Driving Improvement in Falls

Falls prevention remains one of the greatest challenges for residential aged care facilities with falls providing a major cause of harm to the elderly, requiring facilities to have a proactive approach to preventing and managing falls. This includes identifying risks and causal factors early to reduce resident's potential of falling and minimise harm sustained as a result of falls.

Reevedon Rest Home is a not for profit facility opened by Presbyterian Support Central (PSC) in 1991 and have been part of the QPS Benchmarking Program since the 1st of July 2004, participating for over 10 years. Enliven Services is a division of Presbyterian Support and provides a full range of services that support people to maintain their independence and enjoy fulfilling lives throughout New Zealand. Enliven, PSC provides services and support throughout the lower North Island including rest homes, hospitals and dementia care, retirement villages, in-home support and personal care services, respite, day activity programmes and social clubs. Reevedon Home has shared their falls prevention approach and the processes and strategies implemented which have led to continual improvement in the falls rate over the past 15 month period.

What triggered the falls initiatives?

Through the close monitoring of accidents and incidents, Reevedon Home noted a steady increase in the number of falls over a two quarter period with falls peaking in September 2013 at 118%, as evidenced in the QPS Benchmarking Trend Report below. A frequent faller had been identified as a contributing factor to this increase which was proving to be a challenge when it came to falls prevention interventions. The facility started to look at possible strategies to bring the falls rate down. The analysis of falls data was discussed both at staff meetings and at management/senior team meetings.

Falls Prevention Approach

Strategies IntroducedReevedon's falls prevention approach involved monitoring and analysing data on falls, discussing this information at monthly management meetings which at this time consisted of the care manager for Reevedon Home and quality coordinator and facility manager who also are responsible for Reevedon's sister site, Levin Home for War Veterans. In addition, there were weekly discussions between the quality coordinator and the care manager to formulate possible solutions. These were then discussed at the monthly staff meetings. Fundamentally Reevedon started with the simple things, focussing on the basics, coupled with system and senior team changes. The implementation of an exercise programme was also introduced by the recreation officer which focused on muscle strength and balance. A full overview of the falls prevention strategies implemented have been outlined below.

• Detailed direction at handovers, driven by the care manager,
• Staff discussions at handover in regard to specific resident falls risks and sharing of ideas to minimise risk for a particular resident,
• Focus on quicker response times to call bells/alarms,
• The care manager accessed site specific information in regard to call bell answering times online to identify trends and delays when analysing incident reports. Staff were educated that sensor mat calls were to be treated as emergency calls at all times,
• De-cluttering of rooms and the facility in general,
• Attention to appropriate placement in rooms of commode chairs, call bells, urine bottle etc. ensuring all are at hand for the resident,
• Placement of sensor mats in at-risk resident's rooms,
• Beds of at-risk residents placed at lowest position,
• High risk residents placed on 30 minute monitoring while most appropriate supports are being considered and put in place,
• Timely reassessment for higher level of care,
• Change in practice in responsibility of data entry of falls into the incident register - from quality co-ordinator to care manager. This meant the most senior registered nurse was aware of falls in a timely fashion and able to instantly recall preceding falls. This facilitated earlier detection of frequency and patterns. The improvements also allow Reevedon Home to identify what information was necessary for 3 monthly resident reviews,
• Earlier identification of trends, patterns or residents of concern led to earlier implementation of strategies to minimise further falls,
• Focussed participation in a vitamin D programme, the majority of residents are receiving oral vitamin D supplements,
• Development of a well attended exercise programme which includes a formal exercise group with an external instructor and exercises that can be carried out either sitting or standing, a daily walking bus where residents get together for a less formal walk around the home and grounds, twice weekly indoor bowls and once weekly movement to music.

Engaging staff in the Implementation of Strategies

The key to the successful implementation of new strategies or processes is staff engagement and commitment. Ensuring staff understand the strategies and the importance of the new initiatives is a vital step in the process. The staff at Reevedon Home were encouraged to share ideas at meetings and handovers for minimising falls risks for specific residents. Staff were also educated about the importance of prompt reporting of falls to identify risks early. Involving all stakeholders in the falls prevention process is important with the facility discussing falls risk management strategies with both residents and relatives.

An example of this collaborate approach at Reevedon Home has been shared below;
Example: An alert 104 year old lady with visual impairment and CCF sustained frequent falls, usually overnight from her chair. She was a restless sleeper, taking sedation and known to get out of bed to sleep in her leather chair. Her room was small and cluttered and in a low traffic area of the home. After discussion with the family, it was decided to move her to a larger room closer to the office. Unfortunately, she had her family rearrange her room in a manner that still caused clutter and was resistant to changing the layout. She had a low bed and a sensor mat was in-situ to alert staff when she got out of bed. After more falls, causing injury, family were requested to meet with the care manager to discuss management of risk. With the aid of family, we were able to de-clutter the room and arranged to remove the leather chair from her room at night, thus alleviating the problem of her slipping off it when experiencing the effects of her sedation. Incidence of falls decreased dramatically.

Monitoring the Strategies Introduced

Closely monitoring new initiatives is critical to measuring the success of the strategies implemented and whether further investigation is required. All Enliven, PSC sites use an online incident/accident register which allows staff to identify how, where and the time of day falls occurred, which makes it simple to identify any emerging patterns and enables the facility to analyse, discuss and implement strategies at an early stage. This has proved to be highly effective with frequent fallers.

Reevedon can track the effectiveness of the strategies implemented so changes can be made where necessary until they identify what is working well and what isn't. The facility has fortnightly senior team meetings and monthly staff meetings. Practices and strategies are also reinforced at handovers.

Outcomes of Initiatives

These initiatives have led to positive outcomes for Reevedon Home with a continued decline in the falls rate noted over the past 5 quarters since the implementation of the falls prevention strategies. The falls rate reduced from 118% in September 2013 to 29% in December 2014 and is currently performing well below the industry benchmark as per the QPS Benchmark Graph below. Positive re-enforcement has been provided to staff via handovers, staff meetings, written reports and congratulation posters have been put up throughout the facility. Families were also notified and received regular verbal feedback in relation to management strategies.

Learning's

As a result of the falls prevention program staff at Reevedon Home learned that the greatest contributing factor for residents falling was the lack of attention to the basics of falls prevention. The facility has benefitted greatly from the discussions held with staff identifying where they could do better without apportioning blame. When issues arise we tend to blame each other which leads to a negative culture, the research demonstrates that the vast majority of time the causes of our problems are the processes not people. Measuring performance allows us to identify which part of the systems and processes are not working so that we can change the way things are done. This ultimately leads to successful outcomes for residents, relatives, staff and management.