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Falls…Not on my Watch!

A Fall Prevention Program in an Assisted-Living Facility with the use of the STEADI Tool Kit

A Scholarly Project Presented to

The Faculty of the Maryville University

Catherine McAuley School of Nursing

In Fulfillment of the Requirements

For the Degree of Doctor of Nursing Practice

Jaritza Smith

Spring 2018

Table of Contents

ContentsTable of Contents2Abstract6Acknowledgements8Dedication10Chapter One11Purpose12Background13Extrinsic Factors13Intrinsic Factors14Medications Factor16Multifactorial Causes16Falls in Assisted-Living Facilities17Significance18Nursing18Healthcare19Advanced Practice Nursing19Practice Support for Project20Benefit of Project to Practice21Chapter Two21Search History21Integrated Review of the Literature22Concept 1: Fall Risk Assessment23Concept 2: Multifactorial Risk Assessment25Concept 3: Evidence-Based Fall Intervention27Research Critique30Strengths30Weaknesses30Gaps31Limitations32Concepts and Definitions33Theoretical Framework35Chapter Three36Context36Interventions38Study of the Interventions41Measures42Analysis44Ethical Considerations44Chapter Four45Results45Initial Steps and Details of the Process45Table 148Pre and Post Results48Table 249Descriptive Statistics49Table 350Paired Sample Statistics for Stay Independent Questionnaire50Table 450Paired Sample t-test for Stay Independent Questionnaire50Table 550Paired Sample Statistics for TUG Test Scores50Table 651Paired Sample t-Test for TUG Test Scores51Table 751Paired Sample Statistics for Recommendations vs. Followed Interventions51Table 852Paired Sample t-Test for Recommendations vs. Followed Interventions52Contextual Elements and Observed Associations52Unintended Consequences53Missing Data54Chapter 554Summary54Interpretations55Limitations59Conclusions61References63Appendices71Appendix A: Recruitment Flyer7171Appendix B: Script of Presentation72Appendix B: Script of Presentation (continued)73Appendix C: Informed Consent74Appendix C: Informed Consent (continued)75Appendix D: HIPAA76Appendix D: HIPAA (continued)77Appendix D: HIPAA (continued)78Appendix E: TUG Test79Appendix F: Stay Independent Questionnaire80Appendix G: STEADI Fall Risk Assessment Questions and Algorithm81Appendix H: Quality Improvement Project Data Collection Sheet.82Appendix I: SAFE Medication Review Framework: A Team Based Approach83Appendix J: Check for Safety: Environmental Survey84

Abstract

Evidence suggests that morbidity and mortality are real threats for the older adults when they experience a fall. Many of these older adult live in assisted facilities and are at risk of losing even more independence when a fall occurs. Fall prevention is key in keeping the older adult healthy and safe. Fall prevention strategies are varied and the evidence supports some strategies with a high level of certainty while other strategies despite being good recommendations get a low level of certainty regarding net benefit. Fall prevention strategies that include a valid and reliable screening tool, those that promote a good fall risk assessment with care to include multifactorial risks assessment and those that encourage the use of evidence-based interventions provide a more holistic approach. The screening, assessment and intervention approach works best for the older adult population since its’ the interaction among multiple factors that places them at risk for falls.

The purpose of this scholarly project is fall prevention and to promote resident safety. The STEADI tool kit served as the main guide for the project. The fall risk assessment algorithm served as the road map to guide the screening, the assessment including the multifactorial fall risk assessment approach, and the interventions. The quality improvement attempted to answer three questions: (a) Is there a significant difference between the before Stay Independent Questionnaire results and after (implementation and participation in STEADI recommended interventions) Stay Independent Questionnaire results? (b) Is there a significant difference between the before TUG test scores and after (implementation and participation in STEADI recommended interventions) TUG test scores? (c) Is there a significant difference between the number of STEADI Interventions recommended and the number of STEADI interventions followed? The subjects had 34 days of intervention. The results were surprising and indicated a significant difference in the before and after Stay Independent Questionnaire results and in the number of recommended interventions versus the interventions followed. There was also evidence of clinical significance with the findings of this project. It is important to note that fall prevention strategies in assisted living facilities can be accomplished and sustainable with an easy tool like the STEADI tool kit.

Acknowledgements

A very special thank you goes to Dr. Boniface Stegman for being the project Chair. Dr. Stegman provided advice, mentorship, and endured countless revisions of my IRB application and my scholarly project chapters. Dr. Stegman provided a great sense of calm and reassurance that I would be able to finish my project and graduate on time and for this I say many thanks. A big thanks to all the instructors and fellow classmates at Maryville University for guiding me along the way and providing constructive feedback during this great adventure. A heartfelt thanks to Dr. Landry who is an amazing person and instructor and who provided all the statistical data analysis for the project. Dr. Landry was undeniably a key player in the completion of this project. Acknowledgements and thanks also goes to the many mentors I’ve had throughout my career that encouraged me to go complete my terminal degree. Thanks to all the colleagues who provided me with countless scholarly project topic ideas and were always available to provide feedback and support. Thanks to all my patients for their unfailing support and understanding when their appointments were rearranged so that I could complete school work. Thanks to Juniper Village Assisted Living Facility and Ayla Harwood for allowing me to go into their facility to recruit participants for my scholarly projects. Thanks to the participants in my scholarly project because without you there would have been no project.

To my husband and children, thank you for your support, encouragement, dedication and for all the sacrifices you’ve had to endure. It did not go unnoticed and I want to thank you for all you have done. Remember that this is not only my Doctorate degree, but our degree as the goal has always been to provide for a better future for the family. Thank you.

Dedication

This scholarly project is dedicated to my geriatric patients. You have been my teacher and have taught me more about life and living than any textbook. You have provided me with countless stories, examples, and learning experiences. You have helped me transform my practice and continue to trust in my abilities with keeping you healthy. Thank you for your trust. Thank you for keeping me on my toes and motivating me to continue learning. It is my honor to take care you in the many assisted living facilities that I provided services to.

Falls…Not on my Watch!

A Fall Prevention Program in an Assisted-Living Facility with the use of the STEADI Tool Kit

Chapter One

Aging gracefully and enjoying independence whether at home or in an assisted-living facility is a common goal for many adults 65 years of age and older. This goal is being accomplished by modern medical practices, preventive medicine, lifestyle modifications, and improved environmental conditions which have helped in increasing life expectancy for the older adult (National Institute on Aging, 2017). In fact, as of 2014 the United States adult ages 65 years or older represented 46.2 million or 14.5% of the population with this number expected to double in size by the year 2060 (Administration on Aging, 2016). Many older adults live independently in the community and lead heathy lifestyles. However, those that are frail live in assisted-living facilities. As of the year 2016, there were 1.2 million residents living in assisted-living facilities in the United States (National Caregivers Library, 2016). Regardless of their place of residence the older adult values independence and the thought of losing control is a depressing thought for them. An unfortunate occurrence that places the older adult at risk for not being able to age gracefully and places them at risk for losing their independence is falls. The impact of a fall in the life of the older adult are many with physical injury being common and fatal injury being the most serious with one reported death every 29 minutes resulting from a fall (Center for Disease Control and Prevention, 2016a). Additionally, falls are said to be the leading cause of nonfatal trauma-related hospital admissions with over 2 million older adults treated each year (Center for Disease Control and Prevention, 2016a; National Council on Aging, 2017, para. 3). Yet, one cannot discount the psychological distress and social isolation that can occur after a fall which prevents the older person from making a full recovery. Loss of independence, loss of control, long term institutionalization, and disability are some of the ramifications following a fall. The focus of this quality improvement project will be falls in older adults living in assisted-living facilities.

Purpose

The purpose of this scholarly project is fall prevention and to promote resident safety. Fall prevention in the elderly is a topic of concern for many healthcare providers and was one of the reason why the Center for Disease Control and Prevention (2016a) developed the tool kit Stopping Elderly Accidents, Death & Injuries (STEADI). The STEADI tool kit provides tools and educational materials for providers on ways to assess and address fall risk in the clinical setting. More specifically, the aim of the project is to: (a) use the STEADI tool kit to assess residents at an assisted-living facility using the fall risk assessment algorithm, (b) conduct a multifactorial risk assessment as recommended by STEADI, (c) and implement the recommended evidence-based interventions based on the residents score. The quality improvement project will attempt to answer three questions: (a) Is there a significant difference between the before Stay Independent Questionnaire results and after (implementation and participation in STEADI recommended interventions) Stay Independent Questionnaire results? (b) Is there a significant difference between the before TUG test scores and after (implementation and participation in STEADI recommended interventions) TUG test scores? (c) Is there a significant difference between the number of STEADI Interventions recommended and the number of STEADI interventions followed? The target population are those 65 to 89 years of age and older living in an assisted living facility. The goal is to have at least 50 participants.

Background

A fall can be defined as an unintended movement that causes one to lose control of balance which causes one to fall against or toward something and may or may not cause injury. The unintentional and unexpected movement may cause the person to land on the ground or another level and the person may or may not strike an object to break the fall (Kelsey et al., 2010; Lamb, Jostad-Stein, Hauer, & Becker, 2005; Rubenstein, 2016). There are three phases to a fall with the first being a sudden event that causes the body’s center of mass to become displaced beyond its base of support, followed by the inability of the body’s regulatory system to detect the displacement and to maintain upright posture, ending with the body’s impact against an environmental surface (Berg & Cassells, 1992). Unfortunately, with the older adult there is an inability to self-regulate to maintain the upright position or break the fall. Factors related with failure to maintain upright may be due to slower reflexes, inability to rapidly shift weight at the hip to prevent the fall, or an inability to take a quick step to avoid the fall (Rubenstein, 2006). Another reason for this inability to maintain an upright position may be due to the reduced step length that is noted with older persons which increases head and pelvis instability during ambulation (de Souza Moreira, Mourao Barroso, Cavalcanti Furtado, & Ferreira Sampaio, 2015). Nevertheless, the reasons for older adult falls are multifactorial with reasons categorized as those stemming from either extrinsic or intrinsic factors. Extrinsic factors are those related to environment and are many times modifiable. Intrinsic factors are those related to medical conditions in the person and are often more difficult to control. In addition, medications use can also be a risk factor for older adult falls and warrants discussion.

Extrinsic Factors

Common factors associated with older adult falls can be attributed to physical environment. Poor lighting, loose carpeting, cluttered walkways, lack of handrails, and lack of or inappropriate use of assistive devices are common environmental factors that result in falls. Falls that result from extrinsic factors are preventable and the goal should be to modify these environmental factors.

Intrinsic Factors

Psychological issues such as the cognitive decline, depression, and fear of falling may all increase the risk for falls. With cognitive decline, there may be a loss of safety awareness, impaired judgment, impaired visuospatial perceptions and orientation inability placing the older adult at risk for falls (Rubestein & Josephson, 2006). Depression can increase the risk for falls twofold (Rubestein & Josephson, 2006). This may occur from decrease activity, which can cause weakness and debility or inattentiveness to the environment. Fear of falling is also a risk factor for falls as the older adult may self-impose functional limitation to prevent a fall. The likely result of the self-imposed limitations is weakness, debility and immobility which increases the risk for falls. The fear of falling may be justifiable and arise out of a previous experience with a fall. Older adults with a history of a previous fall have a threefold increase risk of falling again (Rubenstein & Josephson, 2006).

Physiological changes that increase the risk for falls occur from an aging body system or from chronic illnesses; the most common disorders will be discussed here.

A physiological change in the older adult is age related sensory degeneration. Presbycusis, vestibular system degeneration, presbyopia, cataracts, glaucoma, macular degeneration, and presbypropria affect sight, touch, equilibrium and spatial orientation which are needed for maintaining a balanced upright position (Rubenstein, 2016; Zalewski, 2015).

The nervous system also undergoes changes with aging such as the slower processing of nerve impulses due to a reduction in the number, thickness and density of myelinated peripheral nerve fibers (Peters, 2002). This is evidenced by slowed or decreased in reflexes which then poses a risk for the older adult as they are not able to self-regulate their body’s position when they are falling. In addition, neurological conditions such as cerebral vascular accidents and Parkinson’s increase the risk for falls as paralysis, hypoakinesia, postural abnormalities and tremors may be present.

Cardiovascular changes that result from an aging heart and the corresponding disease process such as dysrhythmias, decrease cardiac output, decrease tissue perfusion, peripheral vascular disease and congestive heart failure all are fall risk factors. These cardiovascular changes may cause the older adult to have signs and symptoms such as shortness of breath, dizziness, nausea, lower extremity edema, pain at lower extremities, and varicosities which increase the risk for falls. Baroreceptor response and sensitivity are also reduced in the older adult and increases the risk for falls due to inability to maintain a constant blood pressure resulting in postural hypotension and dizziness (James & Potter, 1999). Respiratory changes with the aging lung and the resulting disease process are common in the older adult and include decrease vital capacity, decrease lung capacity, decrease lung response and the inability to reach homeostasis when hypoxemia or hypercapnia are experienced are all considered fall risk factors. Metabolic conditions especially diabetes can increase risk for falls. More specifically the hypoglycemic and hyperglycemic episodes that can occur in the diabetic; the diabetic retinopathy and the subsequent loss of vision; and diabetic neuropathy and the resulting nerve damage that occurs to the extremities are all risk factors for falls. The musculoskeletal changes that occur as part of aging can precipitate a fall. Some of the changes include weakness from deconditioning, decreased muscle strength and gait disorders. Weakness that occurs from deconditioning can result from prolonged bedrest, lack of exercise or walking, or activity intolerance from chronic illness. The weakness and deconditioning results in skeletal muscle inactivity and reduction of muscle fibers from disuse, atrophy and decreased strength. In addition, gait disorder which are common in the older adult can stem from specific body system dysfunction or age-related changes. Up to 50% of persons 85 years of age or older and up to 40% of persons 65 years of age or older have identifiable gait problems that affect function with varying degrees of severity (Rubenstein, 2006). Finally, disease process such as osteoarthritis which causes pain and deformities in the bones and osteoporosis which results in decrease bone density and structural weakening of the bone places the older adult at risk for falls.

Medications Factor

Polypharmacy and certain types of medication have been linked to increase risk for falls (Hammond & Wilson, 2013; Rubenstein & Josephson, 2006). The more common medications that increase risk for falls are analgesics due to their effect on alertness and slow central processing; anti-arrhythmic and antihypertensive and their effect on cerebral perfusion; anticholinergics and the subsequent confusion and delirium that may occur; loop diuretics and their direct vestibular damage; and psychoactive drugs such as antidepressants, antipsychotics, hypnosedatives and benzodiazepines which reduce alertness, sedate, impair balance, slow central processing and cause extrapyramidal syndromes and other antiadrenergic effects (Rubenstein, 2016).

Multifactorial Causes

Evidence suggests that falls do not occur from a single factor, but from multifactorial issues with interacting predisposing and precipitating causes (Rubenstein & Josephson, 2006). Therefore, a comprehensive multifactorial approach to fall prevention programs is more effective in dealing with the older adult falls which should include assessment, intervention, medication reviews, and an exercise program (Costello & Edelstein, 2008; Jung, Shin, & Kim, 2014). Since the focus of this quality improvement project is falls in older adults living in assisted-living communities a comprehensive multifactorial approach will be implemented.

Falls in Assisted-Living Facilities

Older adults living in assisted-living facilities are known as residents. Residents are at an increased risk for falls despite living in a semi-controlled setting with additional assistance from nurses and aides. In fact, a national survey found a higher average rate of injuries from falls occurring in assisted living communities compared to falls occurring in skilled nursing facilities (Lamb, Engel, & Hollinger-Smith, 2005). The increase risk of falls in assisted-living facilities are probably due to the autonomy and independence that residents of these communities enjoy. Yet, common finding among residents of the assisted-living faculties are frailty, multiple chronic illnesses, and inability to safely perform activities of daily living or instrumental activities of daily living. The decline in activities of daily living, the aging process, and the multiple comorbidities become risk factors for falls in this population. Currently many assisted-living facilities conduct fall risk assessment on admission and yearly thereafter. Risk factor assessments are superficially completed by the admitting licensed practical nurse and are often overlooked. A comprehensive multifactorial approach with prevention techniques are the key to addressing the problems with falls. Therefore, it is important to properly complete fall risk assessments more frequently and perhaps quarterly for early identification of those at risk, assessing and modifying for risk factors, and implementing evidence-based interventions. Undoubtedly falls increases the risk for morbidity and mortality in the elderly and causes considerable suffering to the patient and increases healthcare costs and it is the responsibility of all healthcare workers to help ease this burden.

SignificanceNursing

Resident falls are a significant burden to nursing care. The fall may or may not cause injury to the resident, yet the cascade of processes that occur after a fall and are common in many assisted-living facilities and are worrisome and many. Each assisted-living facility has their own policies and procedures as to the steps the nurse should take after a resident fall, but the main steps are as follows: the nurse will first assess the resident, make a judgment call about the severity of the fall, then contact ambulance services if necessary or other team members for assistance in getting the resident up. This is followed by a call to the primary care provider, the family, the head of nursing and/or the administrator to report the fall. The fall is also documented in a fall log book or in the electronic medical record with exact details as to who, what, when, where, why and how the resident fell. The resident may be placed on hourly checks for 24 hours if available as a service at the assisted-living facility. After all the tasks are accomplished the nurse may questioned if the fall preventable? If so the nurse may feel a sense of responsibility and may feel that due to time constraints he/she was not able to prevent this. The nurse may also start analyzing the fall scenario and intervene with fall prevention strategies within his/her scope of practice. What few fail to see is that even when the fall occurred in a matter of seconds, the cascade of work that is added to the nurses/staff takes hours. Additional significance to nursing is the human aspect of caring. Nurses do not want to have patients’ fall and sustain an injury. Nurses are in the business of caring and curing and do not want to see patients suffer.

Healthcare

Resident falls are a significant problem for our healthcare system. In 2015, the United States was spending over $31 billion annually in direct medical costs related to falls occurring in the elderly (Center for Disease Control and Prevention, 2016b). This amount is Medicare costs only and does not include private insurances or the long-term effects of the injuries associated with a fall. It is predicted that by the year 2020 the financial burden related to older adult falls and the complications will surpass $67 billion (National Council on Aging, 2017). The costs related to older adult falls are astounding and government and regulatory agencies have taken notice. Healthy People 2020 is an example of the government taking action to address and prevent falls and fall related injuries in older adults (Office of Disease Prevention and Health Promotion, 2017). Specific goals related to fall and injury prevention with measurable objectives and recommendations were put forth by this initiative and agencies at the state and federal level are working together on meeting the objectives (Office of Disease Prevention and Health Promotion, 2017). The Joint Commission on the Accreditation of Healthcare (2017) has put forth a specific national patient safety goal that addresses reducing the risk for falls by following the five recommended elements of performance. The elements of performance include: performing a fall risk assessment, implementing interventions based on fall risk, staff education of fall reduction programs, educating patient and family of fall reduction strategies, and evaluation effectiveness of fall reduction strategies (Joint Commission on the Accreditation of Healthcare, 2017). It is evident that there is high interest in addressing falls in older adults not only due to deterioration of health, but also the costs related to falls.

Advanced Practice Nursing

Resident falls are a significant concern for advanced practice nurse providers. Providers obsess with assessing the resident thoroughly for fall risk factors. The provider will review labs, medications, and diagnostics and implementing interventions to combat the identified risk factors. What makes this challenging for the provider and the older adult is the high prevalence of clinical diseases and the increase in susceptibility to injury from the simplest of falls. However, it remains the responsibility of the provider to try to prevent falls by taking a comprehensive multifactorial approach to fall prevention including assessment, resident specific interventions, doing a thorough medication review, and encourage exercise program participation. These processes are done with the goal of preventing falls and complications. Unfortunately, despite the best of efforts residents will continue to fall as sometimes these falls are not preventable. Of greatest concern for the provider is when the fall is preventable. In retrospective analysis of causes and circumstances that lead to a fall related death it was found that up to two-thirds of deaths were potentially preventable (Rubenstein, 2006). Preventable falls and preventable deaths are a concern for providers as guilt, blame and grounds for litigation will likely take place.

Practice Support for Project

The facility of interest is in Lee County, Florida and has a census of 84 as of this report and is licensed for 100. This facility has a limited nursing service license and provides basic nursing services within the scope of practice of the licensed practical nurses. The facility has recently experienced an increase in the number of resident falls. The facility staff, nurses, and administrators are all committed to improving the health of the resident and therefore, want to immediately address the problem with falls. The facility is reporting that a yearly functional and fall risk assessment is being done on all residents. The fall score is documented on the EMR and no further action is taken. When residents fall, a basic head to toe assessment is done and vitals are taken. Some residents are sent out to the hospital depending upon the complexity of the fall such as if they hit their head, if they have a large laceration requiring evaluation, or if they are unable to get up with assistance. After the fall, the resident may be referred to physical therapy, have a medication review for possible adverse effects, have diagnostics ordered, or may require no further intervention. Residents are treated reactively in this scenario instead of proactively as is being proposed in this research study. The facility is open and welcoming of this quality improvement project and have offered support and assistance with the project. The project will involve the administrator, director of nurses, staff nurses, medication technicians, nurse’s aides, home care nurses, physical therapists and occupational therapists that come into the facility for resident care and services.

Benefit of Project to Practice

The assisted-living practice setting will benefit from this project with improved fall rates, healthier residents, and provide better care. The nurses will have improved fall risk assessment skills, a comprehensive multifactorial approach to falls will promote interdisciplinary communication which improves overall care provided to residents. The residents will be more educated on their fall risk, more aware of potential fall risk factors, more apt to accept changes recommended and more involved in prevention of falls. The benefits of this project are many with the most important being patient safety, promotion of safe independence, and good quality of life.

Chapter TwoSearch History

The literature review search concentrated on two main electronic databases, which included CINAHL Plus (Cumulative Index of Nursing and Allied Health Literature) and MEDLINE Complete (Medical Literature Analysis and Retrieval System Online). Key words used were: older adult falls, elderly falls, falls in assisted living facilities, fall prevention strategies, evidence-based fall interventions, and multifactorial fall risk assessment.

CINAHL Plus database includes nursing and allied health literature from journals, books, dissertations, conference proceedings and standards of practice. A search of the published literature relating to the research question revealed 21,672 items. After refining results to include only English, full-text publications, with dates from years 2007-2017, in the United States, with residents over the age of 65 the results indicated 2,634 items. Further limiters were placed on the results to include all articles with major headings of waking, functional status, community living, instrument validation, clinical assessment tool, gait, fracture, geriatric assessment aging, wounds, and injuries, risk assessment, accidental falls, physical therapy, muscle strength, physical activity, Vitamin D, dementia, cognition, quality of life, physical mobility, exercise, gerontological care, frail elderly, ADL’s. therapeutic exercise, mortality, quality improvement, gerontological nursing, geriatric functional assessment, tai-chi, hospitalization, outcomes, balance training, nursing-home, nursing home patients, long-term care, cognitive disorders, patient safety, and balance and posture. These limiters yielded a result of 74 items.

MEDLINE Complete database includes biomedical and life sciences literature from medical, nursing, and allied health journals. Using the SmartText Searching option of key words found in the question which revealed 12,535 items. Refining results to include only English, full-text publications, with dates from years 2007-2017, in the United States, with residents over the age of 65, the results indicated 102 items.

Integrated Review of the Literature

The research available on fall prevention in the older adults is quite extensive. Yet, the three overarching concepts found throughout the literature related to falls are (1) fall risk assessment identification, (2) using multifactorial fall risk assessment approach, and (3) implementing evidenced-based interventions based on the persons’ individualized needs.

Concept 1: Fall Risk Assessment

Current guidelines from the American Geriatrics Society (AGS) and British Geriatrics Society (BGS) (2011), is for the primary care provider to perform an annual fall risk assessment on adults 65 years of age and older by asking the patient about their fall history, their gait, and if they have balance problems. The key word in the recommendation is for the provider to ASK the patient, since less than half of older adults who fall fail to report this to their healthcare provider (AGS & BGS, 2010; Stevens et al., 2012). As of this project, evidence-based fall risk assessment tools to accurately detect those older adults at increased risk for falls are scarce (Moyer, 2012). In addition, the U.S. Preventative Task Force has no recommendations available for reliable screening tools for fall risk identification. Therefore, the annual interview by the primary care provider is the best initial clinical assessment tool. Unfortunately, research findings indicate that only about 37% of older persons were asked about falls in a primary care setting (Chou, Tinetti, King, Irwin, & Fortinsky, 2006). Furthermore, 67% of primary care providers interviewed during the data gathering for the development the STEADI initiative reported they did not routinely asked their patients about fall history unless evidence suggested the patient was at high risk for falls or the patient had suffered a recent fall (Stevens & Phelan, 2013).

In other patient care settings such as in the emergency department the older adult may be asked if they have fallen in the last month or use of assistive devices as part of the fall risk assessment and triage processing (Southerland, Slattery, Rosenthal, Kegelmeyer, & Kloos, 2017). However, these two questions are very superficial and provide little information about fall risk in older adults and much less information on interventions and management strategies for frequent fallers. The lack of validated questionnaire tools to assess fall risk in the older adult in the emergency department setting is because many tools that were evaluated in a meta-analysis were found to be inadequate (Carpenter et al., 2014).

It is evident that fall risk stratification tools are scarce and those that exists are not readily translatable to other settings. In addition, self-reporting of fall risk is not an adequate solution as many older adults either minimize their risk factors or underestimate their own fall risk (Southerland et., 2017). Combining the functional balance testing (4 Stage Balance Test) to the fall triage questions identified 34% more patients at risk for falls who had initially been screened as no fall risk based on their answers to fall triage questions (Southerland et., 2017). Therefore, a functional, quantitative fall risk assessment tool is best when used in combination with fall triage questions (Southerland et., 2017).

Perhaps the most complete program and clinical assessment tool available that addresses fall risk in older adults is the STEADI initiative, which was organized and developed by the Center for Disease Control and Prevention (2016) with input from practicing clinicians. The STEADI program is a more complete and thorough program as it involves fall risk questions with an additional functional balance testing component. The STEADI algorithm for fall risk assessment and interventions follows the recommendations from AGS and BGS (2011) guidelines but adds additional information for the provider to share with the patient for the prevention of falls. STEADI was developed as a direct response to the increase in fall-related injuries and fall related deaths seen in the older adult as well as the rising health care costs associated with falls. Not much has been written in the literature about field testing the components of the STEADI tool kit or on the success of the program due the initiative being promoted just a couple of years ago. Currently the CDC has funded several fall prevention cooperative agreements with the health departments in the states of Colorado, Oregon, and New York and results are pending (Stevens & Phelan, 2013). However, the goal of STEADI is to have providers ask their patients’ annually about falls, conduct a fall risk assessment, implement intervention for fall prevention and to use an interdisciplinary approach with appropriate community referrals (Stevens & Phelan, 2013).

It has been established that fall screening by the provider is an important component of fall prevention for the older adult. Evidence from systematic reviews suggests that clinical assessment by a healthcare provider in addition to individualized intervention for identified risk factor, appropriate referrals as needed, and follow-up reduced fall rates by 24% (Gillespie et al., 2009).

Concept 2: Multifactorial Risk Assessment

Falls occur due to multiple risk factors and it is the combination among those risk factors that places the older person at an increased risk for falls. Because fall is not a single and independent event it is logical that the issue is addressed from several avenues. Multifactorial risk assessment addresses the problem of falls from a holistic perspective and accounts for all those external and internal forces that may increase the older persons’ risk for fall. Clinical guidelines from AGS and BGS (2011), suggests a multifactorial risk assessment for those older persons who present with falls and/or those older persons who reports gait or balance problems.

An approach to fall prevention involving a multidisciplinary fall prevention team and multifactorial fall prevention interventions proved to have high clinical relevance in reducing fall rates of those older adults in the intervention group (n=249) vs. the control group (n=269) (Neyens et al., 2009). The reduction of all rates in this study was accomplished by taking a multifactorial approach to falls prevention where mobility and the use of assistive and protective aids were assessed, individualized exercise programs were implemented, medications were critically reviewed, and identification of the circumstances and causes of falls were also reviewed (Neyens et al., 2009). In a systematic review with Cochrane Collaboration that included 19 trials and 9,503 participants found that individualized multifactorial interventions with modifications of risk factors reduced the number of falls in older adults (Gillespie et al., 2009; Gillespie et al., 2012). The multifactorial risk assessment and interventions in Gillespie et al. (2009) were individualized according to risk assessment findings and included reviewing of medication, Vitamin D supplementation, interventions that improved home safety, and exercise program to name a few.

A prospective cohort study in residential aged care facilities with 670 resident participants and 650 staff members evaluated multifactorial risk assessment approach with corresponding individualized modifications and evidence-based falls prevention intervention program (Nitz et al., 2012). The multifactorial risk assessment and interventions implemented included a fall risk assessment process, staff education, exercise program, vitamin D/calcium supplementation, increased sunlight exposure, environmental audit, hip protector use and/or compliance, use of high-low or low-low beds, use of bed/chair alarms, observation, alerts for high falls risk residents, monitoring sensory aids, feet/footwear interventions, medication review/medical management, allied health hours, and information for residents and family (Nitz et al., 2012). Findings to this study indicated a significant reduction in the number of people contributing to the fall total (Nitz et al., 2012).

In a review that compared the findings of single interventions programs vs. multifactorial risk assessment and intervention programs, the findings were favorable towards multifactorial intervention program for older adults with a previous history of falls (Costello & Edelstein, 2008). The single intervention program consisted of exercise as the intervention and included10 studies and 2,443 participants whereas the multifactorial intervention included 12 studies and 4,251 participants consisted of referrals to other providers, medication review with appropriate changes made, psychotropic medication withdrawal, vision assessment, home visit assessment and modification of extrinsic factors, patient education on fall risk factors, diet and exercise guidelines for healthy aging, and exercise and balance training programs (Costello & Edelstein, 2008).

The STEADI initiative includes a multifactorial risk assessment. Despite field testing of this specific program, research findings indicate that fall programs that include multifactorial risk assessment are effective. The three main areas of the STEADI multifactorial risk assessment are: reviewing with patient the Stay Independent brochure, conducting a falls history, and conducting a physical exam that includes assessing for postural dizziness/postural hypotension, medication review, cognitive screening, feet and footwear, use of mobility aids, and visual acuity check (Stevens & Phelan, 2013).

Concept 3: Evidence-Based Fall Intervention

It is important to note that conducting a fall risk assessment and a multifactorial risk assessment alone does not prevent falls. The fall prevention portion of the fall risk assessment and the multifactorial risk assessment come into play when one modifies risk factors and implements evidence-based interventions. Evidence-based interventions, fall risk assessment and multifactorial risk assessment approaches when combined and tailored to meet the needs of the specific patient can help prevent falls in the older adult (Stevens & Phelan, 2013).

The literature support that exercise alone is effective in reducing fall risk (Alvarez et al., 2015; Beling & Roller, 2009; Moyer, 2012; Sherrington et al., 2008). This may be since upper and lower extremity weakness are significant risk factors for falls (Moreland, Richardson, Goldsmith, & Clase, 2004). In addition, findings from a study that included 62 participants which were assigned to groups based on a history of falls (n=20) vs. group without falls (n=42) found the frequent fallers to have reduced lower limb strength gait alterations, poor dynamic balance and an overall increase risk for falls (Cebolla, Rodacki, & Bento, 2015).

Exercise as a group-based activity, or as an individual with the assistance of a therapist that focuses on improving strength and balance, should be the goal for every older adult. For the older adult population, the U.S. Department of Health and Human Services (2008) recommends 150 minutes per week of moderate intensity with muscle strengthening activities, or 75 minutes per week of vigorous intensity with muscle strengthening activities. For older adults who have had a recent fall or have difficulty with ambulation the U.S. Department of Health and Human Services (2008) recommends balance training 3 or more days per week. The AGS and BGS (2011) recommend exercise interventions that include balance, strength and gait training with a level [A] strength of recommendation rating.

Clinical guidelines from AGS and BGS (2011) recommend vitamin D supplementation of at least 800 IU per day for older adults residing in long term care settings with gait abnormalities and balance impairment that are at increased risk for falls with a level [B] strength of recommendation rating which indicates fair evidence exists about intervention improving health outcomes and benefits outweigh harm. Clinical guidelines from the U. S. Preventative Services Task Force recommends vitamin D supplementation with a grade [B] level of recommendation with a high certainty that the net benefit is at least moderate (Moyer, 2012). In a systematic review with Cochrane Collaboration findings indicate that Vitamin D supplementation may reduce the risk of falls in older adults with lower levels of Vitamin D (Gillespie et al., 2009; Gillespie et al., 2012).

Managing medications by reducing the use of psychotropic medications was found to have a significant effect on reducing rate of falls in a study with 93 participants (Gillespie et al., 2009; Gillespie et al., 2012). Similarly, in a study that investigated a prescribing modification program for providers with 659 patient participants found a significant reduction in the rate of falls. Other studies have investigated relationship between fall risk increasing drugs and increase risk of falls in older adults and found significant association between falls and the use of certain types of drugs such as psychotropics (Askari et al., 2013; Woolcott et al.,2009).

Educating the patient about fall risk is an important intervention. However, education as a single intervention is not effective preventing falls (AGS & BGS, 2011; Gillespie et al., 2009; Stevens & Phelan, 2013). Education about fall prevention strategies in the way of educating the older person on proper use of assistive devices, transferring techniques, identifying and mitigating fall hazards, proper choice of footwear, and education on a new exercise program are all encouraged as part of fall prevention programs (AGS & BGS, 2011).

Optimize home safety whether at home or in a facility is an encouraged intervention and focus should be on identifying and mitigating fall hazards and has a level [A] strength of recommendation rating which indicates good evidence exists about intervention improving health outcomes and the benefits substantially outweigh harm. (AGS & BGS, 2011). It is important to look at extrinsic factors when optimizing home safety.

Other interventions recommended in the fall intervention initiative by STEADI such as addressing vision problems, foot problems and managing and monitoring hypotension will not be explored. Although these interventions are important addressing vision problems and foot problems both have a [C] strength of recommendation rating which indicates no recommendation for or against this intervention and managing and monitoring hypotension has a [D] strength of recommendation rating which indicates recommendation is made against this intervention (AGS & BGS, 2011). Therefore, these interventions will only be evaluated in a patient if they are symptomatic.

Research CritiqueStrengths

Strengths in the research is in support of fall risk assessment, multifactorial risk assessment, and evidence-based intervention to help prevent falls in the older adult (AGS & BGS, 2011). The AGS and BGS (2011) which are solid and reputable organizations provide guidelines for fall prevention after looking at “meta-analysis, systematic literature reviews, literature reviews, randomized controlled trials, controlled before and after studies and cohort studies published between May 2001 and April 2008” (AGS & BGS, 2011, p. 148). Furthermore, the AGS and BGS (2011) considered expert panel opinion. Following the recommendations of AGS and BGS (2011) the CDC also took action and created the STEADI initiative with input from practicing clinicians (CDC, 2016a). These organizations, the research investigated, the findings and recommendations are reputable and provide strength to any research project.

Weaknesses

Weaknesses found throughout the research is the lack of congruence between in the fall risk assessment tool, or which multifactorial risk assessment and evidence-based interventions are best. This is evident even in the guidelines and recommendations made. For example, as mentioned previously the AGS and BGS (2011) recommend that primary care providers perform an annual fall risk assessment on adults 65 years of age and older by asking the patient about their fall history, their gait, and if they have balance problems. However, no specific tool for the fall risk assessment is recommended by this guideline which may be considered a weakness. AGS and BGS (2011) are also in favor of multifactorial risk assessment, and evidence-based intervention to help prevent falls in the older adult. In contrast, the U.S. Preventative Task Force does not recommend multifactorial risk assessment with management or modification of identified risk factors and they rated the benefit of this practice as small (Moyer, 2012). The complete opposing views between these two organizations make this a weakness.

Also, the U.S. Preventative Task Force does not recommend a tool for fall risk identification in the older adult which is also a weakness.

Gaps

Three main gaps exist in the literature with regards to fall prevention in the older adult. First, the effect of resident self-determination and concordance on fall risk. Self-determination and concordance is something to consider in assisted living facilities as some residents still retain some independence and are in full capacity to make their own decisions and may not buy into fall prevention intervention. This is an issue to consider due to the possibility of noncompliance with participation in fall risk assessment or with recommended interventions (Child et al., 2012). Second, the effect of residents that require higher level of care and are frequent fallers who continue to reside in assisted living facilities. This scenario is seen frequently when a resident has lived at a facility for many years, has had a decline in status, is now under hospice services and because they are hospice they are not required to move from the facility, yet are frequent fallers. Finally, the effect of facility factors on fall risk. Facility factors such as staffing issues and nurse staffing patterns can contribute to fall risk (Willy & Osterberg, 2014). Limited staffing in some assisted living facilities and level of training are of concern and contribute to fall risk for the older adult as most facilities operate with minimally trained staff and turnover is high.

Limitations

Limitations in the fall risk assessment research findings were evident. In the study that indicated only about 37% of older persons were asked about falls in a primary care setting, the limitations were that only 18 physician participants were interviewed (Chou, et al., 2006). A similar finding, only 18 healthcare providers were interviewed, was evident in the study that found only 67% of primary care providers interviewed routinely asked their patients about fall history (Stevens & Phelan, 2013). Although, these studies have legitimate reports from practicing providers, caution must be taken when interpreting the results due to the low number of participants.

Limitations in the multifactorial risk assessment research findings were also evident. In the study by Costello and Edelstein (2008) the findings were favorable towards multifactorial interventions. However, when reviewing the several studies that included multifactorial interventions the researchers found it challenging as the programs compared did not all utilize the same interventions (Costello & Edelstein, 2008). Therefore, the finding of multifactorial interventions being found as favorable is interpreted with caution as the combination of interventions used is unknown. Another study that found multifactorial fall prevention interventions with high clinical relevance in reducing fall rates was one by Neyens et al. (2009). Possible limitations with this study were the motivation rates of nursing home residents and/or staff (Neyens et al., 2009). Out of 119 nursing home invited to join the research study only 34 nursing homes were agreeable. This brings up two questions: are the participating nursing homes more motivated to prevent falls because of motivated staff? and are the residents more willing to participate and make the necessary changes because they are more motivated and alert and oriented? If these are both true, then this would add a limitation to this study as the results would not be transferrable because motivation to participate in fall prevention strategies by staff and resident can help decrease fall rates.

Limitations were found in the evidence-based interventions research studies. The research by Alvarez et al. (2015) which concluded that exercise alone is effective in reducing fall risk, was the lack of control group. The study only assessed those that participated in the exercise program and did not include a comparison group. Another study that found exercise alone as effective in reducing fall risk was conducted by Beling and Roller (2009) but was limited in the number of participants which included only 23 participants making these findings not transferrable. Finally, in the research by Costello and Edelstein, (2008) that looked at home hazard assessment with modifications concluded that although some benefits were evident and number of falls for older adults were positively affected, the results also depended on who did the home hazard assessment. Limitations with this study were the use of various disciplines such as physical therapy, occupational therapy, nurse, physiatrist, and ergotherapist to conduct the home hazard assessment and the concern for inter-rater reliability (Costello & Edelstein, 2008). Another concern is the many different home modifications were based on individual needs and since the modifications were not the same for each person, the results may only be used with the understanding that all the participants did not get the same interventions.

Concepts and Definitions

Assisted Living Facility: A residential facility that provides basic level of care by 24-hour staff oversight, housekeeping services, meals, and personal assistance with at least two activities of daily living such as eating, bathing, dressing, toileting, transferring, continence care, and/or medication administration (U.S. Department of Health and Human Services, 1999). People that live in these facilities are called residents.

Falls: A fall can be defined as an unintended movement that causes one to lose control of balance which causes one to fall against or toward something and may or may not cause injury. The unintentional and unexpected movement may cause the person to land on the ground or another level and the person may or may not strike an object to break the fall (Kelsey et al., 2010; Lamb, Jostad-Stein, Hauer, & Becker, 2005; Rubenstein, 2016).

Stay Independent Fall Risk Self-Assessment Tool: A validated self-assessment brochure within the STEADI tool kit to completed by the resident with 12 (yes) or (no) questions, each assessing individual fall risk factors (Center for Disease Control and Prevention, 2016a).

Stopping Elderly Accidents, Death and Injuries (STEADI): a fall prevention tool kit for providers that contains educational materials on integrating fall prevention into practice and resources for assessing and addressing residents’ fall risk (Center for Disease Control and Prevention, 2016a; Stevens & Phelan, 2013). Materials to be reviewed by the resident are also included in the tool kit such as the Stay Independent brochure, What YOU Can Do to Prevent Falls brochure, Check for Safety brochure, Postural Hypotension: What It Is & How to Manage It brochure, and an instructional handout on Chair Rise exercise (Center for Disease Control and Prevention, 2016a).

Timed Up and GO Test (TUG): a mobility assessment tool that quantifies ambulation performance, evaluates lower extremity function, and dynamic equilibrium (Herman, Gilaldi, & Hausdorff, 2011). The test is conducted by measuring the time it takes a resident to rise from an armless chair and walk at a normal pace to a designated marking three meters away then turn and walk back to the chair and sit down (Center for Disease Control and Prevention, 2016a; de Souza Moreira et al.,2015; Herman et al., 2011).

Theoretical Framework

It has been well established throughout this research paper the importance of fall risk assessment by provider, the benefits of a multifactorial fall risk assessment approach, and the need to implement evidenced-based interventions that are individualized to meet each residents’ needs. This fall prevention strategy involves not only the provider and facility staff buy in and change in usual assessment “behavior,” but also a change in behavior for the resident. The Transtheoretical Stages of Change Model is a good theoretical framework to guide this process.

The Transtheoretical Stages of Change Model can be applied when a change in behavior is warranted, but the person may be resistant to change, unaware about the need for change, uneducated about his/her risks, or shows little to no interest in changing. The Transtheoretical Model involves five stages which the person must progress through to have the health behavior change (Prochaska & Velicer, 1997). The stages of change are precontemplation, contemplation, preparation, action and maintenance (Prochaska & Velicer, 1997). Furthermore, the model posits that a person is always in one of the five stages of change with about 40% of the at-risk population being in the precontemplation stage, 40% in contemplation stage, and 20% in the preparation stage (Prochaska & Velicer, 1997).

The precontemplation stage is the initial stage where the resident may be unaware of the problem and perhaps not ready to change (Prochaska & Velicer, 1997). During this stage, the resident may be unaware of their fall risk and may minimize their unsteady gait or balance issues. The responsibility of the provider during this stage is to perform a fall assessment risk and provide the resident with the Stay Independent Brochure (Stevens & Phelan, 2013). Performing a fall risk assessment and sharing the results will start to create awareness of the need to change behaviors.

The contemplation stage is the second stage where the resident may be aware of the problem and may be weighing pros and cons (Prochaska & Velicer, 1997). The resident in reviewing the Stay Independent Brochure is made aware that they have answered YES to certain trigger questions. The provider in this stage has shared the fall risk assessment results and has evaluated gait, strength and balance. The resident begins to realize their deficits and provider attempts to convince the resident to make the necessary changes.

The preparation stage is the third stage where the resident intends to act in the immediate future (Prochaska & Velicer, 1997; Stevens & Phelan, 2013). The role of the provider in this stage is to review the multifactorial risk assessment, educate the resident, discuss modifying risk factors and start to offer interventions to prevent falls.

The action stage is the fourth stage where the resident takes immediate action, is making necessary changes as recommended by provider and is practicing the new safer and healthier behaviors (Prochaska & Velicer, 1997; Stevens & Phelan, 2013). The role of the provider in this stage is to facilitate the action by making appropriate referrals such as to home health agencies, therapist, podiatrist, optometrist, and recommending assistive devices.

The last stage is the maintenance stage where the resident continues to work to sustain the behavior over time (Prochaska & Velicer, 1997; Stevens & Phelan, 2013). The role of the provider in this stage is to reinforce the change and follow up with the resident within a designated time such as 30 days for those at high risk for falls.

Chapter ThreeContext

The facility chosen for this project is called Juniper Village in Cape Coral, Florida. Juniper Village is an assisted living facility with a census of 84 residents as of this report and is licensed for 100 residents. Juniper Village is a two-story facility with 79 apartments with some of the apartment having double occupancy. The residents live in apartment like rooms which are between 280 square feet to 380 square feet. Apartments at this facility are spacious, well lit, carpeted, furnished with residents’ personal furniture and decor, and some have an area for a refrigerator, microwave, sink and kitchen cabinetry. Each apartment has a wheelchair accessible bathroom with a walk-up shower, sink and toilet.

The residents at this facility vary in ages from 62 to 106 years old. They have typical older adult comorbidities affecting their health such as history of high blood pressure, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, stroke, osteoarthritis, frailty, and weakness. The residents use a variety of assistive devices such as canes, walkers, wheelchairs, and/or motorized scooters. Many of the residents require assistance with one or more activities of daily living such as walking, bathing, dressing, toileting, brushing teeth, and/or eating. Most residents require assistance with at least three or more instrumental activities of daily living such as cooking, driving, using the telephone, shopping, keeping track of finances and/or managing medications.

The direct resident care staff vary in number from day to day, but on most days, includes a director of wellness, a wellness nurse, two medical technicians, and two floor staff. The residents wear life alert necklaces that alert the direct resident care staff via pager system. The corresponding staff assigned to that room will clear the life alert once they have arrived and met the residents’ need. The direct resident care staff also document using an electronic health record system called PointClickCare®. In addition to the direct care staff, the facility also works closely with various home care agencies, hospice, and health care providers as needed for resident concerns and issues.

Juniper Village’s administrator and direct resident care staff reported many falls in the year 2016. The facility administrator reports a total of 47 witnessed fall incidents and 185 unwitnessed observed on floor incidents which are considered falls and documented as such. The total falls for the year 2016 was reported as 232 falls. In comparison to year 2015, in which the facility administrator reports a total of 22 witnessed falls incidents and 57 unwitnessed observed on floor incidents which made the falls total 79. Unfortunately, this is nearly a three-fold increase in falls which negatively affects the health of the resident and places their safety and independence at risk. The reasons for the falls are varied. Therefore, a fall prevention program such as STEADI, that addresses fall risk assessment, multifactorial risk assessment with modifications of risk factors, and the use of evidence-based interventions effective in reducing fall risk is a welcomed strategy and quality improvement plan at Juniper Village.

This is a quality improvement project that will use a mixed methods design. The sampling of the population of interest will be a nonrandom convenience sampling of older adults willing to participate and living at Juniper Village. Inclusion criteria are residents at Juniper Village Cape Coral, 65 to 89 years of age, English speaking, and residents able to sign for themselves and that do not have an activated Power of Attorney. Exclusion criteria are residents under the hospice program, residents under the age of 65. residents that have an activated Power of Attorney and are not able to sign for themselves and residents under the respite program at the facility.

Interventions

The STEADI tool kit will guide the project. The materials and resources are not copyrighted and therefore can be printed and used without requiring permission from the Center for Disease Control and Prevention web site (Center for Disease Control and Prevention, 2016).

Step 1: After the approval of the IRB application a date will be selected for the resident meeting. This date will be selected by the activities director based on room availability. Flyers will be distributed throughout the facility to inform of quality improvement project, inclusion and exclusion criteria and date and time of project meeting. During the meeting, the researcher will discuss the risk for falls in the elderly population, the project goals, and inclusion and exclusion criteria. Families will also be notified of the meeting and are welcomed to attend. Expected meeting time 15 minutes with 5-10 minutes left open for questions and answers. Expected attendance will be about 40-50 residents. Refreshments and snacks will be served.

See Appendix A: Recruitment Flyer

See Appendix B: Script of Presentation

Step 2: All the residents interested in participation will receive an informed consent and HIPAA form with an appointment date scheduled for their first home visit. Researcher will verify with director of wellness if those that attended and are interested in participating in the project meet the inclusion and exclusion criteria.

See Appendix C: Informed Consent

See Appendix D: HIPAA Privacy Authorization Release Form

Step 3: A return visit to the participants home will be made to pick up all the informed consent and HIPAA forms. This will allow ample time for participants to review forms and understand the level of commitment required to participate in the project.

Step 4: Each resident participant which is predicted to be 30-40 residents, will have a formal home visit. The first home visit is the “getting to know you and your needs visit.” Discussion will include a review of the history and physical, medications being taken, a home safety evaluation, and the results of their latest Timed Up and Go (TUG) test which will become the pre-intervention TUG score. The TUG is a functional test conducted quarterly at the facility, to every resident, by the facility occupational therapist and documented in the residents’ electronic medical record. During this visit the Stay Independent Questionnaire will be answered by the participant and this will become their pre-intervention score. A fall risk assessment will also be performed using the questions from the STEADI Algorithm for Fall Risk Assessment & Interventions. This visit is expected to last 1 hour. A follow up visit to discuss results will be scheduled for the following week.

See Appendix E: “Timed Up and Go (TUG) test.”

See Appendix F: “Stay Independent Questionnaire.”

See Appendix G: “STEADI Algorithm for Fall Risk Assessment & Interventions.”

Step 5: All information gathered during the “getting to know you and your needs visit.” will be reviewed immediately following the visit. Identification of fall risk factors will be recorded using the Quality Improvement Project Data Collection Sheet. At the follow up visit recommendations for interventions based on individual findings of STEADI Algorithm for Fall Risk Assessment & Interventions will be discussed with the participant. The Stay Independent Questionnaire and TUG test scores will also be reviewed. Participants will be referred to their primary care provider for possible intervention. The doctor and the facility will arrange for implementation and monitoring of interventions as is done with any other doctor’s order. All the data and information will be kept in a secure locked box in the researcher’s home. This visit is expected to last 30 minutes.

See Appendix H: Quality Improvement Project Data Collection Sheet.

Step 6: Each participant will have a “conclusion of project” home visit 1 month after the follow up visit. Discussion will include any changes in their plan of care made by their primary care following the recommendations by STEADI Algorithm for Fall Risk Assessment & Interventions findings, current medications being taken, a home safety evaluation, and the results of their latest TUG test. If the participants are receiving therapy services, then monthly TUG tests are completed by their therapists and this will be used as the post intervention score. If the participants did not receive therapy services, they are still eligible to request a TUG test to be repeated by the therapy department and this number will be use as the post intervention score. During this visit a Stay Independent Questionnaire will be repeated and this number will be used as the post intervention score. The preintervention and postintervention findings will be reviewed with each participant. This visit is expected to last 40 minutes.

Step 7: All information gathered during the “conclusion of project” home visit will be reviewed immediately following the visit. All post intervention scores will be recorded using the Quality Improvement Project Data Collection Sheet. Comparison findings will include the Stay Independent Questionnaire, TUG test scores, and the interventions recommended versus the interventions followed.

Step 8: Results will be analyzed in chapter 4.

Study of the Interventions

Baseline data needed prior to starting the interventions will include the name of the primary care provider for each participant, history and physical of each participant, medication list, assisted device being used, access to labs such as vitamin d and calcium level, and any other medical condition that can be a risk factor for falls. The facility will provide the researcher with access to their electronic health record system called PointClickCare®. The information will be gathered for all participants and then steps 3-7 of the interventions will be initiated.

The approach for assessing the impact of the interventions will be comparing the TUG test scores pre and post intervention, comparing the Stay Independent Questionnaire score pre and post intervention, and comparing the number of recommended interventions with the number of interventions followed.

The STEADI tool kit does not provide a post intervention survey for falls. However, to be able to determine if the observed outcomes were due to the implementation of STEADI program, a “conclusion of study” visit is scheduled about one month after initiation of interventions. During this visit the lived experience of the resident participant in the STEADI program will be discussed among other topics. A resident self-reporting that he/she feels stronger, steadier on their feet, using the assistive device appropriately and proud to report they’ve had no falls, is a success in the eyes of the researcher. A single fall prevention by the implementation of the STEADI program is a success in the eyes of Juniper Village.

Measures

All the tools used for this study are available at the CDC web site under STEADI materials for the health care providers (Center for Disease Control and Prevention, 2016a). The STEADI program is theory driven and the tool kit, recommended activities, and interventions are evidence-based and were adapted from the current guidelines from the American Geriatrics Society and British Geriatrics Society (AGS & BGS, 2011; Stephens, 2013; Stephens & Phelan, 2013).

Measuring resident falls: Fall occurrences for each resident will be gathered from the PointClickCare® fall incident reports tab. The dates for review would be December 2016 until December of 2017 will be used to gather baseline data on falls for the past year. The data will be displayed as falls in the last year, falls in the last 6 months, and falls in the last 30 days.

Stay Independent Questionnaire: A self-assessment brochure to be completed by the resident with 12 (yes) or (no) questions, each assessing individual fall risk factors (Center for Disease Control and Prevention, 2016a). The Stay Independent brochure was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and it is an evidenced-based tool with clinical acceptability and has proven concurrent validity (Rubenstein, Vivrette, Harker, Stevens, & Kramer, 2011). See Appendix F, for sample of Stay Independent Questionnaire.

STEADI Fall Risk Assessment Questions and Algorithm: There are three questions that the resident will be asked that will then lead the researcher to use the algorithm line that best fits the residents based on their answers. The three questions are: (1) “fell in the past year?” If yes, then the resident will be asked how many times? And was he or she injured? (2) “Feels unsteady when standing or walking?” (3) and “worried about falling?” (Center for Disease Control and Prevention, 2016a). See Appendix G, for sample of STEADI Fall Risk Assessment Questions and Algorithm.

Timed Up and Go test: an assessment tool used to assess mobility in a resident (Center for Disease Control and Prevention, 2016a). The TUG test has been found to be an effective test for assessing functional mobility (Herman, Giladi, & Hausdorff, 2011). Reliability and validity of the TUG test is questionable and has been found to be more effective at ruling in a risk for falls than ruling out a fall risk (Barry, Galvin, Keogh, Horgan, & Fahey, 2014). See Appendix E, for sample of TUG test.

SAFE Medication Review Framework: A Team Based Approach: STEADI advises the use of this tool to conduct a medication review. SAFE is an acronym for (S) screen, (A) assess, (F) formulate, and (E) educate (Center for Disease Control and Prevention, 2016a). See Appendix I, for sample SAFE Medication Review Framework: A Team Based Approach.

Check for Safety: Environmental Survey: A home fall prevention checklist used to identify environmental hazards found throughout the home (Center for Disease Control and Prevention, 2016a). Some of the areas looked at with this checklist are floors, stairs and steps, kitchen, bathrooms, bedrooms, and other safety tips to prevent falls in the home (Center for Disease Control and Prevention, 2016a). See Appendix J, for Check for Safety: Environmental Survey.

Analysis

The analysis will start with a review of the Quality Improvement Project Data Collection Sheet. This sheet will include all the data of the Stay Independent Questionnaire pre and post intervention, TUG test scores pre and post intervention, and the interventions recommended versus the interventions followed. The study will use a mixed methods research design to address the data. The data will be discussed in narrative form and gathered from interviews and themes from visit conversations but will also be discussed using numerical data and using inferential statistics. Excel will be used to organize data for pre and post intervention comparison. The measures of central tendency (mean, mode, medium) for the results of the Stay Independent questionnaire and TUG test pre and post intervention will be evaluated. Finally, the interventions recommended, and the interventions followed will also be analyzed.

To ensure appropriate, systematic, and valid data collection takes place, only the researcher will conduct visits and interpret data. To avoid reliability issues the TUG test will only be performed by therapists and not by the researcher at pre-intervention and post intervention.

Ethical Considerations

The researcher has taken great care in ensuring that ethical aspects related to the study have been addressed. The first step was the successful completion of the Collaborative Institutional Training Initiative (CITI) course on protection of human subjects. The second step is the open communication and frequent updates between the is the DNP chair person, Dr. Pohlman, and the researcher. This communication has allowed for the revision of the study making it more meaningful for the participant. The third step is the submission of the required paperwork for approval or revision of the study by the Institutional Review Board (IRB). The study will not begin until approval from IRB. The fourth step is the strict adherence to the Code of Ethics for Nurses throughout the study (American Nurses Association, 2015). The fifth step are the strict adherence to the basic principles of medical ethics which include participant autonomy which must be free of coaxing and coercion; beneficence which to do good for the participant and follows the goal of the project, fall prevention and to promote resident safety; and nonmaleficence which is to do no harm (Stanford University, n.d.). Lastly, the researcher will follow all policies and procedures as set by Juniper Village.

Chapter FourResultsInitial Steps and Details of the Process

The quality improvement project meeting date was scheduled for December 1st, 2017 with eligible subjects at the chosen facility. There were 38 eligible subjects that attended the meeting of which 28 subjects expressed an interest in becoming participants/subjects. After inclusion and exclusion criteria was reviewed the 28 interested subjects were given the consents and HIPAA (Health Insurance Portability and Accountability Act of 1996) forms to review over the weekend. On December 4, 2017 28 consents were picked up and an appointment was made for an initial visit for data collection. All subjects were assigned a numeric code to protect confidentiality. There were 2 subjects that signed the informed consent and HIPAA form, but then decided not to participate which were identified as participant 11 and participant 16. This left a total of 26 project participants/subjects. The subjects ages ranged from 65-89 with a mean age of 81 years old ± 7.2 years. Subjects consisted of 65% females and 35% males.

The initial data collection occurred on December 5-8. A total of 26 subjects were interviewed and data collection began with a health history (detailed in medical diagnosis, medications being taken, vitamin D needs and supplementation), discussion of falls and what lead to the falls, environmental survey with specific focus on home safety, having the subjects take the Stay Independent questionnaire, and TUG test scores from the last quarter of 2017 (specifically October and November, 2017). Subjects main medical diagnosis were chronic in nature with most diagnosed with one or more chronic illnesses which included diabetes, congestive heart failure, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, or history of cerebral vascular accident with and without residual paralysis. On average these subjects were on 3 high risk meds ± 1 medication. Additionally, 11% of subjects were found to have vitamin d deficiency but were not on supplementation. As a result of the health history and subject self-reporting issues associating with falls 27% self-identified needing specialist referrals such as seeing a podiatrist, optometrist, or neurologist to address issues increasing their risk for falls. The initial data collection also identified that on average subjects had 2 falls ± 4 falls within the last year December 4, 2016 to December 4, 2017. Subjects had varying levels of functional mobility with 27% having no assistive device, 8% using a cane, 54% using walkers, and 11% were wheelchair bound. The home environmental survey revealed 27% of subjects needed to make home modifications which posed a fall risk. The pre-intervention Stay Independent questionnaire self-assessment results indicated the average yes answers for the subjects was 6 ± 3 yes responses. Four or more yes responses in the Stay Independent Questionnaire indicatives a higher fall risk (Center for Disease Control and Prevention, 2016a). The pre-intervention Timed Up and GO (TUG) test scores were gathered from electronic health records with the average score of 30 seconds ± 34 seconds. It is important to keep in mind that a score of more than 12 seconds on the TUG test is indicative of a higher fall risk (Center for Disease Control and Prevention, 2016a).

The information gathered from subjects during the initial visit and data collection was then organized and analyzed for needed interventions. A follow up visit to review findings and make recommendations occurred on December 10-12, 2017. There were seven possible interventions that were to be recommended to subjects: (a) 27% of subjects having home modifications recommended, (b) 23% of subjects having assistive device modification recommended, (c) 100% of subjects having exercise recommended, (d) 81% of subjects having therapy services recommended, (e) 11% of subjects having vitamin D supplementation recommended, (f) 100% of subjects having a medication review recommended, and (g) 27% of subjects having specialist referrals. The subjects were instructed to document the recommendations and make the necessary changes based on the recommendations or after discussing recommendations with their providers.

A conclusion of project visit occurred on January 13-15, 2018, which allowed for 34 days of intervention to take place. During this visit a review of the health history, discussion of falls in the last 34 days, a repeat Stay Independent questionnaire was completed by subject, latest TUG test scores from January 2018, and a review of the interventions recommended and followed. The post-intervention Stay Independent questionnaire self-assessment results indicated the average yes answers for the subjects was 7 ± 3 yes responses. Findings of the post-intervention TUG test indicated an average score of 34 seconds ± 40 seconds. The average number of recommended interventions followed by the subject was 2 ± 1 intervention. Submission to statistician was immediately made after data collection was organized see Table 1 and Table 2.

Table 1Pre and Post Results

ID

Pre-SIQ

Post-SIQ

Pre-TUG

Post-TUG

#Rec

# Foll

1

10

10

165

188

5

4

2

8

9

60

57

3

2

3

1

1

15

10

4

2

4

7

8

89

91

5

4

5

8

8

25

18

4

2

6

7

7

2

1

7

5

6

32

19

6

5

8

3

4

17

15

2

0

9

11

11

4

1

10

4

5

18

65

3

0

12

6

7

24

30

4

1

13

6

7

18

16

3

2

14

4

5

25

22

3

1

15

2

4

20

17

4

3

17

9

9

18

17

4

3

18

6

6

19

23

6

2

19

10

10

25

18

3

2

20

10

10

3

2

21

5

7

14

19

5

1

22

2

3

13

11

2

0

23

4

5

14

17

4

0

24

4

5

22

23

4

1

25

9

10

24

70

4

3

26

0

0

12

12

2

1

27

9

10

15

15

3

1

28

4

6

8

10

4

1

Note. ID (Code given to subjects, subject 11 and 16 dropped out of project); Pre-Post SIQ (Stay Independent Questionnaire yes answers); Pre-Post TUG (Timed Get Up and Go measured in seconds, subject 6, 9, 20 did not participate in TUG); # Rec - # Foll (Number of Interventions Recommended and Followed).

Table 2Descriptive Statistics

Pre-SIQ

Post-SIQ

Pre-TUG

Post-TUG

#Rec

#Foll

Valid

26

26

23

23

26

26

Mean

5.92

6.65

30.09

34.04

3.69

1.73

Median

6.00

7.00

19.00

18.00

4.00

1.50

Mode

4

10

18

17

4

1

Standard Deviation

3.058

2.870

34.180

39.996

1.123

1.313

Minimum

0

0

8

10

2

0

Maximum

11

11

165

188

6

5

Note. Pre-Post SIQ (Stay Independent Questionnaire yes answers-12 total questions); Pre-Post TUG (Timed Get Up and Go measured in seconds, 3 subjects did not participate); # Rec - # Foll (Number of Interventions Recommended and Followed, maximum number of interventions that could be recommended is 7).

The paired samples t-test was the statistical test chosen for the inferential statistics of this project. This test allows for dependent samples or a single group to be tested before and after the intervention as in the case of the pre-post intervention Stay Independent questionnaire, the pre-post TUG test score and the number of interventions recommended versus the interventions followed. The paired samples t-test was calculated using Statistical Package for the Social Sciences (SPSS) and with the assistance of a statistician.

A paired-sample t-test was calculated to compare the mean pretest score of the Stay Independent Questionnaire to the posttest score. The mean on the pretest was 5.92 (sd = 3.058) and the mean of the posttest was 6.65 (sd = 2.870). A significant difference from pretest to posttest was indicated (t (25) = -5.588, p = .000). Therefore, for this t-test we will reject the null hypothesis. (See Table 3 and 4).

Table 3Paired Sample Statistics for Stay Independent Questionnaire

N

Mean

Std. Deviation

Std. Error Mean

Pair 1

Pretest

26

5.92

3.058

.600

Posttest

26

6.65

2.870

.563

Note. Std. Deviation = Standard Deviation; Std. Error Mean = Standard Error Mean.

Table 4Paired Sample t-test for Stay Independent Questionnaire

95% CI

Mean

Std. Deviation

Std. Error Mean

Lower

Upper

df

Sig.

(2tailed)

Sig. Pair 1

Pretest

Posttest

-7.31

.667

.131

-1.000

-4.61

-5.588

25

.000

Note. Std. Deviation = Standard Deviation; Std. Error Mean = Standard Error Mean; CI = confidence interval; df = degrees of freedom; Sig. (2tailed) = two-tailed p-value.

A paired-sample t-test was calculated to compare the mean pretest score of the TUG test to the posttest score. The mean on the pretest was 30.09 (sd = 34.180) and the mean of the posttest was 34.04 (sd = 39.996). Although an increase from pretest to posttest was indicated, there was no significant difference (t (22) -1.269, p = .218). Therefore, for this t-test we fail to reject the null hypothesis (See Table 5 and 6).

Table 5Paired Sample Statistics for TUG Test Scores

N

Mean

Std. Deviation

Std. Error Mean

Pair 1

PreTUG

23

30.09

34.180

7.127

PostTUG

23

34.04

39.996

8.340

Note. Std. Deviation = Standard Deviation; Std. Error Mean = Standard Error Mean.

Table 6Paired Sample t-Test for TUG Test Scores

95% CI

Mean

Std. Deviation

Std. Error Mean

Lower

Upper

df

Sig.

(2tailed)

Sig. Pair 1

PreTUG

PostTUG

-3.957

14.956

3.119

-10.424

2.511

-1.269

22

.218

Note. Std. Deviation = Standard Deviation; Std. Error Mean = Standard Error Mean; CI = confidence interval; df = degrees of freedom; Sig. (2tailed) = two-tailed p-value.

A paired-sample t-test was calculated to compare the mean score of the number of interventions recommended to the mean score of the interventions followed. The mean of the interventions recommended was 3.69 (sd = 1.123) and the mean of the interventions followed was 1.73 (sd = 1.313). A significant difference is indicated in the recommended interventions versus followed interventions (t (25) = 9.293, p = .000). Therefore, for this t-test we will reject the null hypothesis (See Table 7 and 8).

Table 7 Paired Sample Statistics for Recommendations vs. Followed Interventions

N

Mean

Std. Deviation

Std. Error Mean

Pair 1

Recommended

26

3.69

1.123

.220

Followed

26

1.73

1.313

.258

Note. Std. Deviation = Standard Deviation; Std. Error Mean = Standard Error Mean.

Table 8Paired Sample t-Test for Recommendations vs. Followed Interventions

95% CI

Mean

Std. Deviation

Std. Error Mean

Lower

Upper

df

Sig.

(2tailed)

Sig. Pair 1

Recommended

Followed

1.962

1.076

.211

1.527

2.396

9.293

25

.000

Note. Std. Deviation = Standard Deviation; Std. Error Mean = Standard Error Mean; CI = confidence interval; df = degrees of freedom; Sig. (2tailed) = two-tailed p-value.

Contextual Elements and Observed Associations

Contextual elements that interact with interventions can include many forms. First, if the facility staff is aware that a quality improvement project is being conducted on falls this may bring about behavior changes in staff as they are aware that subjects are being monitored. Second, subject behavior modification can also occur as they are aware that they are part of a project and being monitored. Third, the timing of project which was conducted over a major holiday may interact with interventions as it may have limited subjects from making appointment with their providers or following through with all the interventions. Fourth, the availability of primary care providers to discuss project findings and recommendations with subjects may have prevented some subjects to follow through on some of the interventions, Fifth, subject may have been concerned about having the project answers affect their level of care at the facility and therefore may have not answered questions truthfully. Lastly, subject participation in interventions may have been limited based on the stages of change that the