MDS Alert

Creativity in individualizing care -- and persistence -- can pay off.

If your facility has a resident who continues to fall no matter what -- or a family insisting their resident have a device that's acting as a restraint -- you might take some notes from two facilities that tackled those issues and triumphed.

Case No. 1: An 86-year-old resident with mild dementia had suffered 11 falls at an average rate of about a fall per month, relayed Ann Donovan, RN, director of nursing at a Pennsylvania facility, in a panel presentation at the recent annual American Association of Homes & Services for Aging meeting in Chicago. Luckily, the resident hadn't suffered any significant fallrelated injuries other than bruises and abrasions.

The care team initially identified the resident's morbid obesity as a "contributing cause"to her falls and sought a dietary consult about a weight loss plan, Donovan said. They also did a pharmacy review and made "multiple med changes," she reported. The staff placed cue cards instructing the resident to call for assistance before getting up. And they put alarms everywhere, including in the bathroom.

Lesson learned: "We have found that safety devices do not prevent falls," although it's the first intervention that "we all want to grab onto" when a resident falls, Donovan cautioned.

As the team members continued to analyze the resident's falls, they made an important discovery: The resident showed "increased distress behaviors" resulting in a fall when she experienced "any disruption of her normal routine," Donovan said. "That became the common theme through all of her falls," she added. If the resident had a different staff member caring for her, or had dinner at 6:30 instead of 6 p.m., she would fall. The pattern became more evident as the resident's dementia level increased.

The resident was found crying at the time of a fall and saying, "I don't know what to do next ... what is going to happen next," Donovan relayed.

Identifying the pattern started to "paint a clear picture" of why the resident was falling, said Donovan. Even though the resident had been assessed as having only mild cognitive impairment, "these facts, as well as her cognitive decline, although very slow," convinced the team to move the resident to the dementia unit as a "main intervention" for her falls.

The dementia unit, Friendship Gardens, is "built on consistency," Donovan explained. The residents"do the same thing at the same time every day" and, thus, know what's coming next.

Since the resident transitioned to the unit, she's becoming "fully engaged" there, Donovan relayed. And the unit's schedule, which is like "clockwork," proved to get to the root cause of the resident's falls -- her need for consistency.

A second case study focused on a resident with Alzheimer's disease who used a lap buddy at her daughter's insistence. The resident's daughter was "very adamant" that if the staff removed the lap buddy,she'd have an attorney there, explained Mary Blattner, RN, director of nursing at another Pennsylvania facility, which is now restraint-free. The facility staff eventually couldn't justify use of the lap buddy, which was acting as a restraint. The resident didn't need it for positioning, and she never tried to get up on her own to walk. She had no behavioral issues.

To wean the resident's daughter from the notion that her mother needed the lap buddy for safety, the care team got restorative nursing aids to remove the lap buddy as part of an exercise where they tossed the resident a ball. The family would come and see the restorative activity, which made them feel "a little more comfortable" about the lap buddy being off, Blattner said. Next, the care team got the daughter to agree to remove the lap buddy while she spent time with her mother. That went on for six months. "Finally we had another meeting with the daughter" and removed the lap buddy for good, Blattner reported.

Editor's note: The facilities involved in the presentation are participants in the Pennsylvania Restraint Reduction Initiative (PARRI), which provides educational assistance to help facilities with quality improvement: http://parri.kendaloutreach.org/.