Preventing falls, promoting fitness - in nursing homes - 1998 Optima Award - Cover Story

Nursing Homes, Sept, 1998

Resident falls are an ongoing concern for many facilities that strive to be "restraint-free," yet maintain a safe environment for residents. The lines of resident freedom and resident safety are not etched in black or white and, consequently, team members must continually grapple with appropriate interventions for "high-risk-for-fall" residents. The specific problems in our facility were as follows: as of December 1996, 29% of our population was restrained, compared with a state norm of 13.4% and a national norm of 18%. We had a total of 204 resident accidents/incidents, or an average of 17 per month (Figure 1). In short, too many residents were restrained and too many residents were falling. Both problems required attention, intervention and correction.

The Plan

Planning our response began with three fundamental objectives. The focus committee involved would:

1. Use a monthly tracking tool to determine any underlying patterns/trends that might contribute to resident falls.

2. Identify those residents who might be candidates for restraint alternatives.

3. Create imaginative and innovative programs designed to promote both independence (restraint-free) and safety (no falls) for the residents.

These objectives were quantified as follows:

1. No more than 10 falls per month.

2. No more than 12 (10%) of the resident population restrained.

3a. Patterns/trends of falls would be analyzed using a monthly accident-/incident-tracking tool (Figure 2).

3b. Once patterns/trends are identified, initiate specific activity groups or interventions.

Implementation

Although resident falls and the number of restrained residents were of concern to all our interdisciplinary team members, it was decided that a smaller committee would focus on this issue. The team decided to select a physical therapist, nursing supervisor, recreation therapist and the director of nursing services (DNS) to pursue this project.

The nursing supervisor was responsible for collecting the monthly data regarding resident falls. Each month, for a period of three months (1/97-3/97), the nursing supervisor would complete the accident-/incident-tracking form and bring it to a meeting with the other members of the focus group. It was during this process that trends were identified and patterns noted. The following were our benchmark data from which all interventions followed:

* Falls occurred most frequently between 10 and 11:30 am (60%) and between 3 and 4:30 pm (30%).

* Ninety percent of the falls occurring between 10 and 11:30 am involved extremely confused residents who were attempting to stand/walk/move from the confines of a wheelchair.

* All the falls occurring between 3 and 4:30 pm involved alert and oriented residents attempting to go beyond their limits (e.g., walk without walker or assistance, bend down to pick up something off the floor).

Inherent to all of the noted falling patterns was a common desire by the residents to move. The confused residents wanted to get up, turn around or just stretch and feel free. The oriented residents wanted to move also, even if the movement was more than their limited capabilities would permit. The team decided to channel the residents' desire for movement into positive and productive activities. The focus team conceived, developed and implemented the following three interventions designed to promote movement and fitness while providing a safe environment: a geriatric conditioning program, a tai chi program and a ballroom dancing program.

Geriatric Conditioning Program

This program was designed for confused residents who were at high risk for falls and/or were candidates for "no restraints."

The program begins at 10:00 am each day and ends at 11:30 am The nurses on each unit decide (on a daily basis) which three or four residents they believe are at high risk for falls. (On some days, residents are agitated or have more energy than other days.) These three or four residents from each unit are invited to the geriatric conditioning program for the day.

Since the morning is extremely busy for the nurses and nursing assistants, it is difficult to continuously supervise the high-risk residents. Accommodating them in a closely supervised area reduces the chance that an accidental fall will occur.

The residents selected for geriatric conditioning spend one and a half hours enjoying themselves while they move to music, with direction and supervision. A physical therapy assistant, a recreation assistant and a nursing assistant lead the exercises. Exercises are varied and include modalities such as upper and lower body strengthening, and ball tossing to improve dynamic sitting balance.

Because the ratio of staff to residents is approximately 1:3 or 1:4, group members receive much individualized attention. Those residents who are agitated or eager to move about have the perfect opportunity to do so, but within safe confines. When the music stops and everyone pauses for a breather, refreshments are served. At the conclusion of the program, the residents are transported back to their units.