PSC Longview - Fall Free Days: A Long-Term Commitment

Falls risk factors can be complex involving a multitude of varied factors including; poor balance and mobility, unsafe footwear, medical conditions and the environment. To minimise a residents risk of falling Residential Aged Care Facilities require a persistent multi-factorial falls prevention approach involving all stakeholders. It is important to engrain falls prevention strategies in resident’s day to day life and the organisations culture to achieve long term success. A multi-disciplinary approach involving medical officers, nurses and physiotherapists is also essential to ensure expert advice from all disciplines is utilised when identifying and implementing targeted individualised falls prevention strategies.

Longview is a not for profit Presbyterian Support Central residential aged care facility located in Tawa, Wellington, New Zealand and provides rest home and hospital level care for 60 residents. Michael Nestmann, Clinical Nurse Manager at Longview takes us on their falls prevention journey from the initial stages of identifying falls as a key opportunity for improvement, the implementation of their falls project and associated prevention strategies, through to their success in achieving a continual decline in falls over 18 months.

Initial Stages of Falls Project:

The falls minimisation quality improvement project was initiated after the number of resident falls had rocketed to exceptionally high numbers in June 2014. The peak in falls was discussed with the senior team at our Quality Meeting, including the Facility Manager, Care Manager, Quality Coordinator, Senior Recreation Officer, Senior Cook, Administrator and Health & Safety Nurse.  A number of serial fallers who were falling almost every day were identified as contributing significantly to this upward trend in falls. The individual residents with multiple falls were investigated, graphs were used to illustrate falls patterns of times and places and these documents were included in the resident’s notes.

We identified that due to a lack of regular physiotherapist visits at the home during this time, residents were seen after they fell providing a reactive role instead of a proactive role. It was also highlighted that a review of management strategies to increase supervision of residents at high risk of falling particularly in common locations and times provided an opportunity for improvement. The analysis of falls data demonstrated that 68% of falls occurred in the bedrooms, 68% of falls occurred from 8am-8pm with clusters of falls occurring just before and mid-afternoon. From this information we developed some initial aims of what we needed to do to improve our falls rate as outlined below;

Early Aims of Falls Project;

1. Continue individual clinical review of residents at risk of falling, including Physio assessment;

• At admission,
• 3 month reviews,
• Change of condition e.g. fall, near miss, health status change.

 2. Review management strategies for increased supervision related to time and place;

• Identify residents at high risk of falls when isolated in bedrooms,
• Review use of current staff, volunteers, care regimes and activity programs to provide more supervision of the identified group.

Falls were discussed and documented at every staff meeting, we reviewed which residents had fallen and looked for and identified patterns and trends of falls every month. We also reviewed the interventions and measures in place and increased significantly staff awareness of possible interventions, E.g. sensor mats, hi-lo beds, hip protectors, walking aids.

To increase staff awareness of medium to high falls risk residents a red tape was attached to their bathroom mirror and walking frame

Falls Prevention Strategies Implemented:

We established a contracted physio to complete all mobility assessments, for every new resident, when mobility changed significantly, or when a resident had several falls.

Vitamin D supplementation was another focus, where medically appropriate each resident is provided vitamin D and every new admission gets considered for vitamin D supplementation on admission as part of our admission routine.

Next, we have promoted the use of Tai Chi to improve balance and mobility, which is offered weekly and the attendance has slowly increased over the last few months. Additionally, GP and physio do recommend the attendance to residents as well.

Another point is, that all residents with medium to high falls risk had a red tape attached to their walking frame and to their bathroom mirror as an alert. Therefore, all staff and families were aware of high falls risk residents and could/would intervene when someone was walking alone. Staff were informed at meetings and handovers that they must stay with these residents until they can be settled into a chair or handed onto the HCA responsible for their care, thus reducing falls risk significantly.

We increased supervision of residents during identified peak times of falls and during handovers. A specific recreational program was developed for residents with dementia and who have a high risk of falling called the “The Red Rose Club”.  Additional general recreational programs were also implemented during high risk hours as a strategy to prevent falls for those residents with a high falls risk.

Staff were reminded at handovers to encourage and assist residents to participate in exercise programmes and we highlighted the aim and benefits of our exercise program in our newsletter so families would also encourage residents to attend.

Additional education was provided for nurses on what to do after a fall occurred. A package of relevant policies and procedures was provided to each nurse and nurses were required to complete a falls self learning package. The senior management team also mentored and monitored verbal and written communication between nurses and health care assistants.

Staff Communication & Engagement is Key:

Lastly, communication with staff and their assistance with analysis of how and when falls occurred was also essential. It was important to tap into their expertise as carers for reducing falls risk. Trends were discussed at handovers and facility meetings and graphs were placed on the staff room notice board to communicate results. The use of falls charts was also important, but unlike traditional charts, we focused on Falls Free Days, celebrating every day without a fall. This motivated staff to reduce falls risk even more and to try to do better month by month.

Figure 1: Longview Falls Free Days: January 2016

Outcomes of Falls Project:

In our recent QPS Benchmarking Report it was highlighted that our falls rate has continued to decline over the past 6 quarters which coincides with the implementation of the falls project and our current result is performing in line with the QPS industry benchmark as demonstrated in the QPS Trend Graph below.

Figure 2: Resident Falls (TOTAL) General - Trend Graph

In summary our robust falls project improved and resulted in the following outcomes;

• Reduction in falls rate for high risk residents,
• Increased communication between staff, particularly HCA’s and Nurses,
• Understanding and use of Nursing Assessments,
• Change in Support Plans and notifying HCAs of changes,
• Identification of resident group with dementia who have a high falls risk, resulting in the new dementia specific recreational program. “The Red Rose Club.”
• Increased supervision of residents & use of additional recreational programs during identified high risk times,
• Contracted physio completing all mobility assessments,
• Vitamin D supplementation,
• Red tape system to alert staff of high risk fallers and
• Use of Tai Chi and participation in exercise programs.

Other Clinical Initiatives:

Although not directly related to falls, the initiation of a skin tear project at Longview has also shown some interesting changes. Supplying every resident with skin care (Healthy E or DP lotion) applied twice a day and providing additional skin tear prevention training has reduced skin tears and a significant shift in the indicator “falls with injury” has also occurred. Prior to the skin tears project many falls with injury resulted in substantial skin tears. Post project commencement, many residents who fall experience bruising now instead of an actual wound due to improved skin health and durability.

Since the implementation of the project falls have been at the forefront of attention and a primary focus for staff and strategies are engrained in our day to day life. We continue to use early interventions and a multifactorial and multi-disciplinary approach to falls prevention involving nurses, HCA’s, GP’s and Physiotherapist.

 *Appropriate consent has been provided to publish the photographs.