Managing Injuries Resulting from Falls

Corangamarah is a 75 bed facility and includes a 15 bed specific dementia unit. It is located at Colac in the south west of Victoria. Corangamarah is a facility of the Victorian Government's South Western network of health services. It is a relatively high care facility and averages around $145 per day in ACFI funding.

Ensuring that residents can have maximum freedom and yet be cared for in a safe environment often presents challenges for the aged care team. Most aged care facilities experience a significant number of resident falls, and in this regard Corangamarah is no different. It does however manage to achieve a low rate of injuries resulting from falls despite having a large number of very frail residents.

For Bambi Vagg, (Aged Care Services Manager) and Deb Ellis (ACFI Coordinator) minimising injuries resulting from falls starts with good resident assessment and necessitates strategies that are specific to the individual needs of the residents.

It has been the policy for some time that all residents are to be assessed on admission. Up until recent times, that generally meant that residents were assessed within the first two or three days after admission. A review of some incidents involving falls, showed that a two to three day delay in the assessment process could lead to missed opportunities and now "assessment on admission" means that the "assessment is done on the day of admission". Since enforcing this policy, we have noted that the processes for minimising harm can be put in place before the resident has had the opportunity to fall.

Assessment is an ongoing process. The condition of the aged care resident can change, and at times, quite quickly. Every resident at Corangamarah is assessed at least monthly. Residents are allocated a day of the month when they are given a full re-assessment. This involves use of an evidence based Falls Risk Assessment Tool (FRAT) and also assessment for the risk of skin tears, pressure areas, infections, wounds and weight loss. On the day of assessment, residents also have their weight, blood pressure, urine, and blood glucose levels (regardless of diabetic status) checked and analysed. From the results of all these checks, our processes for looking after the resident are re-formulated and documented.

It is one thing to complete this assessment and document what needs to be done, and yet another to ensure that appropriate action takes place. To follow up the assessment outcomes, three monthly documentation compliance audits are completed. This is done to ensure that what we say needs to be done, is done. The audit is done on five randomly selected residents from each wing of the facility. The audit covers documentation compliance to ensure that the assessments are being done as per our policies, and that the risks and actions flowing from the assessment processes are being actively monitored or put in place. As part of this audit there is a specific part relating to the actions being taken (and documented) relating to falls and pressure areas.

These audits are given to different registered nursing staff each month so that all staff understand the process and it also provides the opportunity for staff to peer review one another and to give us their perspective on the effectiveness of the strategies documented in the assessment outcomes and care plans, explains Bambi Vagg.

Benefits for ACFI

Deb Ellis is also responsible for the ACFI assessment and believes that this commitment to the assessment and auditing of compliance all links back to good management of the ACFI process. Not only are the ACFI assessment processes aided by the above mentioned systems but the documentation of what we do to meet the needs of our residents has few if any gaps. It might sound a little bit like double handling but by placing this information back into the resident's ACFI files it helps to minimise issues at the time of an ACFI compliance audit. The last audit of Corangamarah was approximately 12 months ago and the auditors did not have to leave the room where the ACFI files were stored to verify our ACFI assessments. The auditors were in and out of the facility in a short period of time and commented that if all nursing homes put their files together in this way it "would make their job so much easier".

Specific Strategies for Individuals

With our assessment processes in order, the next important part of the risk management solution is to recognise the fact that the needs of each individual resident will vary, and likewise the solutions to prevent harms from falls will also vary from resident to resident. The Falls Risk Assessment Tool (FRAT) will highlight the need for specific items such as:

• Hip protection and or other protective clothing options;

• The need for a lo-lo electric bed;

• The need to clear the room of clutter (falls obstacles);

• A change of lifestyle activities to perhaps increase supervision or meet the specific physical needs of the resident;

• The need to relocate the resident so that nursing supervision can be increased;

• Our ward round system ensure residents are subject to frequent checks day and night

We have developed a flow chart for what we do to manage falls and we can audit what we have done for the resident against this flow chart. When we first started this process a year ago, our documentation compliance rate was 30-40%. That is we were not either doing or documenting what we had planned on doing for our residents. Our compliance rates now sit between 85-100% and we communicate these results to staff on a regular basis, in this way we have been able to sustain our higher levels of achievement. Continually reviewing what we have done increases staff awareness and reinforces both good practice and a focus on the individual residents who need the most assistance.

It is also critical that we apply the quality cycle here. We often find ourselves going through the process of "trial and error". If one solution does not work then it may be a different solution or several different strategies that will. Despite numerous efforts to reduce the falls for one particular resident we have resorted to encouraging the resident to wear a specially made helmet to protect his head. The head protection was removed one day for cleaning and he fell over and injured his head. We now have two helmets so that in the event that one has to be washed there is a back up. We would prefer if we did not have to resort to the use of such things as head protectors but in the case of this particular resident, it was the right solution for him when the issues of independence and risk management were considered together.

In summary the processes of assessment, risk management, ACFI, CQI and meeting the needs of individual residents go hand in hand at Corangamarah.