Caring for nursing home residents at risk for fall.
Falls are a common hazard faced by nursing home residents and can be an indicator of health problems. It makes sense to take particular care with incidences of falls in older people and their subsequent care. In today’s episode, nursing home abuse attorneys Rob Schenk and Will Smith discuss prevention of falls in nursing home residents and care of residents at risk of falling with guest Teresa Boynton, a clinical consultant at Hill-Rom.
TRANSCRIPTION OF EPISODE
Schenk: Hello out there and welcome to this episode of the Nursing Home Abuse Podcast. My name is Rob Schenk.
Smith: And my name is Will Smith.
Schenk: And we are your co-hosts for this episode. Very important information in this episode. We’re going to be talking about one of the most common injuries that we encounter as nursing home abuse attorneys, nursing home neglect attorneys, and that’s injuries from falls that occur in nursing homes, how and why they’re prevalent in nursing homes and what we can do to prevent them.
And we’re not doing it alone today. We have a special guest, and who is that guest, Will?
Smith: That guest is Teresa Boynton. She is a Hill-Rom clinical consultant on safe patient handling and mobility, a position she has held for about three years. She assists healthcare facilities across the U.S. with implementing and sustaining these types of programs, which include a focus on preventing patient and resident falls.
Before this, she worked for Banner Health for over 30 years. She led the Banner Health Safe Patient Handling and Falls Prevention team. She developed and worked with a Banner team on validating and implementing the bedside mobility assessment tool for nurses, or BMAT. And she has authored two articles on the BMAT. She is certified by the Association of Safe Patient Handling Professionals. She’s presented at numerous conferences, including the 2017 National Fall Prevention Conference on mobility is a fall prevention intervention and at the 2016 Greenhouse Long-Term Care Conference on meaningful life and mobility safe lifting practices. So to say the least, she is definitely a well-recognized expert in the area of falls and fall prevention, and we are delighted to have her today.
Schenk: Yeah, Teresa, welcome to the show.
Teresa: Thank you.
Are seniors more at risk for falls than the general population?
Schenk: Great. So Teresa, as we mentioned before we brought you on, one of the most if not the most common injury that we see as attorneys is injuries from falls in nursing homes. And so we were really happy you agreed to come on and talk about the different aspects of fall risks in nursing home residents. And I think the first general question that we have for you today is why is the senior population more at risk than the general population for falls in the first place, whether or not they’re in a nursing home? Why is that?
Teresa: Well there are a number of factors that play into that. Typically as you get older, our risks factors increase, especially if we’re looking at people 65 or older as we get into that even older category of 85. And what we usually see are one or more risk factors, sometimes significantly more than one or more risk factors, such as muscle weakness, becoming more fatigued easily. Gait and balance disturbances can increase for a number of reasons. It could be because of vestibular disorders, a number of disease processes that can impact both balance and gait. Poor vision or visual impairment can lead to balance, gait disturbances, and again, just not being able to navigate through your environment as easily or as safely. Delirium, depression can have an impact – those are considered risk factors. Cognitive functional impairment – and again, these are things that typically as we age, we start to see more of these risk factors.
Orthostatic hypertension or postural hypertension – when you go from lying down to sitting to standing up, a number of things happen in our bodies to allow us to not pass out, but as we get older, some of these functions aren’t working as well. We don’t respond as quickly, so we’re more likely to become dizzy and lightheaded, and again, that can lead to falls.
There may be some laboratory abnormalities – low platelet count, anemia, hypoglycemia, hyperglycemia. Another one that we see a lot of especially as we get older is urinary incontinence, so got to go to the bathroom, got to go now, got to go fast. And that definitely can contribute to falls. Nocturia, having to urinate frequently at night and getting up and, again, a sense of urgency, not being quite oriented, that can definitely lead to falls.
There are also high-risk medications that are attributed or contribute to or are associated with falls – sedatives, hypnotics, anti-anxiety agents, there’s a long list of medications that can contribute to falls. So a variety of factors.
What are the common triggers of falls in nursing homes?
Schenk: I see that. So understanding that – I don’t know if this statistic is true, but they say something along the lines of most automobile accidents, if you’re involved in them, occur within a mile of your home. Is there any such – I don’t want to say same statistic, but where are falls, based on these symptoms, where are falls most likely to occur? Is it getting out of bed because of that sense of urgency? Where is it most likely to be that a nursing home resident would fall?
Teresa: Well if we’re talking about nursing home residents, there is some research. The research is it’s not maybe as strong as we’d like it to be, because different nursing homes will have a different case mix, a different type of resident, but what we do know based on the research is that nursing home residents are at a higher risk of falling than elderly folks in the community. Falls in resident homes, in nursing homes, tend to take place around the bathrooms and in the bathrooms more so than in common areas, so a resident is more likely to fall in their own room, in a bathroom or on their way to the bathroom.
Some research indicates that sit-to-stand or stand-to-sit transfers are associated with a higher percentage of falls than, for instance, walking. And some long-term care research indicates that about 25 percent of falls are linked to walking to the bathroom or are falls in the bathroom, particularly during the night – again, get up, have that sense of urgency, not well oriented, and fall either on the way to the bathroom or in the bathroom.
Why do prior falls increase the likelihood of future falls?
Schenk: I see. You listed several factors that increased the risk of someone falling. One of them was have they fallen before – and this is something we get questions from clients about, but why has, if you’ve fallen before, why does that increase the likelihood that you will fall again?
Teresa: Well, and again, a number of factors play into that, and there is some research that really does support that. Fear of falling may be contribute to the increased risk of falling. If you’re afraid of falling, you’ve already fallen once, so you limit your activity. By limiting your activity, you’re becoming more deconditioned, you’re becoming more weak, so then when you finally do decide to get up, you’re afraid, you’re anxious, and you now are more deconditioned – you’re weaker.
If a person has previously fallen and even if they’ve had a minor injury, that causes pain, distress, and they just don’t have the reserve, the functional reserve to want to get up and walk again. So even fainting or feeling uncomfortable, you go to rise up and you know you’ve fallen before and you’re starting to rise up and you’re starting to realize you’re becoming dizzy, so it’s like, “No, I don’t want to move,” so there is research that shows that after a nursing home resident or simply anyone in the community has fallen, that they’re more afraid and that does increase their risk of falling again.
What are some fall prevention techniques?
Schenk: So that makes a lot of sense, and actually from that, that risk assessment in terms of if they’ve fallen again, that increases that risk, there seems to be a lot of factors that could be observable by family members that would lead to the next fall. So for example, you said that they have a fear of falling so they might not participate in physical activities, which would make them weaker, which, again, would make them more susceptible to the next fall.
So could you walk us through some things that family members could do, maybe some best practices for family members of loved ones that are in nursing homes, what they can do to observe, what they can observe, and what they then can do to prevent the next fall?
Teresa: Well I think you mention a good point – family members can be observant and then can share their concerns in a productive way with the staff of the nursing home. If they can be communicating with aides, it’s like, “Have you noticed a change in my loved one? Have you seen that they’re getting more weak?” or “When I visited this afternoon, it appeared to me they were having a significantly harder time getting up out of their chair. They’re having a difficult time going from sitting to standing.” So family members being aware of those types of things, and then frankly looking at what are the resources that the nursing home has in place to assist their family member, and are those readily available? If a resident needs a walker, the walker close by? Is it in good repair? So family members looking for those types of things.
And then because it’s something that I’m so involved in, I also think that some nursing homes have good safe resident handling and mobility programs where they frequently use lifts. They use mechanical lifts to help with transferring residents. So if a resident is having a difficult time getting from sit to stand, then family members would notice. Well then the caregiver comes in, the aides, the nurse comes in, and they’re bringing in a sit-to-stand lift and helping my loved one get up that way and transferred to the bathroom. So they’re aware that the resident needs the level of assistance.
So I would, as a family member, be looking at what type of assessment or screening is the nursing home doing? Are they doing it on a regular basis? So for instance, one of the tools I’m very familiar with – helped to develop it and validate it – is the bedside mobility assessment tool for nurses. It’s a screening tool and it can be done quickly, and it really gives a good idea of what is the resident’s current status. They may be doing better in the morning. They may be able to get up more easily and walking independently to the bathroom. But in the afternoon, they’re more fatigued, so let’s check them out. Let’s see. Has their physical status changed in any significant way? But now in the afternoon, yeah, I’m going to go get the assistance with the lift.
What is the BMAT Fall Assessment?
Schenk: Sorry, I was going to say can you us through a little bit of that BMAT process? What’s the analysis and how is it done? How long does it take?
Teresa: It doesn’t take long and one of the reasons I like it, especially in a long-term care and nursing home facility is when I talk about postural hypertension, going through a BMAT, it’s an assessment, it’s a screening, but it also allows for some of the fluid shift, some of the things that have to happen within the body for the person not to pass out.
So it just consists of four different assessment levels. The first one is can the resident sit in either their chair unsupported or on the bed unsupported? Can they cross the midline, for example, the right-hand crosses across to their left side? And can they shake your hand and maintain their seat of balance. So that’s the first assessment. If they can’t do that, I know that they don’t have enough balance, seated balance, postural stability that I’m not going to be asking them to get up and walk independently, nor am I going to try and drag them up with a gait belt. So that’s the first assessment.
The next one is they have to straighten out their leg and pump their ankle. That does a number of things. First of all, that sees do they have adequate ankle control so they’re not going to have a foot drop. If they get up to walk, are they going to trip because they can’t control what’s happening with their ankle? But the other thing that it does is by pumping or by flexing or pointing, moving their ankle, we’re helping our calf muscles’ venous return, helping to put some pressure on our large veins in our leg and that’s helping to get the blood shifting back up to help with that venous return. So that’s the second assessment.
The third is having them stand and they may decide if they’re really kind of weak, they’re inclined to stand with the sit-to-stand lift, or I have them stand at the edge of the bed or the edge of the chair. I just have them stand for a while. And again, are you feeling light-headed? Can you balance there? So I’m not just going to have them go from sitting to upright to now let’s try walking, and I’m surprised when they fall. So I just have them stand there for a period of time. How are they doing?
And then the last part of the assessment is they march in place or step in place, just little steps. Again, they’re shifting their weight, pre-walking, pre-ambulation, and then they step forward with one foot, bring that foot back, step forward with the other foot, bring that foot back, and that is the assessment.
So it’s quick, and if you notice a change in the resident during that, again, you stop and go, “Okay, they’re not doing this well with this like they did this morning, so I’m going to get the sit-to-stand lift, for instance.” Or it’s like, “I just want to do a quick transfer, so I’m going to get my sit-to-stand lift.” I’m a big fan of the sit-to-stand lift.
I also like for a resident who’s maybe been wheelchair-bound for quite a while, but just to get them upright and standing in a safe mode, well supported, it allows them to be upright again, allows for some of those fluid shifts, and frankly it can be comfortable. We’re designed to be in an upright position.
What other fall risk assessments are there?
Schenk: I’m sorry to interrupt you again, but what is, in your opinion, is the difference, positive or negative, of the BMAT versus any other fall risk assessment?
Smith: Like the FRAT, the fall risk assessment tool, or the Moore scale? The Moore fall scale?
Schenk: It seems like yours is quicker but more spot-on with what you’re looking for.
Teresa: Well it’s a different tool. So I absolutely agree in the hospital setting and frankly the nursing home setting, there should be more than just the BMAT. There needs to be a good fall risk assessment, and the nursing home setting, which frankly to me looks different than the hospital setting. And so I’m very familiar with the Moore, I’m familiar with a lot of the other fall risk assessment tools and I think that they’re good.
The difference with the BMAT is that it’s really intended to be a real-time apply to know. An aide comes in and notices a resident is sitting more slumped or saying they’re feeling more tired, well before I get them up to walk, when I walked in, they were doing that earlier, but we know that in a nursing home setting, just as in a hospital, that a patient or a resident’s status can fluctuate throughout the day. So it’s a way of just checking in with them and, again, allowing some of those fluid shifts, a little bit of stretching, a little bit of exercise before I get you up, and then based on what I’m seeing, I’m going to choose the appropriate safe resident handling or safe patient handling piece of equipment.
In the nursing home setting of health, there needs to be other regular assessments to see if their status’s changing, so there are other tools that are considered mobility tools, the timed up-and-go test, the four-step balance test, so there are a number of tests that I think need to be part of a comprehensive assessment.
The BMAT is that real-time, I’m noticing that there’s a change in your status, I want to use the appropriate piece of equipment so that I’m being neither too restrictive, but I’m absolutely not being unsafe and I’m not risking a fall. And again, by just doing this quick assessment, I can pretty easily tell that your status has changed and I need to be more conservative because your status has changed. It now puts you at greater risk of a fall. Let’s avoid the fall. Let’s be more conservative. Let’s get you to the bathroom on time and not keep you either bed-bound or chair-bound because I’m so concerned about falls.
What can the nursing home do to prevent falls?
Schenk: Sure. And let’s say we’ve established through the comprehensive care plan what the individual resident’s risk of fall is. And let’s say, for instance, this individual is a high risk for fall. What are some of the things in terms of execution of a fall prevention program that the nursing home can do, in terms of can they put down floor mats? Make sure that the rounding occurs often enough that they can go to the bathroom, that kind of thing? What are some of the things that the nursing home can do?
Teresa: So a good comprehensive fall prevention program, you mentioned a couple of things, that first of all, the acknowledgement, and I think if you talk to any staff in a nursing home long-term care facility, every single resident is at risk at fall. Some are at higher risk and some are at higher risk for having an injury related to a fall or a fall-related injury – they fall and there is going to be an injury. So I think acknowledging it’s something they need to have a comprehensive program that is standardized, that has processes and procedures in place, that they look at the difference between a newly admitted resident and what their needs might be. Some research shows that new admits are at increased risk of falling and they’re also at increased risk of having a fracture when they fall, so do they have a new admit program versus a resident who’s been well-established at the home? We’re going to kind of shift what our focus is going to be.
We might look at those types of residents now – how can be optimize exercise opportunities? Are there medications that are taking care? Looking at that – I’m also looking at in a comprehensive program, there’s good communication between the caregivers and the physicians, that they quickly communicate that yes, the resident’s status is changing – let’s look at what might the underlying issue with it so that staff are empowered, that they just don’t feel like, “Oh my gosh, I just can’t allow these residents to fall,” so that automatically leads them to, “Well let’s just keep them in their beds or keep them in a chair, and then I’m not going to be worried about that,” but how can we empower the aides working the nursing home to participate in – what can we do to both improve the quality of life, keep residents as active as possible, but also be aware that we do not want them falling.
So do they have some type of comprehensive regular assessment that they’re using to get a screening program, and then do they have the right equipment? So a number of nursing homes really are using safe resident handling equipment well. They’ve installed ceiling lifts over patients’, residents’ beds, tracking to the bathroom, tracking to the toilet, tracking to the shower, so that to me is part of a comprehensive mobilization program, but also there is definitely a focus on how can we reduce falls. How can we get our residents up both for comfort, even if they really are having to rely on their wheelchairs? So again, do we have the right equipment to allow that?
I’m going to say part of fall prevention programs also involve do we have optimal staffing levels? Do we have enough caregivers per the case mix of our residents to adequately care for them? So when we talk about doing regular rounding, what does that really look like? At some hospitals, part of their fall prevention program is they do schedule voiding programs, in other words, I’m going to get you up and take you to the bathroom. I’m not going to ask you, “Do you have to go to the bathroom?” I’m going to say, “Let’s get you up and take you to the bathroom now,” so we avoid some of that sense of urgency. We stay on top of the elimination needs. We allow residents to go to the bathroom when they need to and not when it’s like, “Oh, I’ve got to go quickly.” So that to me is part of a comprehensive program, and it’s that part of the rounding that we’re going to go around and make sure that every resident is adequately toileted on a schedule.
How can the family get involved in fall prevention at the nursing home?
Schenk: Right. And so how would a family member know what is involved in the fall prevention program? How would they even know this is what the nursing home is saying would be adequate to prevent the falls? Is there a piece of paper? Is there a document? Is there a meeting they can attend?
Teresa: I would say there should be, so you should sit down with the administrator, with the charge nurse, with staff, and that should be part of the question is what are you doing at your facility to prevent falls? So an awareness campaign. So if a family member knows going into it that falls are an issue both in the community for elderly and in our homes, but in nursing homes and in long-term care facilities, that what do you have in place? And do you have standard procedures and processes? And are they well-communicated? So I would like it if I went into a nursing home and said, “Do you have a fall prevention program? Can you show me an outline? Have you documented what that looks like?”
And I also think a real good place to get information is to say, “I’d like to talk to one of your aides. What is their training around fall prevention, because we know this is a big issue within long-term care, within nursing homes, within hospitals, so what does your program look like?”
I would be looking as I do a tour. I see you have a lift here or what is that piece of equipment? Well that’s a lift. It’s a sit-to-stand lift. Do you use that with all of your residents on a regular basis? Are you competent with using it? Again, you might have to have a list of questions ready to go, and I’d look for it. “Do you have ceiling lifts?” A number of homes, if I go in and see that they have a ceiling lift and that it’s well-placed and that it tracks into the bathroom, that tells me they’re going to be getting my loved one up, helping them to toilet, getting them back to bed and doing it in a very safe way. So they already have that awareness of how we mobilize and transfer a patient is important, and we want to do it safely, and we want to do it so we can avoid falls. That’s part of that. So I’d be looking at those types of things.
And have they reoptimized exercise opportunities, stretching opportunities? And I think some nursing homes make a good attempt at that. Some from my personal experience do a much better job or they really are looking at what are the types of exercises we need to do, for instance, to help decrease the risk of orthostatic hypertension, postural hypertension? How do we keep our residents as active as possible? And when it becomes apparent that we’re closer to end of life, how are you using exercise, stretches, your lift as part of comfort care?
Smith: Well excellent, Teresa. We really appreciate all this information.
Schenk: A breadth of knowledge there, yeah.
Smith: Yeah, I mean it’s unfortunate, and you’re very aware of this, I know, falls are just way too common. They’re preventable, not completely – never are they ever going to be completely preventable, but we can certainly cut down the number of falls that occur. But thank you for coming on. We really appreciated it. Rob, you got anything else?
Schenk: Actually Teresa, is there a good place to contact you if there’s an audience member out there that wants to follow up with you, maybe ask you some questions? What’s a good way to get a hold of you?
Teresa: Yes. They can call me – I believe you have my phone number, that’s 970-699-8218, or they’re welcome to email me, Teresa.Boynton@hill-rom.com.
Schenk: And we’ll have it up on the screen for the audience members who are actually viewing instead of listening on the website. But again, Teresa, thank you so much for being on the show. That’s a lot of great information and we’ll definitely need to – we’ll get you back on the show to go a little bit more in-depth in this stuff next time.
Teresa: Thank you, I appreciate it.
Smith: All right, thank you, Teresa. Have a great day.
Teresa: You too. Bye.
Schenk: Bye-bye. That’s a lot of good information.
Schenk: Look, I can see out of my periphery that Will has pulled something up on the Internet. It’s Burger Baby. Why are you looking up Burger Baby?
Smith: Because I’m starving and this may be where I go later today.
Schenk: To Burger Baby?
Smith: They’re supposed to be the best burger in Atlanta.
Schenk: Really? I’d never heard of it. I thought that was Googie Burger.
Smith: No, it’s the newest thing.
Schenk: The best burger in Atlanta as far as I’m concerned is from The One-Eared Stag. It’s not on the menu. It’s an off-menu burger, which I don’t like that kind of stuff – it’s hipster, but actually two of the best burgers I’ve ever had have been off-menu because the other one is at a restaurant called The Liberty and Social? The Social Liberty? It’s in the MGM Grand Casino in Las Vegas. It’s also off menu.
Smith: So here’s the thing about this one. It’s in a gas station.
Schenk: Of course it is. Why wouldn’t it be in a gas station?
Smith: So it’s super different.
Schenk: Is this where they yell at you?
Smith: No, I don’t think it’s like the Soup Nazi thing.
Schenk: But it’s new though?
Smith: Yeah, I just started paying attention to it. People have been talking about it. It’s the hottest new thing, like Stephon says on Saturday Night Live. All right.
Schenk: Well hopefully we’ll get done with this podcast in time for you to go enjoy some lunch. But anyways, that concludes this episode of the podcast. I can hear Will’s stomach grumbling from here. I can also hear him breathing very loud through this episode. I think he might have a cold. But anyways, this concludes this episode of the Nursing Home Abuse Podcast. You can watch or listen to this podcast via Stitcher, Spotify, iTunes or wherever you get your podcast from, or you can watch it on our YouTube channel, or on our website, which is NursingHomeAbusePodcast.com. And with that, we will see you next time.
Thanks for tuning into the Nursing Home Abuse Podcast. Nothing said on this podcast, either by the hosts or the guest, should be construed as legal advice, nor is intended to create an attorney-client relationship between the hosts or their guests and the listeners. New episodes are available every Monday on Spotify, iTunes, Stitcher or on your favorite podcast app as well as on YouTube and our website, NursingHomeAbusePodcast.com. Again, that’s NursingHomeAbusePodcast.com. See you next time.