Interventions for fall risk prevention in nursing homes
According to recent studies, an elderly person will be treated for injuries from a fall every 13 seconds. An elderly person will die from injuries sustained from a fall every 20 minutes. The statistics for seniors living in nursing homes is even higher. These numbers tell us that interventions to prevent falls are paramount in skilled nursing facilities. In this week’s episode, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Dr. Pat Quigley to discuss common interventions for the reduction of nursing home falls.
Schenk: Hello out there and welcome back to this episode of the Nursing Home Abuse Podcast. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: Glad to have you. This Sunday, September 22 is Fall Prevention Awareness Day, so we wanted to have an episode dedicated to preventing falls in the long-term care setting, and we don’t do that by ourselves. We have a guest, Dr. Pat Quigley, to talk about that.
Smith: And Dr. Quigley has a very impressive resume. She is – this is what she does. When it comes to fall assessments, fall risk assessments and fall preventions, she is the go-to expert on this. She is the associate director of Vision Eight Patient Safety Center of Inquiry at the James A. Haley Veteran’s Hospital in Tampa, Florida. She’s both a clinical nurse specialist and a nurse practitioner in rehabilitation. As associate chief of nursing for research, she was a funded researcher with the Research Center of Excellence, and her contributions to patient safety, nursing and rehabilitation are evident at a national level with emphasis on clinical practice and innovations designed to promote elders’ independence and safety – independence and safety in the context of reducing falls but still being able to live their lives. And she’s nationally known for her program’s research in patient safety, particularly in fall prevention. The Falls Program research agenda continues to drive research efforts across health services and rehabilitation researchers.
Schenk: Dr. Pat, welcome to the show.
Pat: Well thank you so much.
Schenk: All right. Well Will and I are very pleased you can make it on for this topic. I know that in our general practice, injuries resulting from falls constitute a high proportion of the cases that we have, so being able to have an episode dedicated to talking to interventions for fall risk and fall prevention is very important to us, so we’re glad to have you on.
But just from a general standpoint, from the standpoint of a nursing home resident versus just an average senior citizen that is not in a long-term care, what are some of the common factors that would place a nursing home resident at risk for falls just to begin with?
What are common fall risk factors in nursing home residents?
Pat: Well you know I’m just so delighted, Will and Rob, that you’ve taken on this topic as a priority for a conversation because, you know, this is so my world because as a nurse in my work, I’m doing all I can to reduce preventable falls and injuries from falls. And long-term care facilities, residents of long-term care are such a special population for me because they’re so vulnerable. So when you think about the patient population, just by virtue of entering into a long-term care, these are people who have all kinds of different medical diseases and medications on board and frailty and functional limitations. Coming in for long-term care or maybe chronic care is just by virtue of the chronic state that they’re in or maybe the acute care stay in a hospital that resulted in long-term care, they’re more at risk for falling.
Sometimes patients who have come into long-term care become residents, these are individuals who have already been falling. They’ve already experienced repeat falls and I think it’s so important from the big picture to be able to help everyone to appreciate who’s listening today that unintentional injuries are estimated to be the fifth-leading cause of death among older people, and falls account for like two-thirds of those deaths. And in long-term care, we have people that are really frail and old. You’ve got a population of individuals living in over the age of 85, and you know, falls is the leading cause of unintentional injury death in people over the age of 85.
What is the rate of falls in nursing homes compared to general public?
So in long-term care in nursing homes, the rates are like twice as high as they are even in the community. People are falling more than once in a year. So when you think about people who are repeat fallers, they’re so at risk for injuries. I’m so glad you’re targeting injuries.
So part of what happens is after these falls, there’s less survival and there’s a financial burden associated with it and the others – even some trends now that there’s spinal cord injuries happening in older people because of falls. So I think it’s important for anyone who’s listening and for family members to realize that the joint commission has had a goal of patient safety for fall prevention for long-term care since at least 2015, that we need to find out which residents are more likely to fall and take some actions.
Medical diagnosis can be a fall risk factor in nursing home residents
So it’s really important that you did ask about the fall risk factors. It’s really complex. It’s not simple. When you think about how we, every one of us, grow old gracefully each day, there are things that happen in our bodies. Our bodies change, but there are also diseases that we have. So when you think of risk factors, certainly muscle weakness, gait deficits, problems with vision, changes in cognition, functional impairment, and then there are other changes that occur with other risk factors that start getting more complex. Blood pressures dropping and people have orthostatic hypertension, urinary incontinence is a huge problem in long-term care residents. The medications that they’re taking, medications to help them maybe even to adjust to long-term care – it’s a whole new setting. And there’s depression that goes on, maybe they’re anxious. So some of the medications that treat behaviors and depression, anxiety are risk factors for falling.
And you know there’s even some of the disease states that patients have. Patients who maybe have Parkinson’s disease or Parkinson’s-like symptoms or they have a shuffling gait, that increases their risk for falls. So it is so complex, Will and Rob, when you think about all the risk factors that a person can present with.
And then on top of that, there’s the risk factor associated with injury. So you have residents in long-term care who maybe have already had a fracture, so they’ve got a history of fall-related injuries already, they’ve got osteoporosis, maybe they’re anti-coagulated. So there’s just a host of fall-risk factors that people live with that are also injury risk factors that make them even more vulnerable.
Smith: Yeah, and what are fall risk assessments and how do they flesh out these different factors? And how are they performed?
How do nursing homes assess a resident’s specific risk for falls?
Pat: Well that’s such a great follow-up question because as I mentioned in terms of the joint commission’s goal, we want to be able to identify what are those risk factors and get them treated, and which residents are more at risk than others? So to everyone who’s listening today, your loved one has to get screened before they get accepted into a long-term care facility. So part of that screening for admission includes all the risk assessments to begin with. They’re going to start looking at medications that can contribute to fall risk, issues maybe surrounding vision, low vision problem, maybe depth perception problems that an older resident, older person has. They’ll start looking at muscle weakness, incontinence. They even will start reading for prior hip fractures. They will know whether or not whether your loved one was admitted because of a fall, maybe they got admitted to a hospital because of a fall that resulted in a hip fracture and now they’re coming in the nursing home. So you can rest assured that before someone even gets admitted into long-term care that they have been screened for fall risk factors.
You know what – everyone who comes into long-term care is at high fall risk, so we don’t even have to talk about that anymore. We’re always trying to get at what their risk factors are. So when an individual gets admitted into long-term care, there is some data that is collected that’s required by CMS, and part of that is the fall risk factor, the indicator that I just mentioned to you. But there’s also the screening scale that the clinical staff will use and nursing home registered nurses and licensed practical nurses who are helping with the admissions process. So they’ll start asking about fall history. They’ll start looking at the actual medications that make someone at risk for a fall. They’ll look for trouble or difficulties being able to transfer, to stand up, to be able to walk, cognitive status, their mental status.
All nursing home residents are at some risk of falling
So there are different tools that are out there to be able to start that screening process, but the entire intent is to get to the actual fall risk factors because it’s more than a score that indicates someone is high fall risk. Everybody is high fall risk to be admitted into long-term care, so we don’t even have to talk about that. What we want to talk about are fall risk factors.
And then there are individuals, of course, who get admitted for rehabilitation, maybe some acute rehabilitation or some a bit more intense rehabilitation in long-term care, and those residents will also get evaluated by physical therapy, occupational therapy, and those evaluations, each of those therapists will do a more in-depth evaluation of someone’s fall risk. So physical therapists will maybe look to see, they will assess someone’s strength, their muscle strength in their legs, their arms, their hands, their reflexes. They’ll look at range of motion, if someone has any pain. They’ll do a balance assessment and gait assessment. I just want you to hear how comprehensive this is. In occupational therapy, they will evaluate someone’s perceptions of their activities of daily living, how well can they perform their bathing, their dressing, how well they can feed themselves, even some of the transfers to and from the bathroom, all the things that they will do in their upper extremities in terms of being able to manage their own personal needs and activities of daily living.
They also get into cognition, some of the issues surrounding cognitive impairment. So it’s very complex, the evaluations that are done by the rest of the interdisciplinary team.
If you happen to have a resident who has problems with their speech or slurring, maybe being able to combine different kinds of skillsets to be able to dress themselves. They may even need some speech therapy. So all together, working with the entire team, nurses, therapists, will complete a comprehensive fall risk assessment. And that fall risk assessment will result into a care plan. But I just want you to hear how complex this can be.
Most nursing home residents have multiple fall risk factors
What’s also really unique to the long-term care resident population is people don’t come into long-term care with only one fall risk factor. So it’s really important to appreciate that it’s very complex and there’s a lot of fall risk factors, so I think it’s really important for everyone listening that if your loved ones who have family members in long-term care is to know what those fall risk factors, to learn about them and be part of the process to helping implement these plans of care to help reduce these fall risk factors, because that’s what it’s about.
Schenk: Yeah, I like that you said that.
Pat: Yeah, you have to be able to mitigate and eliminate these risk factors.
Schenk: Yeah, and it’s refreshing you said that, like if a medical doctor signed off on you going to a nursing home, you are automatically a fall risk, because as you know, that doesn’t happen in every nursing home. It doesn’t happen in every nursing home assessment. Sometimes people that should be marcotted as a fall risk are not.
Smith: I’ve always thought it was incredibly absurd and just risky from a business standpoint to have somebody who’s listed as a low fall risk. Like why even take that chance? Just everybody’s a high fall risk.
Generalized fall risk assessments may not be the best method for preventing falls
Pat: That is such a good point and that happens in hospitals as well because this overreliance on screening tools to identify the likelihood of someone falling again, so I can tell you all the national directives in today’s world, actually probably since 2015, is to go away from the screening scales that just reduce someone to a category of a low, moderate or high, or a score, but to identify what the actual fall risk factors are for that one person. Because my fall risk factors can be different from yours, Will, can be different than yours, Rob, but we all three could be high fall risks. So it’s important when getting into individualized care planning is to know what someone’s fall risk factors are and how can we align interventions to be able to reduce those risk factors? Because when you reduce the risks, you improve function and gait and balance and the likelihood of someone not falling.
Smith: And that’s what we wanted to move into is once you do that, how does a care plan change, because at the end of the day, that’s kind of what the goal is, is setting up a care plan?
Pat: Actually the goal is to mitigate and to eliminate the risk or to reduce the complications that are associated with someone’s disease state when they come in, to increase their function. That’s part of what rehabilitation is. There are some cases where maybe their prognosis and function might be limited because you still want to prevent complications from occurring. So for example, someone who comes in with a stroke, they maybe had a stroke on the right side of their brain and the left side of their body is weak, well that kind of a patient, what we’re going to do is we’re going to make sure that patient, we already know has problems with mobility, is going to have trouble with transfers. So we’re going to make sure with someone like that, that they’re going to have a safe exit site set up in their room where that patient or resident, excuse me, is always getting out of bed towards the right side, never towards the side that is weak, that that resident is always instructed with all the steps we’re going to do before we get started because that person has trouble with safety awareness.
Most falls in nursing homes occur in the bedroom or bathroom
So everything we’re going to do is setting up, number one, a safe environment. Most of the falls that happen in long-term care are happening in the bedroom or happening in the bathroom. People are trying to get up out of bed when it happens, they’re trying to get back into bed when it happens, they’re trying to get to the bathroom, or as I mentioned, they’re falling in their bathroom. So the first thing we want to do is to set up a safe environment, to make sure that room is individualized for the safe transfer and mobility of the resident.
Now oftentimes in long-term care, we’re doing all that we can to make that environment as home-like as possible, but safety has to trump making it home-like. So if you have someone who needs to have their left side of the bed against the wall, we’ve got to do that. We’ve got to make sure they only get out of bed on the right side. So setting up a safe environment, looking at their clothing, making sure they’re wearing their shoes – if you have people who have trouble being able to feel their feet, they’ve got to wear their shoes and have proper shoes on. Creating that safe environment, making sure that their clothing is properly fitting, the pantlegs aren’t too long, their shoes are properly fitting. Those are all things the nurses are going to start doing, creating that safe environment, getting a toileting schedule going because get up to go to the bathroom without us. No one wants to have an accident. So hardwiring a toileting schedule is really important.
Exercise is critical in reducing the risk of falls in nursing home residents
Once a therapist has gotten involved and we start getting them into an exercise program, I can tell you, Will and Rob, that exercise is a leading intervention to help someone maintain their function, be able to maybe increase their strength and their balance, which we all want, because no one loses anything as fast as when they’re immobile or not active as they lose their strength. So the leading intervention is to get people into exercise programs. So we’re going to follow that exercise program and work with physical therapy, occupational therapy. Everybody’s going to work together to improve our residents, each and every residents’ functions.
And if there is a resident who is maybe not enrolled in physical therapy and occupational therapy, we’re going to make sure that resident is enrolled in restorative care. Everybody gets restorative care, even people active, making sure that if they’ve been cleared with their mobility aid and they can walk with their two-wheeled walker that they have it within reach and they can get up and they can go walking.
Then we still want to do that assessment because you can have residents coming into long-term care and have medications that are being modified. So we have some medications that are being modified because maybe their blood pressure is a little too high and we want to get that blood pressure down, and they can have some side effects with those medications, maybe some postural hypertension, which is when the blood pressure drops when people get up and start walking.
Changes in condition or medication could have an affect on fall risk
So we always want to make sure the nursing staff is assessing the patient for any changes in medications, any side effects, any kinds of complications that are going on, maybe even someone having some increased delirium. It can be a sign of more confusion, maybe some problems with not having enough fluid, enough nutrition, even cause issues surrounding low blood sugar or that urinary tract infection. So we’re always doing that assessment, but indeed, the care plan intervention should be aligned with the risk factors.
So the care plan gets started right away when people come in for their first interdisciplinary assessment that they do with the resident and the family. The resident is always included. The family is always included. And having that initial care plan to go over what did we find and what are we going to do to work together to help keep you safe while you’re in the long-term care facility with us.
Schenk: Yeah, and that’s…
Pat: Go ahead.
Schenk: No, you’re good. I was going to say, it’s interesting that we’ve had other guests on at previous points talking about different components of fall prevention, and I feel like the overarching theme is just as you said it, that physical therapy and the ability to move and get strong is, if not the number one, one of the most important factors in preventing falls, making sure that people can have mobility and can get their strength. That’s an overarching theme.
Pat: Absolutely. That’s the leading exercise. It’s for everyone. If you were to have just one single intervention, it would be exercise. And then of course with the long-term care residents, making sure that they can see, so vision is really important. I don’t know if we mentioned that already, but certainly, if they’ve got impaired vision, everyone’s got to make sure they have their glasses. And if they haven’t had a recent eye exam, someone should get that done so they can have proper vision. So it’s a different environment, getting that incontinence treated because 25 percent of the falls that happen in long-term care are linked to trying to get to the bathroom, residents trying to get to the bathroom, because as I mentioned, no one wants to have an accident. So I think that that’s one of the most important things for residents working together as a team with the family is making sure people get toileted properly.
So physicians would say after exercising at number one is certainly medication reviews are number two. We don’t always have a physician in long-term care. They will come and they always supervise care, but there’s a nurse practitioner there. And nurse practitioners are reviewing those medications, looking at maybe some psychotropic meds to deal with some of the anxiety, that those can be changed or modified, the anxiety medication, the depression medications, to see what changes we can make to medications.
Schenk: You said it.
Smith: And what are some of the – what are the common interventions that they’re using now? Are there still these pressure pads, the alarms?
Schenk: Yeah, what’s in your experience – where are they moving in terms – aside from physical therapy, aside from what you’ve mentioned, like actual devices for fall prevention?
What are some devices that help reduce falls in nursing homes?
Pat: Well thank you for asking about that. That is part of the toolkit. It’s helping to keep people safe. The beds are usually kept in a low bed position. That’s something that sometimes needs to be reconsidered because a low bed position is really only designed to reduce trauma when a patient falls from bed. So bed heights have to still be individualized. So is someone is going to need to be helped to stand up or transferred, they’re 6 foot, 4 inches tall, someone has to raise the height of that bed up to the proper height for someone to be assisted to stand or transferred, and that’s very different for someone who’s 5-foot-2. So height adjusting furniture, whether it’s the bed, the bedside commode or putting a bedside commode over the toilet is important.
Then there’s other technology that you’re starting to mention that helps to alert the nursing staff if a patient’s starting to get up. So bed alarms have for the most part been reconsidered and they’re used in long-term care because it’s now considered a restraint. I think it’s in 2013 that CMS determined that bed alarms were a restraint. So if the bed alarm is being used solely as an only intervention for preventing someone from getting up and falling, then there would need to be an order for that. So there is an assessment that gets completed by the nursing staff when a patient, when a resident gets admitted to determine the need for whether it’s bedrails or bed alarm. But you know, it’s part of the toolkit. If you have someone who is really impulsive and is very, very agitated, then that’s something that should be in place. But there are different ways to being able to use an alarm. It doesn’t have to necessarily sound. You can have an alarm that is linked to the call light system. So there’s different technology that can be used.
There’s also the seated pressure pad that can be on a chair. So there’s different levels of sensitivity for the alarm, whether it’s a chair alarm or a bed alarm. So it can be set at a level of sensitivity where it starts to make noise or sets off an alarm just when someone’s moving, or it can be set to a lower level of sensitivity where the alarm doesn’t go off until somebody has exited the bed or the chair, which doesn’t quite frankly help because someone has already fallen by the time you get there. And that’s one of the major issues is alarms is by the time someone gets there, someone’s also fallen down.
So there are other ways to be able to keep eyes on patients. There’s new technology that’s telecentre technology, virtual technology to keep eyes on patients in long-term care where you don’t have the alarms, you don’t have to have sitters, you can have someone watching in a distance with a camera. They can still say, “Pat, wait a second. I see you’re starting to get up. I have a nurse on the way. Staff’s on the way.” So there’s other technology that’s out there to help someone not fall.
But I love other strategies too. There are different kinds of mattresses. Not everyone needs to be the same kind of a mattress. You can get a concave mattress where you have a lift that comes up the side of the mattress that helps the older person to know that this is the edge of the bed. Or I love long body pillows to put on the sides of the beds to help people, and they’re very comfortable for residents to help the resident know that this is the edge of the bed. And then of course you can check on people more frequently because some residents need to be checked on more frequently than others.
Schenk: Yeah, I mean that makes a lot of sense. In terms of the body pillows and the curved mattresses, I feel like there is an aspect of the nursing home itself that’s got to consider preventing the falls versus it being a form of restraint. So that’s probably an issue and a line you have to walk.
How do falls occur in wheelchairs?
Pat: Absolutely. Yes. It’s the same thing with wheelchairs. Not every resident should be in the same wheelchair. Usually you have these depot wheelchairs and everybody’s in that kind of a wheelchair, but if you have someone who’s really, really tall like I mentioned my 6-foot-4 person and has trouble being able to keep themselves vertical, they have trouble with sitting balance and doing a lot of leaning, just propping them up on pillows isn’t going to be enough because we haven’t talked about falls from wheelchairs, but the incidents and prevalence of falls from wheelchairs is not known. We know, again, because it’s recorded now, if someone’s had more than one fall in the last 90 days and they’re going to go ahead and count the number of falls, so there are more reliable data on falls in the nursing home and where people are falling but not so much from wheelchairs. So even the family members really need to help with this as well is we all want to keep someone, if they’re in a wheelchair, in that wheelchair and keep them safe because falls from wheelchairs are terrible. People fall and they hit their head and maybe the wheelchair falls with them. So it’s not just falls from walking or getting out of a bed. It’s also falls from chairs and especially wheelchairs because of how they’re positioned and seated in them.
Schenk: Well Pat, this has been a whirlwind of an episode. These 30 minutes have flown by.
Pat: Well you’re so kind. I just have a couple more comments if you wouldn’t mind.
Schenk: Sure, yeah. Go ahead.
Pat: Because my world is protecting people from injuries when they fall because people are going to fall and they’re going to get up. You can’t prevent all falls. And I do believe in long-term care, there’s so much great work that’s going on to keep residents safe. But you know, what we want to do is to protect people from these serious injuries because injuries result in loss of function and loss of life. So older people don’t even have to have a head strike to have late onset subdural with bleeding in the head, but just sometimes the velocity from the fall, even from a low bed position, can result in microtears around the head and they can bleed.
So my world of research is helping to implement floormats on the bedside to reduce trauma from when someone falls. So floormats work. Floormats work. Floormats work. You can use floormats instead of chairs. That science has been published, and we use hip protectors. So my legacy is in the department of Veterans Affairs, and our goal was to make sure that we protect our veterans who’ve won the battle for us to be free by not breaking a hip, because hip fractures are grave. There’s current research where 37 percent of older residents who fall and break hips in long-term care die within six months.
Smith: Oh wow.
Pat: They become totally dependent in activities for daily living. So I want family members on the call. I want nursing home administrators and staff to go after using hip protectors on people with osteoporosis or hip fracture and get those floormats on the bedside because we can’t replace all the floors but we can protect people when they fall from the amount of trauma.
Pat: And that’s what floormats do.
Pat: So thank you for just a couple more minutes to go after protecting people from injuries because that’s what it’s about. We’re saving lives.
Schenk: No, that’s fantastic, Pat, all the work that you do. We really appreciate you coming on the show and sharing that knowledge with us and our audience.
Pat: Totally my pleasure. Absolutely. Thank you so much for inviting me.
Schenk: Thank you.
Smith: All right, thank you.
Schenk: That was in fact a whirlwind.
Smith: Yeah. She is very…
Smith: It’s always interesting to talk to somebody that, like she said, that’s her bread and butter. That’s her whole life. This is the research that she does. She has dedicated her entire academic, professional and clinical career to this subject, which is extremely important because as she said, the vast majority of senior citizens are being injured through falls. It is an enormous problem as we get older. Gravity becomes less and less of a friend.
Schenk: That’s right. And again, just to point out, we talked about this in the top of the episode, but Sunday is Fall Prevention Awareness Day, and in honor of Fall Prevention Awareness Day, not only do we dedicate this episode of the Nursing Home Abuse Podcast to fall prevention, but when we return in two weeks, which will be September 30th, we will also have another episode dedicated to preventing nursing home falls. We’ll have Dr. Mindy Renfro on the episode. But that’s again, in honor of September 22nd being Fall Prevention Awareness Day.
And I guess that’s going to conclude this particular episode of the Nursing Home Abuse Podcast. You can consume each and every episode, or new episodes, every other week on Stitcher, iTunes, wherever you get your podcast from.
Smith: You can go to YouTube, and if you do, make sure you click subscribe and like. You can go to our website, NursingHomeAbusePodcast.com.
Schenk: And check us out there. And with that, we will see you next time.
Smith: See you next time.