Copyright 2010 by Health Professions Press, Inc. All rights reserved.

Contents
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preface to the Fourth Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Content of the Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION ONE Chapter One Chapter Two Chapter Three Chapter Four Chapter Five Chapter Six SECTION TWO Chapter Seven Chapter Eight Chapter Nine SECTION THREE Understanding Falls and Falls Management Consequences of Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Causes of Falling and Fall Risk . . . . . . . . . . . . . . . . . . . . . . Clinical Assessment and Evaluation . . . . . . . . . . . . . . . . . . . Preventive Strategies to Reduce Fall Risk . . . . . . . . . . . . . . Environmental Modifications . . . . . . . . . . . . . . . . . . . . . . . . Reducing Mechanical and Chemical Restraints . . . . . . . . . Fall Prevention Practice Key Process Steps and Interventions . . . . . . . . . . . . . . . . . . Organizational Requirements . . . . . . . . . . . . . . . . . . . . . . . . Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resources 169 176 181 186 193 195 200 203 206 207 210 213 214 218 221 223 225 229
v

vii ix xi xiii

3 13 33 47 63 89

101 127 149

A. Fall Prevention Guidelines Best Clinical Practices in Acute Care Hospitals and Nursing Facilities . . . . . . . Fall Prevention Program: Organizational Self-Assessment . . . . . . . . . . . . . . . . . Fall Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fall Prevention and Restraint Avoidance Programs . . . . . . . . . . . . . . . . . . . . . . Restraint/Non-Restraint Utilization Assessment . . . . . . . . . . . . . . . . . . . . . . . . . Framework for Reducing Physical Restraints . . . . . . . . . . . . . . . . . . . . . . . . . . . Measuring Fall Rates and Restraint Use Rates . . . . . . . . . . . . . . . . . . . . . . . . . . Eyes and Ears Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ambulation Device Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ambulation Device Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bed Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Side Rail Utilization Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Adjustable Low Beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Hip Protectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developing an Effective Hip Protector Program . . . . . . . . . . . . . . . . . . . . . . . . Achieving Hip Protector Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Fall Alarms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Selecting Fall Alarms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Copyright 2010 by Health Professions Press, Inc. All rights reserved.

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Content s

Maintaining Effective Fall Alarm Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fall Risk Monitoring Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Fall Management Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Selecting and Implementing Fall Management Technology . . . . . . . . . . . . . . . . Fall Management Technology Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Roles of Nurses and Certified Nursing Assistants in the Use of Fall Management Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Home Safety Guidelines Home Safety Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist for Spotting and Correcting Home Safety Hazards . . . . . . . . . . . . . . Self-Assessment of Fall Risk in Your Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

232 234 238 244 248 250 255 257 258

C. Forms Performance-Oriented Environmental Mobility Screen (POEMS) . . . . POEMS-1 Ambulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POEMS-2 Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POEMS-5 Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POEMS-11 Key to Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POEMS-12 POEMS Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POEMS-13 Performance-Oriented Bed Mobility Screen . . . . . . . . . . . . . . . . . . . . . . . . . . . Injury and Acute Medical Problems Checklist . . . . . . . . . . . . . . . . . . . . . . . . . Fall Risk Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HighFall Risk Room Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Process Steps in Reducing Bedside Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Restraint/Non-Restraint Assessment and Care Planning Tool . . . . . . . . . . . . . Side Rail Assessment and Care Planning Tool . . . . . . . . . . . . . . . . . . . . . . . . . . Wheelchair Problems and Modifications Checklist . . . . . . . . . . . . . . . . . . . . . . Discharge Teaching Sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist to Assess Components of a Successful Fall Prevention Program . . . Checklist to Audit Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administrators Safety Walk Rounds Checklist . . . . . . . . . . . . . . . . . . . . . . . . . Safety Culture Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A: Case Study Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix B: Problem Solving: Questions and Answers . . . . . . . . . . . . . . . . . . . Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III-1 III-2 III-3 III-5 III-7 III-10 III-14 III-17 III-18 III-21 III-23 III-25 III-27 263 283 293 305

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Introduction
One of the most common and often critical problems faced by institutionally based health care providers is that of falls among older adults. Hospital falls represent a leading cause of adverse events, accounting for 25%89% of all reported inpatient incidents.1 According to hospital fall statistics, the overall risk of a patient falling in the acute care setting is approximately 1.9% to 3% of all hospitalizations.2 Inpatient fall rates range from 1.7 to 25 falls per 1,000 patient days, depending on the care area, with geropsychiatric patients having the highest risk.3 To a large extent, this wide range is attributable to differences in various institutional policies (i.e., how falls are defined and reported) and the specific site or location of fall occurrence (e.g., rehabilitation, psychiatric, critical care, orthopedic, medical, surgical). For instance, in subacute or rehabilitation settings up to 46% of patients fall,4, 5 and in psychiatric hospitals up to 36% of patients experience one or more falls.6 In the psychiatric or behavioral health setting, fall rates range from 4.5 to 25 falls per 1,000 patient days.7 In addition, more than 50% of falls in hospitals are not witnessed,8 which is another factor responsible for inexact knowledge of fall frequencies. Regardless of exactly how many people fall, people age 65 and older experience the majority of these falls. Studies that compare the age distribution of people with falls show that older people are overrepresented,9, 10 averaging about 1.5 falls per bed annually.11 As many as 50% of these older inpatients fall repeatedly.12 In the nursing facility, a setting to which older people are often admitted for safety reasons, falling is equally problematic. Up to 75% of all nursing facility patients fall each year and greater than 40% experience recurrent episodes. Approximately 50% of those who fall once will have at least one additional fall.13, 14, 15, 16 An average nursing home with 100 beds will experience anywhere from 100 to 200 falls annually, with the typical nursing home patient experiencing a fall 2.6 times per year.16 The probability of falling, in both hospitals and nursing facilities, increases with advancing age; the highest incidence of falling occurs in the 80- to 89-year-old age group.17, 18 This high incidence is more a reflection of the increasing illness and frailty that accompanies aging than it is of old age itself. Falls, particularly repeated falls, are a major cause of physical and psychological trauma. Falls that occur repeatedly are likely to produce a cumulative adverse effect on the individuals capacity for mobility, causing periods of immobility and, as an outcome of complications, premature death (see Figure I-1). In an effort to prevent falls, health care professionals have tried to protect patients by limiting their mobility, often resorting to the use of mechanical or chemical restraints. However, mobility restrictions and restraint use have
Copyright 2010 by Health Professions Press, Inc. All rights reserved.

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Fall Loss of confidence (restricted ambulation) Fall (hip fracture) Bed immobility Complications of bed rest (pressure sores, pneumonia) Death
Figure I-1. The downward-spiraling effects of falls.

proven to be ineffective in reducing falls and are associated with a host of negative outcomes for older people. Moreover, federal and state governing bodies responsible for regulating hospitals and nursing facilities are focusing their attention on the problem of mechanical and chemical restraints and the methods employed to reduce them. In particular, they have stated strongly that mechanical restraints have a very limited role in the prevention of falls and are asking institutions to implement restraint-reduction programs. A better understanding of the phenomenon of falls will help health care professionals to prevent falls without resorting to traditional methods of restraint use. Historically, the blame for falling has, for the most part, been borne by the host, the person who falls. Popular mythology holds that falls are attributable to either individual carelessness or the process of aging. Falls are considered to be either a normal phenomenon of aginga manifestation of a general decline that is bound to occuror, in people with multiple disorders, one aspect of a hopeless state in which one disorder after another leads inevitably to a negative conclusion. Many health care providers have dealt with falls and their adverse consequences for so long that they have become hardened; they no longer identify them as problems with solutions, other than to restrict the individuals mobility. Moreover, providers may be reluctant to consider the possibility of better solutions. Contrary to popular myth, falls, to a large degree, rarely just happen they are neither accidental nor random events. They are predictable occurrences, the outcome of a multitude of host-related and environmental factors that occur either alone or in conjunction with one another. Many of the factors that contribute to falls are potentially amenable to interventions. By minimizing or eliminating these risk factors, falls can be reduced or prevented altogether. In order to implement preventive measures, health care providers must first understand the conditions under which falls occur and the factors that are associated with fall risk. With an increased knowledge of why older people fall and what factors are associated with fall risk, providers will be able to more easily identify patients at risk and explore appropriate solutions aimed at reducing fall risk. Many of the factors responsible for falls are quite easy to fix, particularly for someone with a practiced eye, a different perspective, and different expertise. The second step health care providers must take is to mount an organized approach to the clinical assessment of fall risk and falls and put in place intervention strategies for both.
Copyright 2010 by Health Professions Press, Inc. All rights reserved.

Introduction
Table I-1. Characteristics of hospitals and nursing facilities Hospitals Diagnose and treat acute disease Patients are medically unstable (i.e., are experiencing acute illness and/or exacerbations of chronic disease) Institutional stay is temporary Staff Acute care orientation Daily physician presence Higher nursing staffpatient ratio Environment Designed to facilitate acute medical care services Nursing facilities Manage chronic disease

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Characteristic Goal Population

Residents are medically stable but require ongoing medical or personal assistance In general, institutional stay is long term Chronic care orientation Irregular physician presence Lower nursing staffpatient ratio Designed to accommodate residents levels of function

Although hospitals and nursing facilities more or less differ in their goals, distribution and orientation of staff, population of individuals cared for, and environmental design principles (see Table I-1), the factors associated with falls as well as intervention strategies within each institution are similar in many respects. An apple-to-apple comparison between the two institutional settings may not always be possible (e.g., what works for hospitals with respect to preventing falls may not work for nursing facilities and vice versa); so when it becomes necessary to consider the specificity of each institution, it is noted and differences appropriate to each are set forth. Falls by hospital patients and nursing home residents are a complex problem. Acquiring a base of knowledge is an important start. An awareness of falls (e.g., their extent, complications, risk factors, and causes) and strategies and approaches aimed toward their prevention can lead to a greater understanding of how to solve the puzzle. Although it is unrealistic and unreasonable to assume that all falls are preventable, there is much that can be done to reduce falls in hospitals and nursing homes. The possibility that we as health professionals can identify people at riskand do something about a condition that may not be inevitable (i.e., falling) after allis what fall prevention is about. Therefore, although it may not always be possible to prevent a fall from occurring, anticipating a fall is possible. By using a multidisciplinary team approach in which all staff members participate in the creation of fall prevention activities and understand the reasons behind certain required actions, institutions can significantly reduce the risk of falls. I have been involved in fall prevention for more than 20 years. In closing, I would like to leave the reader with my wisdom or lessons learned over the years, which I hope can be put to good use. An important starting point in redesigning a fall prevention program and its components is recognition that the existing program and activities are not working. Remember, every system or fall prevention program is perfectly designed to achieve the results it gets. There is no quick fix for preventing falls; getting all the gears in place, working in harmony or unison takes time. Fall prevention programs that
Copyright 2010 by Health Professions Press, Inc. All rights reserved.

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Under s tanding Fall s and Fall s Management

are pushed or rushed into place often do not succeed. Rather, it is important to start slow. Fall prevention takes organizational commitment; without buy-in and involvement from top management, effective fall prevention is not possible. Although nurses in many ways are the foundation of fall prevention, their involvement is simply not enough; fall prevention requires a multidisciplinary team approach. Fall prevention, like politics, is local. Hospitals and nursing homes vary greatly; what works in one may not work in another. In redesigning a fall prevention program, it is important to rethink, refocus, and retool rather than simply repuff (i.e., change the name but do the same thing over and over again). Designate a fall expert. With so many safety issues and safety regulations being put forward, it is easy for hospitals and nursing homes to go into crisis mode and lose their focus on fall prevention. An outside fall expert can be instrumental in helping organizations refocus, provide valuable feedback on program shortcomings, and support redesign efforts. Education, education, education! In order for change to take hold, the importance of staff education and training cannot be overemphasized.

ENDNOTES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Kerzman, H., Chetrit, A., Brin, L., & Toren, O. (2004). Characteristics of falls in hospitalized patients. Journal of Advanced Nursing, 47, 223229. Vassalo, M., Sharma, J.C., Allen, S.C. (2002, May/June). Characteristics of single fallers and recurrent fallers among hospital in-patients. Gerontology, 48, 147150. Halfon, P., Eggli, Y., Van Melle, G., et al. (2001). Risk of falls for hospitalized patients: A predictive model based on routinely available data. Journal of Clinical Epidemiology, 54(12):12581266. Tutuarima, J., van der Meulen, J., de Haan, R., van Straten, A., & Limberg, M. (1997). Risk factors for falls of hospitalized stroke patients. Stroke, 28, 297301. Teasell, R., McRae, M., Foley, N., et al. (2002). The incidence and consequences of falls in stroke patients during inpatient rehabilitation: Factors associated with high risk. Archives of Physical Medicine and Rehabilitation, 83(3):329333. Tay, S.C., Quek, C., Pariyasami, S., Ong, B.S., Wee, B.M., Yeo, J., & Yeo, S. (2000). Fall incidence in a state psychiatric hospital in Singapore. Journal of Psychosocial Nursing, 38, 1116. Draper, B., Busetto, G., & Cullen, B. (2004). Risk factors for and prediction of falls in an acute aged care psychiatry unit. Australasian Journal on Ageing, 23(1): 4851. Nyberg, L., & Gustafson, Y. (1995). Patient falls in stroke rehabilitation: A challenge in rehabilitation strategies. Stroke, 26, 838842. Goodwin, M.B., & Westbrook, J.I. (1993). An analysis of patient accidents in hospital. Australian Clinical Review, 13(3), 141149. Rigby, K., Clark, R., & Runciman, W. (1999). Adverse events in health care: Setting priorities based on economic evaluation. Journal of Quality Clinical Practice, 19, 712. Rubenstein, L.Z., Robbins, A.S., Schulman, B.L., Rosado, J., Osterweil, D., & Josephson, K.R. (1988). Falls and instability in the elderly. Journal of the American Geriatrics Society, 36, 278288.

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12.

13. 14. 15. 16. 17. 18.

Krauss, M.J., Nguyen, S.L., Dunagan, W.C., Birge, S., Costantinou, E., Johnson, S., et al. (2007). Circumstances of patient falls and injuries in 9 hospitals in a midwestern healthcare system. Infection Control and Hospital Epidemiology, 28(5), 544550. Nygaard, H. (1998). Falls and psychotropic drug consumption in long-term care residents: Is there an obvious association? Gerontology, 44, 4650. Kiely, D., Kiel, D., Burrows, A., & Lipsitz, L. (1998). Identifying nursing home residents at risk for falling. Journal of American Geriatrics Society, 46, 551555. Thapa, P.B., Brockman, K.G., Gideon, P., et al. (1996). Injurious falls in nonambulatory nursing home residents: A comparative study of circumstances, incidence, and risk factors. Journal of the American Geriatrics Society, 44(3):273278. Vu, M.Q., Weintraub, N., Rubenstein, L.Z. Falls in the nursing home: Are they preventable? (2004, November/December). Journal of the American Medical Directors Association, 5(6):401406. Luukinen, H., Koski, L., Hiltunen, L., & Kivela, S.L. (1994). Incidence rate of falls in an aged population in northern Finland. Journal of Clinical Epidemiology, 47, 843850. Rubenstein, L.Z., Robbins, A.S., Josephson, K.R., Schulman, B.L., & Osterweil, D. (1990). The value of assessing falls in an elderly population: A randomized clinical trial. Annals of Internal Medicine, 113, 308316.

Copyright 2010 by Health Professions Press, Inc. All rights reserved.