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1. Program Goal and Background

The Falls Management Program (FMP) is an interdisciplinary quality improvement initiative. It is designed to assist nursing facilities in providing individualized, person-centered care, and improving their fall care processes and outcomes through educational and quality improvement tools. Why is this important? There are several reasons:

• Falls are common in nursing facilities. Of the 1.6 million residents in U.S. nursing facilities, approximately half fall annually. About 1 in 3 of those who fall will fall two or more times in a year.
• Falls often have serious consequences, especially in frail older residents. Fall-related injuries decrease the resident's quality of life and ability to function. Residents who fall without injury often develop a fear of falling that leads to self-imposed limitation of activity. One in every 10 residents who fall has a serious related injury and about 65,000 patients suffer a hip fracture each year. Adverse consequences of falls for residents are listed in Figure 1.

  Figure 1. Adverse consequences of falls for residents

  Reduced quality of life. Increased fear of falling and restriction of activities. Decreased ability to function. Serious injuries. Increased risk of death.

• Falls are a major safety concern for nursing facilities. Injuries resulting from falls are a major reason for lawsuits against facilities and staff, which can result in the loss of large sums of money and higher insurance premiums. Potential consequences for facilities are listed in Figure 2.

  Figure 2. Adverse consequences of falls for nursing facilities

  Increased paperwork for staff. Increased levels of care required for fallers. Poor survey results. Lawsuits. High insurance premiums.

• Many nursing facilities have fall programs in place, but recognize that there is always room for improvement. While not all falls and injuries can be prevented, it is critical to have a systematic process of assessment, intervention and monitoring that results in minimizing fall risk.

2. Causes of Falls

The FMP helps facility staff to identify and intervene, whenever possible, on the common causes of falls. Falls among nursing home residents are usually the consequence of a combination of risk factors, both intrinsic and extrinsic. Examples of these risk factors are illustrated in Figure 3.

Although intrinsic risk factors such as age-related changes and chronic diseases cannot be eliminated, they can be managed in a way to reduce the resident's risk of falling. Medical management of both acute and chronic conditions can be improved through appropriate evaluation and treatment. Extrinsic risk factors can also be addressed to improve safety in the environment and during equipment use. Figure 4 gives examples of specific extrinsic risk factors which can be modified by staff to decrease risk.

The FMP is designed to assist facilities in addressing both intrinsic and extrinsic risk factors. It is important to remember that not all falls can be prevented. Nonetheless, research shows that a facility's fall rate can be substantially reduced by using a multifaceted approach that includes comprehensive falls assessment and individualized care planning by an interdisciplinary team, organizational support and appropriate management using quality improvement methods.

3. Overview of the Falls Management Program

The FMP includes two primary approaches to the management of falls and injuries. The first is through an immediate response to residents who fall. When a fall occurs, careful evaluation and investigation, along with immediate intervention during the first 24 hours, can help identify risk and prevent future incidents. The second approach is long-term management. Here, screening at admission, quarterly, annually and change of condition are key in identifying residents at high risk of a fall. In both approaches, a comprehensive falls assessment should be used to develop individualized care plan interventions. Staff should monitor and manage the resident's response, making care plan revisions as needed. While both approaches are fundamental to a comprehensive program, the burden on staff in terms of increased time and paperwork due to the high number of resident falls is significant. Facilities that master the fall response process can shift from crisis management to proactive reduction of fall risk and related injuries.

4. Culture of Safety

The term "culture of safety" is used to describe how the behavior of staff and management affects the safety of residents. The development of a culture of safety is an important first step to ensure that the FMP is effective and integrated into the organizational system.

Developing a culture of safety requires changes in staff attitudes, beliefs and behavior as well as changes in management style. This change process requires strong leadership, effective communication, new policy development and the formation of multidisciplinary teams to address areas for improvement. Empowered staff should be encouraged to participate in all levels of care. Finally, an environment of "no blame/no shame" will provide an open atmosphere where staff members can report errors and safety concerns without fear of punishment. (Figure 5)

Effective, open communication is crucial to achieving a culture of safety. An open style of communication means that the organization supports discussion about resident safety, and direct care staff are encouraged to report full details of unsafe conditions without fear of punishment. Communication should be built upon trust and clear expectations of performance based on objective criteria.

The administration should discuss with staff the importance of resident safety and the facility's commitment to a culture of safety during orientation of new employees and repeat this message with all employees on a regular basis.

Staff should not be "blamed or shamed" when a resident falls. Rather, the system failure should be examined using a team approach. While falls are liability and survey concerns, it is counterproductive to keep data secret. All staff including nursing assistants should receive concrete information about their performance. Monthly reports of falls should be openly shared by the administration and staff feedback should be used to make program improvements.

Strong leadership is essential in establishing a culture of safety. The primary role of leadership is to make safety a top priority within the facility and to have clearly defined safety policies. The administrator and director of nursing accomplish this by setting goals for the facility and allocating resources to support safety programs.

Table 1 outlines the activities of the administrator and director of nursing during the FMP.

5. Teamwork

Interdisciplinary teamwork is essential for success in the FMP and the selection of members is an important first step. (Figure 6) The falls team can function in collaboration with or as part of a team that addresses residents at high risk for multiple conditions, including falls. The following recommendations should be reviewed by the administrator and director of nursing before selecting the team.

Falls Nurse Coordinator is responsible for full implementation of the program and serves as the clinical champion of the FMP. This person coordinates screening of high-risk residents to be included in the program and performs a falls assessment for each one. The nurse oversees all steps in the Falls Response process and coordinates implementation of individualized care plans. The nurse ensures the education and training of all staff, families and residents and works with the medical director to inform all primary care providers of the program and their role in it.

It is recommended that two nurses be appointed and trained as coordinators so that continuity of care can be maintained during changes in staffing and periods of high demand. It is especially helpful to have more than one coordinator in larger facilities to ensure adequate coverage on all units.

This role is best filled by a nurse leader with the ability to communicate well with frontline staff, management and physicians and who can devote 8 hours per week to this role.

Falls Nursing Assistant(s) is responsible for inspection of the environment and equipment and acts as a leader among frontline staff in support of the falls nurse. This person should be a senior level certified nursing assistant who works well with peers and is an informal leader on his or her unit. In most average size nursing facilities, the selection of two nursing assistants for the falls team is sufficient while in larger facilities, 3-4 nursing assistants are needed.

Falls Therapist helps to assess resident transfer, mobility and wheelchair seating. This role is best filled by a member of the rehabilitation department who has experience in functional positioning and seating, such as an occupational or physical therapist.

Falls Engineer inspects, repairs and modifies equipment and the environment. This role is best filled by a member of the maintenance staff.

Director of Nursing is an ad hoc member of the falls team and may join meetings each week or less frequently if progress is steady.

Some facilities choose additional staff such as activities staff, social workers and housekeeping staff. While the administrator does not attend weekly meetings, he or she should stay informed of progress and be asked to remove identified barriers when necessary. Frontline staff from the units of residents who have fallen should be asked to attend the meeting for 10-15 minutes in order to participate in discussion and problem-solving about their resident. Their input is critical for this process and their participation will help build interest and support for the program.

A primary team responsibility is the development of effective problem solving skills so that appropriate interventions for high-risk residents are selected. This is especially important for managing the high risk of demented residents with unsafe behaviors who often have repeated falls. Under the leadership of the falls nurse coordinator, team members must work with direct care staff to determine new strategies as the resident's cognitive level changes over time. An example of a falls team meeting agenda is provided in Table 2.

The FMP Self-Assessment tool will enable staff to identity strengths and weaknesses in key areas. It should be completed before starting the program in order to develop a facility-specific plan for program implementation. The self-assessment should also be completed after program implementation to evaluate progress and identify further process improvement needs. In particular, completing the chart audit section of the self-assessment quarterly will detect which care processes (screening, assessment, care planning, and monitoring) are being performed and documented adequately and which need improvement. This section includes the major areas of documentation necessary to reflect implementation of best practices and should promote positive results during survey or in case of litigation.