Fall Prevention in Long-term Care: Practical Advice to Improve Care

Mara Ferris, MS, RN, GCNS-BC, CPHQ, FASCP

Disclosures

Topics in Advanced Practice Nursing eJournal. 2008;8(3) 

In This Article

Fall Prevention

Risk Assessment

The first step to preventing a fall is to determine the risk. Although there are many fall risk assessment tools in the literature, no single tool is valid in all practice settings and most are not well validated.[2,4,5] Nevertheless, the logic of identifying elders at risk for falls is undeniable because many risk factors are well documented. An assessment should be completed so that risk factors can be minimized, if not eliminated. Selecting the most appropriate tool for nursing home residents should be based on 2 criteria: The tool should address the most common risk factors, and it should be simple and practical to use.

The Minimum Data Set (MDS) is an interdisciplinary assessment tool required by federal regulations for use in nursing homes. The MDS identifies some of the risk factors for falls, including a history of falls, dizziness, wandering, restraint use, and use of drugs in high-risk classes. As its name implies, the MDS is not a comprehensive assessment tool, and yet it is too lengthy for quick fall risk assessments. So in addition to the MDS, many nursing homes use 1-page tools that are commercially available, posted on the Internet,[6,7] or that have been created within the facility. At a minimum, any quick tool should include the following:

  1. A history of falls;

  2. Cognition, including fluctuating mental status;

  3. Impulsivity;

  4. Vision;

  5. Ambulation;

  6. Continence;

  7. Use of high-risk medications (eg, antihypertensives, diuretics, and hypoglycemics);

  8. Use of assistive devices for transfer or ambulation;

  9. Attached equipment (eg, catheters, intravenous lines, and oxygen); and

  10. Familiarity with the environment.

Considering these 10 risk factors, Ms. P is clearly at high risk for falls.

For residents with a history of falls, it is helpful to determine the circumstances of previous falls, although this information may not be available. In Ms. P's case, her daughters may be able to provide some information about previous falls even if the falls were unwitnessed -- where, when, and how she fell. Despite her cognitive deficits, Ms. P may provide more information than might be expected if she is asked directly. Are there common characteristics to the falls? For example, have the falls happened when she was using the bathroom, at the same time of day, when her blood sugars were low, or when she was wearing her high heels or not wearing her glasses?

When Ms. P arrives at the nursing home, she is pleasant and cooperative, and she is introduced to her new room and roommate, Ms. L. She eats lunch in the main dining room with Ms. L and seems to be quietly "settling in." About 4:30 pm, the roommate goes to an activity that Ms. P chooses not to attend. A few minutes later, a staff member finds Ms. P sitting on the bathroom floor in a puddle of urine.

Fall Prevention Planning

Any plan to prevent falls for elderly residents of extended care facilities is a precarious balancing act. Two conflicting goals must be met: promoting the greatest level of independence and mobility while simultaneously preventing falls and injuries. Although Ms. P's risk for falls may have been anticipated, designing an individualized care plan within the first days of admission to long-term care to prevent falls is very difficult. Even so, in Ms. P's case there is some information that, if gathered in the first few hours of admission, might have prevented this fall. For example:

  • Were her blood sugars stable during the hospitalization?

  • When and what was the last hypoglycemic medication administered?

  • How well did she eat at lunch?

  • In addition to vital signs, is she orthostatic?

  • Was her drug regimen changed while she was hospitalized?

Every fall warrants a postfall assessment to determine the cause or causes of the fall. Unfortunately, there are no comprehensive postfall assessment tools in the literature,[8] and most facilities develop their own. Besides identifying any physical trauma, the physical assessment following a fall must include factors that might have contributed to the fall (for example, orthostasis, low blood sugar, and signs of infection). This postfall assessment should include a history of the fall and the events and circumstances preceding it. The history is gathered with a combination of the patient's report (if possible), witness observations (if any), and consideration of the patient's position and physical environment when found.

In Ms. P's case, it would be helpful to note:

  • Was the bathroom light on and was it sufficient for her?

  • Did she fall as she approached the toilet or as she tried to lower her panties?

  • Have staff assisted or cued her to toilet since arriving this morning?

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