S

• INDICATE: Current status Status

•Everyone is at RISK

•Of falling (Hx)

•Of related injury (smoking, steroids, alcohol, chemo,) (Osteoporosis, Frx, of bleeding)

• STANDARDIZED:

•Facility-wide & resident-level environment improvements

•Regular rounding (1-2 hrs.) (pain, toileting, positioning)

• CUSTOMIZED: (high risk)

•Medication interventions (side effects)

•Observation (intensity / frequency)

•Environmental adaptations

•Personal devices INTERVENTIONS

Standardized and Customized

(frequency and severity reduction)

FALLS RISK

ASSUMPTION

at time of

admission

ASSESSMENTS

8 hrs., 72 hrs.,

5 days , 14 days… OR

COC

COMMUNICATE

EDUCATE

INDICATE

Assessments Interventions

66

• Interdisciplinary

http://www.ihi.org/



67

1. Change something:

a. Policy, practice, assessment (Adopt, Remember, Recognize)

b. Lighting, floor surface, color contrast

i.e. – “Engineered” or “Structural” Changes:

1) Needles, sharps …

2) ONLY O2 lines connect to O2 lines

3) E.M.R. all fields must be typed in (cut/paste)

2. Communicate and Train the Change (WHO?)

3. “Ensure” Compliance - Establish Accountabilities (WHO?)

Evaluating the Strength of Interventions

SIDEBAR: Assessments

2. Hendrich II Fall Risk Model—evidence based, but limited in scope of what it

assesses. http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf

3. Tinetti—good tool, often used by therapists.

http://consultgerirn.org/uploads/File/Tinetti_Assessment_Balance.pdf

4. CDC tool—modified from other tools—this doesn’t have a score and is a pretty

decent tool http://www.cdc.gov/HomeandRecreationalSafety/pdf/steadi/fall_risk_checklist.pdf

5. Modified tool from MedPass that a provider put together and MedPass sells. This

is a good example of a non-standardized test that has a hodgepodge of

assessment questions and non-tested scoring in it. http://www.med-

pass.com/media/pdf/HC1040H_sp.pdf

68

1. Morse: “I’ve seen this one used frequently where facility staff

will select interventions based on a score instead of selecting

based on why the resident got the score.

A score doesn’t tell you if you have balance problems, or

orthostatic hypotension. It’s just a number.”

Liz Jensen, RN, MSN

10

/12

/20

16

Multi-factorial Fall Assessment

1. Focused History (Detailed description of previous falls,

frequency, symptoms, injuries & other consequences, Medications Review; relevant risk factors)

2. Physical Examination (Detailed assessment of gait,

balance, mobility & lower extremity function; neurological function; muscle strength; cardiovascular status; visual acuity, feet and footwear; Focus on

orthostatic hypotension; Timed-up & Go test)

3. Functional Assessment of Resident (ADL skills

including use of adaptive equipment and mobility aids; Perceived functional ability and fear related to falling; Current activity level to determine if concerns are protective or contributing to de-conditioning or quality of life; Ability to navigate safely in the environment)

AMDA Clinical Practice Guidelines, 2011; AGS Clinical Practice Guidelines, 2010 70

http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf

http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf



http://www.cdc.gov/HomeandRecreationalSafety/pdf/steadi/fall_risk_checklist.pdf

http://www.cdc.gov/HomeandRecreationalSafety/pdf/steadi/fall_risk_checklist.pdf

http://www.med-pass.com/media/pdf/HC1040H_sp.pdf






Multi-factorial Fall Assessment (1 of 4)

Focused History

□ Detailed description of previous falls, frequency,

symptoms, injuries and other consequences

□ Medications Review; relevant risk factors



Physical Examination

□ Detailed assessment of gait, balance, mobility & lower

extremity function; neurological function; muscle

strength; cardiovascular status; visual acuity, feet and

footwear

□ Focus on orthostatic hypotension

□ Timed-up & Go test*


1. WHO: By nurses and therapists

2. WHY: 1] Upon admission 2] change in condition 3] policy

3. WHAT:

a. Complete in > 12 sec. (may indicate increased falls risk)

b. Opportunity to observe gait, balance, stability …

Nursing Initiated Strength / Gait tests

1. WHO:

2. WHY:

3. WHAT:

http://www.cdc.gov/homeandrecreationalsafety/pdf/steadi/timed_up_and_go_test.pdf. Accessed 11.1.13

Example: Timed Up-and-Go Test (TUG)

Ask the resident to get up, walk 10 feet,

turn and walk back and sit down again.

http://www.cdc.gov/homeandrecreationalsafety/pdf/steadi/timed_up_and_go_test.pdf




Functional Assessment of Resident’s :

□ ADL skills including use of adaptive equipment and

mobility aids

□ Perceived functional ability and fear related to falling

□ Current activity level (Protective? Contributing to: de-

conditioning? To loss of quality of life?)

□ Ability to navigate safely in the environment


The Individual Resident (4 of 4)

Exercise -- targets improvement in strength and balance

Medication -- evaluation / reduction (if appropriate)

Nutrition -- consider Vitamin D supplementation

Sleep – Quality and Duration

Lighting -- to off-set changes in aging & low vision

Furniture -- Functional & placement (within room)


77

The “Four W’s” of the Fall (Facts to try to establish or verify)

What: What happened? What do you recall about the fall?

What were you feeling at the time of the fall? Was there an

injury? Did you seek treatment?

When: Tell me more about when this fall occurred. (Day of

week; time of year; time of day)

Where: Tell me where this fall occurred

Why: In your opinion, why do you think the fall occurred?

History of Falls – Talking With Your Resident

The “Four W’s” of the Fall (Facts to try to establish or verify)

What: What happened? What do you recall about the fall?

What were you feeling at the time of the fall? Was there an

injury? Did you seek treatment?

When: Tell me more about when this fall occurred. (Day of

week; time of year; time of day)

Where: Tell me where this fall occurred

Why: In your opinion, why do you think the fall occurred?

Gray-Miceli, D. 5 Easy Steps to Prevent Falls: The Comprehensive Guide to Keeping Patients of All Ages

Safe. Sliver Spring, MD American Nurses Association: 2014.



Falls Prevention Strategy

ASSUMPTION: You can’t prevent falls.

REBUTTAL: Falls prevention can be effective.

EXAMPLES: Important falls prevention elements?

27%

22%

17%

12%

7.9% 5.6%7.2%

5.7%5.3%

0%

5%

10%

15%

20%

25%

30%

1999 2000 2001 2002 2003 2004 2005 2006 2007

Silverado Average Percentage of Falls -- Resulting in Injury 1999- (Nov) 2007

*

80 80

http://www.mnhospitals.org/index/tools-app/tool.362?view=detail 81

“Daily Contracting” with Residents SAFE from FALLS Toolkit

Resident and

Family

Engagement

1. Verbal “contracting” by each shift’s care giver:

i.e. “I don’t want you to fall, Mr. Smith. We’re a Team, right?

Please call me so I can help you get up.”

2. Resident and Family Education and Involvement:

i.e. “You know Mom just had a medication change. If you notice

anything different, please let us know.”

What other kinds of reminders?

1. Ask for help! It is OK.

2. Book … glasses … water … etc.

3. Wear your glasses / hearing aids

4. It’s OK to pause before you stand up.

5. Wear your shoes / slippers / non-skid socks

6. Keep your walker/cane/WC within reach and use it

6. Use the handrails in the bathroom and hallways

7. Make sure your pathway is clear

8. Tell us about any spills http://www.mnhospitals.org/index/tools-app/tool.362?view=detail

82 82



“Daily Contracting” with Residents’ Family

Sample tips:

1. Before you go home, please make sure (glasses, water, call

light, over bed table, phone, Kleenex, etc.) are within reach.

2. Please notify staff / us before leaving if you notice

confusion or disorientation in your Dad.

3. Please remind Mom to ask for help when she gets up.

83 83

Mnemonics

“Every Good Boy Does Fine”

+

“FACE”

“ROYGBIV”

86

Transitions between shifts

86

87

I-PASS the BATON

Introduction

Patient

Assessment

Situation

Safety

concerns

Background

Actions

Timing

Ownership

Next

introduce yourself and your role

name, identifiers, age, sex, location

current status and circumstances; including codes status, eval of certainty, recent changes, and response to treatment

critical lab values and reports, socioeconomic factors, allergies, alerts (e.g. falls, isolation)

which were taken or are required, providing brief rationale

level of urgency, explicit timing, and prioritization of actions

who is responsible (eg, nurse, doctor, team), including patient or family responsibilities

what happens next (eg, any anticipated changes in condition or care, the plan, any contingency plans)

presenting chief complaint, vital signs, symptoms, diagnosis

comorbidities, previous episodes, current medications, family history



S-BAR Iterations

SBAR

• Situation

• Background

• Assessment

• Recommendation

SBAR-T

• Situation

• Background

• Assessment

• Recommendation

• Thank the resident

I-SBAR

• Introduction

• Situation

• Background

• Assessment

• Recommendation

SBAR-D

• Situation

• Background

• Assessment

• Recommendation

• Documentation

89 89

You asked me four questions about my job: *

• On December 9, 2014, Kara Butler of Healthcentric Advisors granted Direct Supply permission to use the HATChTM Model.

• Copyright 2013 Healthcentric Advisors and Turnswing, Inc. Produced by Turnswing Studios

Shelly B. RA Woodbury Senior Living,

Tealwood Inc, MN

BEST

HARDEST

MOST IMPORTANT

MOST FRUSTRATING

A Resident said to me, “I knew I’d be OK because YOU are here.”

1 - We need to stay out of the “factory care” approach

2 - Transitions between shifts

RELATIONSHIPS

When I KNOW something needs to change but no one listens ...

91

Staff Dynamics

Authority vs. Familiarity

http://www.apbs.org/conference/denver/files/A18-Bird.ppt#369,13,Federal Regulations: Potential areas of citations


Level of Authority Degree of Familiarity

Administrator

RNs / LVNs

Therapies

CNAs, Activity &

Hospitality Aides*

Seeking

Permissions

CNAs/Activity &

Hospitality Aides

Therapies

RNs / LVNs

Administrator

Seeking

Knowledge

IF You Empower Staff THEN You Achieve Quality and Culture

SHELLY: “When I KNOW something

needs to change but no one listens.”

+

* Nicole Krause and other Life Enrichment directors of Montana



1. Introduction



4. Technology, Strategies + People

Falls Session

Agenda

Sustaining Quality:



92

Technology and Products That Support a

Culture of Safety to Reduce Falls and Injuries

Considerations

Monitor progress in improving strength;

Tracks it over time

Improved incontinence assessment of PVR, addressing

urge / frequency to reduce fall risk

Innovations to combine lift with gait training /

strengthening support

Only work if a resident wears them—look for

acceptability (resident); ease of use (staff)

Use for transfer support, adjust height to support safe

egress if moving independently

Extending sleep surface reduces roll-out; reduces

resident fear; provides reminder of the edge of the bed

Use only as needed

Motion sensor; good for nighttime

Tools to use both in the center and to take home—

supports culture of safety across transition of care

Technology / Product

Exercise equipment

(with outcome measurements)

Bladder ultrasound

Lifts

Hip protection

Adjustable height beds

Wide mattresses;

Bolster mattresses

Bedside mats

Under-bed lighting

Transitional Care Kits 93

Challenge Conventional Thinking

Instead of…. Consider…

Putting beds into

a low position

Adjust bed to the appropriate height for the

resident, legs at a 90 degree angle when

exiting bed

Alarms

Anticipate and respond to the resident’s

needs; Engage in meaningful activities;

promote sleep; get the whole team

involved

Beds against the wall Adjusting the bed so the resident can

safely get out of it when he/she wants to

94



• Air bag hip protection

• Impact absorbent flooring

• Monitoring across care continuum

• Affordable sleep monitoring technology

• Wearables: Gait assessment, balance correction

• Non-contact room sensory technology with unique pattern

identification algorithms

What’s In The “Nearer” Future?

95

1. A thin underlay incorporates multiple

integrated radio modules, proximity sensors

and there is a control unit

2. Various types of events can be identified:

a. A person standing vs. lying on the floor

b. Residents leaving their beds or rooms

c. The direction and velocity of movements

3. The system can switch lights, control

automatic doors, and detect unauthorized

intrusion and transmit alert signals

through call systems or radio components

Large-area Sensor Systems

http://www.future-shape.com/se/technologies/127/sensfloor-large-area-sensor-system 99

FALLS PREVENTION

1. Detect

2. Collect

3. Analyze

and

Identify

4. Detect

and

Alert

5. Report

6. Monitor,

Respond,

Modify

Using Sensor and

Alert Technology

105

http://www.future-shape.com/se/technologies/127/sensfloor-large-area-sensor-system














© 2014-15 Direct Supply, Inc., all rights reserved

But Even With the BEST Technology,

What’s MOST Important to Prevent Falls?

110 110

THREE “GIVENS”

1. Resident safety is an ORGANIZATIONAL PRIORITY

2. EVERY Resident is at risk for falls and injuries

3. EVERY Staff Member has a prevention role

Outside, Inside, Bedside, Person

111


ASSESSMENT:

“Clues & Cues”

NEW:

1. Pain

2. Cough

3. Color change

4. Posture change

5. Change in routines

6. Off patterns or habits

7. Less visible in the community

8. Hospitalization / physician visit: check for changes in meds

PERSON

112


WHO Sees It First?

IF Earlier Identification

THEN Earlier Response

Frontline Staff

+

“Itchy Vigilance” “Responsive Recognition”



The revised Stop and Watch facilitates routine monitoring of high risk residents by adding a

checkbox for "no change".

INTERACT Version 4.0 Tools

https://interact2.net/tools_v4.html

But How Do You “Make” This Happen

Consistently / Willingly / Over Time??

10/12/2016 113

Insert Johnnie The Bagger

How Important Are Your People?

10/12/2016 114

11

8

“When all is said and done,

There is usually a lot more

Said than done.”

Sterling W. Sill April General Conference, 1973

