MDS Alert

Rehab provider finds cognitive impairment a pivotal risk factor.

A one-size fits all assessment form for falls may cast too wide of a net in identifying rehab patients at higher risk of falls. And that means staff won't be able to focus their fall prevention efforts on those who need more special attention to remain safe.

As a case in point, Kernan Hospital, an inpatient rehabilitation hospital in Baltimore, found its standard fall risk assessment tool flagged 85 percent of its rehab patients as being at high risk for falls. The staff's goal, however, was to "identify those five to 10 patients on a unit whom we should watch very closely and use more intensive interventions to prevent falls," says Phyllis O'Day, performance improvement coordinator there.

Looking for an alternative assessment tool, Kernan's fall team found an article in the literature describing a study that used the Functional Independence Measure (now known as the FIM™) scores to identify patients at high risk for falling (Gilewski MJ et al. Rehabil Nurs. 2007 Nov-Dec;32(6):234-40). The FIM is commonly used in rehabilitation to assess a patient's rehabilitation potential and progress.

Next step: The Kernan team performed an internal statistical analysis of the facility's falls, and found the highest rate of falls among patients with cognitive deficits measured by the FIM. As a result, the falls team selected three of the FIM categories that assess cognitive deficits (comprehension, memory and problem solving) to identify patients at admission who are at high risk for falling.

The staff does the FIM on rehab patients but not for three days or so after admission. "And we couldn't wait that long to determine a patient's fall risk which is usually the highest on the first day," says O'Day.

An exception: The team found that if patients can't get up independently, they aren't at risk for falls whether they have cognitive deficits or not, says O'Day.

To reduce fall risk for patients flagged by the FIM, staff reorients, reminds, and redirects the patients related to fall safety at each encounter. The facility also uses low beds and rubber mats on the floor by the bed to prevent injury from falls if they do occur in spite of staff's best efforts.

Kernan is also trialing a fall monitor triggered by a patient trying to get up without help. A pre-recorded message from a family member may say, for example, "Mom, don't get up without calling for help."

"The alarms work for some patients, and not for others," says O'Day, "depending on the patient's cognitive problem."

In addition, the staff has implemented hourly rounding to preempt patients' needs before they try to get up, O'Day reports.

Fall risk heads up: Rehab therapist and consultant Kristen Mastrangelo finds that the majority of falls in the industry occur after a patient gets back from therapy. "They come back and they are tired and confident" due to their therapy session, she noted in an audioconference sponsored by Eli Research. Thus, you want to pay special attention to residents at this vulnerable time.

Resource: For novel strategies to prevent falls caused by rehab residents being overly confident in their newfound abilities, see "Don't Let Rehab Progress Translate Into Accidents," in Vol. 6, No. 3 of MDS Alert in the Online Subscription System.