The purpose of this bulletin is to provide a refresher and update regarding available tools and resources to assist health care providers assess and implement interventions for individuals who have a recent history of falls and/or who are at risk of falls. Information on falls was part of statewide nursing home provider training sessions conducted by the Centers for Medicare and Medicaid (CMS), in December 1999, in Minnesota. This information bulletin is an update of the 1999 CMS falls training and is intended to enhance programs already in place.

This bulletin integrates key information about falls into one document. It includes:

Background
Clinical Practice Guidelines
Assessment
Planning
Intervention
Evaluation
Examples of Deficiencies
Resources/Web Site Links

I. Background:

Falls are among the most common and serious problems facing elderly persons. Falling is associated with considerable mortality, morbidity, reduced functioning and premature nursing home admissions from the community. Incidence rates of falls in nursing homes and hospitals are almost three times the rates for community-dwelling persons over the age of 65, (1.5 falls per bed annually). A key concern is not simply the high incidence of falls in older persons, but rather the combination of high incidence and a high susceptibility to injury.

A number of controlled studies have revealed that detecting a history of falls and performing a fall-related assessment are likely to reduce future probability of falls when coupled with interventions. (Guideline for Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel on Falls Prevention, May 2001).

As stated by Dr. George F. Fuller, in Falls in the Elderly, April 1, 2000 issue of American Academy of Family Physicians:

"Elderly patients who have fallen should undergo a thorough evaluation. Determining and treating the underlying cause of a fall can return patients to baseline function and reduce the risk of recurrent falls. These measures can have a substantial impact on the morbidity and mortality of falls. The resultant gains in quality of life for patients and their caregivers are significant."

II. Assessment

The research, which spearheaded the nursing home reform of OBRA 87, identified that individualized assessment and individualized plan of care were key to quality care.

No assessment checklist can be all-inclusive. Does your staff have the tools to guide them to look for causes of the fall and possible interventions? Remember, the assessment is to be individualized; one size does not fit all.
Does your assessment process include gathering all data, review of the data and then analysis?

Areas for consideration when completing assessments:
Are your assessments truly individualized, or do they all look the same?
How do you gather information for your assessments?
Are you including direct care staff? When staff is involved in an individual's ongoing assessment and have input into the determination and development of an individual's care plan, the commitment to and the understanding of the care plan is enhanced.
Data gathered should be analyzed as part of the assessment process and should be analyzed timely to prevent similar incidents from reoccurring.
Define the scope, frequency, causes and complications of falls. What was the person trying to attempt at the time of the fall? Identify the causes of falling for each occurrence and for recurrent falling. Recurrent falls often have readily identifiable underlying causes. There may be multiple causes for each individual's falls.

Risk Factors, to include, but not limited to:
Does the individual have a recent history of falls?
It may seem obvious, but a previous history of falls is a strong predictor of future falls.
Behavior
Equipment and devices
History of fracture(s)
Environment
Medication side effects
Medical status

Is your assessment complete and accurate?
Blank areas in the assessment form do not allow for complete and accurate data.
Is your documentation clear?
When reassessing after a fall are you comparing whether the care plan was implemented correctly?
Are you reviewing information from other pertinent sources such as staff present at the time of the fall, recent therapy referrals, social service notes, physician/nurse practitioner progress notes?
Are you gathering all data from the assessment, reviewing and analyzing the data?

III. Planning

Is the team developing interventions based on cause(s) derived from the individualized assessment?

Is the team choosing interventions that correlate with the possible cause of the falls?
Does your medical record include the history of ineffective previous interventions and interventions ruled out?
Did the team determine why previous interventions were ineffective?

IV. Intervention

How are you communicating new care plan interventions following the assessment?

Is all involved staff made aware of new interventions?
Is staff told orally only, or are necessary assignment sheets updated?
Are you taking action immediately or waiting until the fall can be reassessed and reviewed by the falls committee at a later time?
Are the interventions preventing falls or minimizing risk of falls when they occur?

V. Evaluation

Are the interventions implemented as planned? Are interventions on the care plan effective and accurate?

Is licensed staff providing adequate supervision?
Is there enough equipment, such as alarms and mats? Are they applied properly?
Are falls influenced by staffing patterns?
Is all staff committed to reducing falls?
Is documentation understandable?
Is documentation voluminous; does documentation diminish effective communication among staff?
Is documentation repetitive and contradictory?
Look at your process with a critical eye. Is your system to breaking down?

VI. Examples of Deficiencies

Some findings, which may lead to deficiency citations, including but not, limited to:

An individual was admitted with diagnoses of fractured femur, osteoporosis and Parkinson's. The individual fell 21 times in a three-year period. Five falls in the past eight months resulted in multiple head injuries and bruises from falling out of the wheelchair. The care plan listed the dates of the falls sustained. The interventions included an alarm in the wheelchair and bed, blue mat on the floor beside the bed, low bed and to not leave unattended in the locked wheelchair. Staff interview verified that the alarm on the wheelchair was not effective and during a recent fall the wheelchair alarm did not activate until the individual was on the floor. The care plan had not been updated nor had other measures been instituted for the safety of the individual. The individual had not been identified at risk for falls and was not reassessed despite repeated falls. A current nursing note stated, "falls continue, care plan continues to be appropriate."
An individual's medical record lacked documentation that hypertensive medications were assessed in relationship to frequent falls. The individual had fallen 13 times in three months. A review of the individual's record established that the individual received two antihypertensive drugs. The individual's blood pressure was noted to be routinely low measuring for example, 96/58, 88/56 and 90/58. After one fall, the individual's blood pressure was documented as 70/46. There is no documentation that the individual's orthostatic blood pressures have been obtained and assessed.
A safety assessment was completed on an individual shortly after admission. The individual was not identified with a history of falls and no preventive measures were implemented despite documentation of a fall within the past 30 days and a fracture in the past 180 days. The individual had diagnoses that included orthopedic aftercare, cerebrovascular accident and a right femoral neck fracture. The record identified the individual as requiring extensive assist with one person for bed mobility, transfers, toilet use and locomotion on and off the unit. The individual fell three months after the readmission and sustained a fracture. The individual had not been identified at risk for falls and there were no fall assessments despite three recorded falls prior to the fracture and two afterwards.
An individual was observed in their room seated in a recliner. The individual attempted to get out of the recliner and set off the personal alarm, which was attached to the individual. The personal alarm sounded for four minutes before a staff member responded and arrived at the individual's room. A review of the individual's record indicated the person was at risk of falls due to dementia, seizures, weakness, a general decline in condition and lack of awareness of safety issues. Twice in the previous three weeks the individual fell from their wheelchair and was found on the floor with the alarm sounding. The falls committee reviewed the individual's fall six days after the first fall and noted since the fall occurred while attempting to go to the bathroom, that a commode chair was to be placed next to the individual whether the individual was in bed or recliner chair. The individual was observed two weeks after the falls committee review, and the commode chair was not next to the individual while seated in the recliner. The commode chair was located across the room next to the clothes closet.

VII. Clinical Practice Guidelines

1. The National Guideline Clearinghouse (NGC), is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans. Use the Search NGC feature. Type in "falls" and Click the Submit button. Website: http://www.guideline.gov/index.asp [expired link]

2. This bulletin includes excerpts from Falls and Falls Risk, Clinical Practice Guidelines, 1998, developed under a joint project conducted by the American Medical Directors Association (AMDA) and the American Health Care Association (AHCA). This guideline can be ordered from: http://www.amda.com/info/cpg/falls.htm [expired link]

Three excerpts from the guideline can also be downloaded at this web site. (Click on the appropriate title.)

Table 5: Examples of Facility Programs or Policies and Procedures to Try to Reduce Falls and Consequences Related to Falls [expired link]
Figure 1: Checklist for Assessing Fall Risk and Post-fall Review [expired link]

VIII. Resources/Web Site Links

Falls and Falls Risk, Clinical Practice Guidelines, 1998. American Medical Directors Association (AMDA) and the American Health Care Association (AHCA). Fee is $8.00 Web site: http://www.amda.com/info/cpg/falls.htm [expired link]

The National Guideline Clearinghouse (NSG), is a public resource for evidence-based clinical practice guidelines. NCG is sponsored by the Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans. Use the Search NGC feature. Type in "falls" and Click the Submit button. Web site: http://www.guideline.gov/index.asp [expired link]

Long-term Care Nursing Leadership and Management Website, University of Minnesota School of Nursing. This website provides a variety of resources and on-line continuing education courses designed specifically for long term-care nurses. Web site: http://ltcnurseleader.umn.edu/index.html [expired link]

University of Iowa Gerontological Nursing Interventions Research Center, resources are available for a small fee to cover the cost of copying. Examples of pertinent resources include: • Prevention of Falls • Acute Confusion/Delirium • Alzheimers Disease and Chronic Dementing Illnesses, • Exercise Promotion Web site: http://www.nursing.uiowa.edu/gnirc/rddc_protocol.htm [expired link]

Falls in the Elderly, American Family Physician, April 1, 2000. Thirteen page article by George F. Fuller, explains risk factors, interventions and evaluations of falls. Web site: Falls in the Elderly, American Family Physician

Cochrane Reviews, provide systematic reviews of the literature to evaluate the evidence on hundreds of clinical issues. Web site: http://www.update-software.com/cochrane/abstract.htm [expired link] Type in "falls" in the Search For window, and then Click on Search.

Cochrane Review, summarizing falls, lists interventions likely to be beneficial/non-beneficial. Web site: http://www.update-software.com/abstracts/ab000340.htm [expired link]

If you have any questions regarding this Information Bulletin, please contact in writing:

Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
85 East Seventh Place, Suite 300
PO Box 64900
St. Paul, Minnesota 55164-0900
Telephone: (651) 201-4101

CM 4-27-2006