Long-Term Care Survey Alert

Head off a survey spill with these 3 strategies.

True or false? A facility can prevent almost all falls.

The answer depends on whom you ask. Some surveyors and litigators act like any fall is a facility's fault. But best-practice nursing facilities that promote residents being "on the go" know that you can't guarantee anyone will remain fall free.

The goal is to proactively reduce the likelihood of falls--and if they do happen, reduce injuries, says Marianna Grachek, MSN, RN, executive director of Long Term Care and Assisted Living Accreditation for the Joint Commission on Accreditation of Healthcare Organizations.

These three strategies will go a long way toward keeping residents on their feet and your survey record off the fast track to decertification.

1. Do performance assessments that look at a resident's gait, balance and lower extremity muscle strength. "Probably about 70 percent of falls result from balance problems ... and most are due to lower extremity weakness and posture," said Denise Wassenaar, RN, MS, in a presentation at the recent American Association of Homes & Services for the Aging annual meeting and exposition in San Antonio.

Wassenaar suggested facilities use the "Timed Get Up and Go" test to assess resident's ability to get up from a chair and walk a few feet unassisted.

Also observe the resident's gait: "A typical gait is heel, toe, heel, toe," said Wassenaar. "Anyone who deviates from that will have an increased risk for falling."

Tip: Structured exercise programs designed to improve residents' balance, endurance and muscle strength can go a long way toward reducing falls, according to Larry Carlson, executive director of Addolorata Villa in Wheeling, IL, who co-presented with Wassenaar at the AAHSA conference. The exercise program should focus on muscle groups related to functional status, such as leg strength for walking, the triceps for pushing up by the arms, and the stabilizer muscles for balance, he told AAHSA conferees.

2. Keep pace with a resident's fall risk status. For example, sometimes facilities don't identify an ambulatory resident who is suffering a slow, subtle increase in fall risk factors, cautions Nancy Augustine, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA. Examples include declines in cognitive performance and activities of daily living--or worsening urinary incontinence. The person with accumulating risks "is the next one to fall," says Augustine. "And when surveyors take a look at the situation, they find the care plan often doesn't address the increased level of risk by adjusting the interventions specific to the resident."

Don't silo your assessments: Sometimes the interdisciplinary team doesn't pick up on a combination of subtle declines because each person does an assessment in his/her own little box and no one puts the big picture together, Augustine cautions.

Develop trigger points for action: In some facilities, a resident who falls or has two incidences of instability triggers evaluation by physical therapy, nursing and dietary, says Garry Woessner, principal of Woessner Healthcare Consulting Group in Edina, MN. "Everyone rallies around the resident to do an evaluation and revise the care plan."

3. Provide extra precautions and monitoring for residents at risk of injury. Develop protocols that focus on conditions that place residents at higher risk for injury if they do fall. For example, a resident with osteoporosis might benefit from wearing hip protectors, if the person agrees.

A study in the New England Journal of Medicine showed that elderly people attending or living in a community health center in Finland who wore hip protectors had 40 percent fewer hip fractures than the control group. The study participants were at risk for falls due to poor balance, vision problems, osteoporosis--or they were taking medications associated with falls.

Editor's note: Read the abstract of the article, "Prevention of Hip Fracture in Elderly People With Use of a Hip Protector," online at http://content.nejm.org/cgi/content/abstract/343/21/1506.

Residents on anticoagulants are at risk of bleeding from what may seem like a relatively minor fall. "Staff should be aware of who is on an anticoagulant and monitor that person carefully if he/she falls," advises nurse attorney Janet Feldkamp in Columbus, OH. "Keep in mind that insidious bleeding can occur over a period of time," she cautions.

A blow to the head can cause a subdural hematoma in a resident on Coumadin--a potentially lethal event that can take some time to become evident. "Thus, if a resident on an anticoagulant has an unwitnessed fall, remind the physician of that fact," Feldkamp says. "The physician can determine if the resident needs a CAT scan or further investigation in addition  to nursing monitoring, such as neuro checks."

What if you aren't comfortable with the attending physician's response to the situation? "Talk to the medical director who has oversight of the quality of physician services in the facility," suggests Feldkamp. "The staff should document their interactions with the attending physician and the medical director about specific care issues," adds Feldkamp.