Although falls may appear to be an inevitable fact of life for older adults, many are preventable with the right tools and know-how. This article outlines some of the key considerations of a comprehensive fall prevention program in senior care settings such as long-term care and skilled nursing facilities.
While falls and fall-related injuries are far from a new concern for nursing homes, it doesn't mean the issue is well in hand. The Centers for Disease Control (CDC) advises that "In the United States, over 14 million, or one in four, adults ages 65 and older (older adults), report falling each year. While not all falls result in an injury, about 37% of those who fall reported an injury that required medical treatment or restricted their activity for at least one day, resulting in an estimated nine million fall injuries."1
With the looming threat of the aging population increasing average resident acuity, financial strain on the long-term care industry and a continuously overstretched workforce providing more and more challenges, it's more important than ever to make sure you have a future-proof, fall prevention strategy in place. Let's outline some vital elements to consider.
In order to first understand how to prevent falls in elderly residents we must first screen for a risk of falls and then assess that risk. Oftentimes, caregivers mistake screening for assessments, but they are not the same thing, although both have their place. The most important distinction is that a screening tool will only tell you whether or not a person is at risk of falls but not why or to what extent.
In Accora’s free webinar Fall and injury prevention: Let’s get clinical,2 fall prevention expert Dr Patricia Quigley explains that every caregiver knowing the specific fall risk factors the residents in their care have is vastly more important than simply knowing that they are at risk of falling.
"Whatever role you have; if you're a nursing assistant, or an LPN, or nurses, or therapists, all that are taking care of residents, you should know what those individual risk factors are, not just that they're a high fall risk."2 - Patricia Quigley
You can read more about Dr Pat’s fall prevention education for nurses and caregivers on the Accora blog.2
Risk factors for falls can be categorized into two groups: elements that are extrinsic and those that are intrinsic. Intrinsic risk factors are inherent to the individual. These typically relate to health conditions and co-morbidities such as cognitive function, mobility and incontinence challenges but can also include demographic information like gender, age and ethnicity.
Extrinsic factors, however, refer to elements that are outside of that patient’s characteristics. These risk factors may be environmental, socioeconomic or dependent on other people, such as their caregivers and the quality of communication in handoffs, for example. Extrinsic factors may affect the person’s risk of falling but are not specific to the individual.
It’s important to be aware of these two categories of fall risk factors so we can then drill down to identify which factors are modifiable and non-modifiable. From here we know where to focus our attention and energy to make the biggest impact on that person’s fall risk mitigation: modifiable intrinsic and modifiable extrinsic factors.
A truly balanced fall prevention program will include a strategy for both along with an individualized plan of care for every resident.
The population of the average skilled nursing facility now is not the same as we've seen in the past. The individuals that residential healthcare providers are caring for now have a higher level of acuity, more complex medical conditions and therefore more complex needs than previously seen. Some of these intrinsic medical factors can contribute to a risk of falls so it's important that caregivers are aware of how existing or new medical complications can affect a person's fall risk.
Residents living with a cognitive impairment such as dementia and Alzheimer’s could be at a greater risk of falling than residents without because of the common side effects of dementia. In addition to dementias and common geriatric conditions like Parkinson’s, we ought also to consider a history of strokes or Traumatic Brain Injuries (TBI) as cognitive risk factors since these can also exacerbate and potentially cause behavioral challenges.
Confusion, agitation and aggression associated with cognitive impairment can all lead to an increased risk of falling. Largely this is due to distress leading to a person being less careful, moving around more, perhaps frantically, and therefore increasing the likelihood of accidents and the risk of fall-related injuries occurring.
In a recent recorded education session regarding reducing fall risk in memory care, Dementia expert Rachael Wonderlin advised that strategic activity planning can assist with effective fall prevention in a memory care setting.3
"We've come to expect falls in senior living, especially in dementia care [but] there are things we can do to prevent falls in dementia care. When people are feeling calm and situated, guess what they're not doing? They're not walking down the hall, stressed as anything, looking for their loved ones, looking for the exit. Getting people to sit and engage, do something with their hands is going to be so key for preventing falls in dementia care." 4 - Rachael Wonderlin
In managing the fall risks in dementia patients it’s important to consider and assess which interventions may be appropriate for them when the individual’s capacity is diminished. An on-demand webinar that deals with the minutia of this challenge can be found on the Accora website titled Fall prevention strategies for residents with cognitive impairment within Skilled Nursing Facilities.5 This session may help those with specific concerns around residents with cognitive impairment and appropriate fall measures.
Issues with balance or gait can present a greater fall risk for residents, but there are things we can do to manage this. Consulting your Occupational Therapist or Physical Therapist is a great place to start because they may have some ideas for programs, exercises or activities to help strengthen muscles, increase balance and promote safer mobility, therefore reducing the incidence of injurious falls.
Physical Therapist Shelly Denes advised in the virtual education session Reducing fall risk in older adults: beyond gait and balance6, that posture can also have a direct impact on fall risk.
"If our clients are standing with their head forward so they have non-erect posture, that's going to impact on their proprioception because they're going to be leaning forward. This means the joint receptors have to accommodate for that. Their posture is going to affect proprioception."6 - Shelley Denes
Improving a resident's proprioception (that is the ability to accurately know and feel where they are in space), can have a positive impact on risk factors for falls. The two main things that can help a person to improve proprioception are movement and sensation.7 So, encouraging gentle movement activities even if only seated and multi-sensory activities is advisable according to PT Shelly Denes.
As we age, our vision can cause issues with how the eye interprets the environment and environmental hazards.7 Glasses are often prescribed to assist with this, but glasses can also cause further issues in the elderly population. Some key considerations regarding vision and how it can impact fall risk are:
To understand more about how the aging eye sees potential hazards and interprets colors and textures, visit our article, Design for anaging population.9
There are multiple elements to nutrition as it fits into mitigating the risk of falls but four to focus on are Sarcopenia, weight loss, hydration and vitamin D deficiency.
In the case of elderly residents, Sarcopenia can cause an increased risk of falls and also worsen the risk of serious fall-related injuries should a fall occur.10 This is because muscle wastage and general bodily weakness can increase a person's chance of not only falling but sustaining injurious falls upon impact.
If our bodies are not strong then they will not tolerate the impact of a fall without sustaining damage and as we know, an injurious fall is more likely to result in recurrent falls as residents become afraid of moving or mobility is further restricted due to recovery. Vitamin D supplementation, nutritional intervention and whole-body treatment of sarcopenia will help the resident's quality of life as well as reduce their risk of falling.
Nutritionist and Dietician Janet McKee stresses that weight loss and muscle wastage can be a key risk factor for falls and injurious falls in her education session, The role of nutrition & hydration in fall prevention.11
According to Janet, "Weight loss causes muscle mass catabolism, muscle wasting and weakness. [...] Muscles that are weak cannot sustain balance and that causes falls. So, we want to keep these muscles as strong as possible."11 - Janet McKee
Failing to prevent continuing weight loss can result in a fall which could result in fall-related injuries such as a hip fracture or head injury. Statistically, this then presents further risks, all of which can severely impact a resident's quality of life and potentially derail recovery altogether.
According to a study published in the National Library of Medicine, dehydration and falls are likely to be linked.12 We all know the symptoms of dehydration in ourselves: difficulty focusing, headaches, dizziness, fatigue etc. but the problem could potentially be more severe for the over 65s cohort.
“Dehydration can lead to impaired brain perfusion, with subsequent dizziness and orthostasis. Orthostatic hypotension has been associated with falls. Decreased elasticity of aging tissues leads to decreased venous blood return when we arise and lowers diastolic blood pressure. Add to this antihypertensive or diuretic medications or diseases that decrease compensatory mechanisms and falls can occur.”12
When we also add into this equation a lack of cognitive capacity in determining lengths of time between eating or drinking or an inability to communicate thirst and hunger to caregivers, the results could be disastrous in terms of exacerbating fall risk.
Vitamin D is vital for maintaining healthy bones among other things. Without sufficient quantities of vitamin D from sunlight, food sources or vitamin D supplementation, residents may be more likely to fall due to weak bones but also may be more likely to sustain a serious injury from the fall.
If you’re keen to reduce falls risk through improving nutrition, hydration and vitamin D intakes in your residents, you may find these 5 tips to minimize nutrition-related fall risk from LTC nutrition expert, Janet McKee particularly interesting.
The above is an excellent start to better understand how medical factors can contribute to fall risk and also how they could potentially exacerbate the risk of sustaining fall-related injuries, but of course, there are many more medical conditions to consider. Health care providers should take a collaborative and thorough approach to assessing fall risk and assembling the plan of care. Furthermore, it is important to acknowledge that one of the biggest enemies to the successful prevention of falls may not be the condition itself but often the medications used to treat it.
We are learning more every day now about high-risk medications that can increase a person's likelihood of falling. In the aftermath of the opioid epidemic, we've come to understand how great an impact commonly prescribed medications can have on the probability of falls.
Drug classes such as antipsychotics, diuretics, benzodiazepines, antidepressants and antiepileptics can all have an adverse impact on a person's risk of falls.
Dr Canterbury (AKA the Deprescribing Pharmacist) stresses that "all psychotropic drug classes are associated with an increased risk of falling. They all have these risks. Additionally, they also have this risk of mortality when used for the behavioral management of Dementia and a cardiovascular risk associated with that as well."13 - Dr DeLon Canterbury
According to the Canadian Deprescribing Network, the single biggest medication-related fall risk factor was not one medication or class of falls risk-inducing drugs but polypharmacy itself.14 It defines this as "4 or more medications" that a person is prescribed and takes concurrently.15
As a rule of thumb, any medication that contributes to dizziness, dehydration, orthostatic hypotension or neurological or cognitive impairment can also contribute to fall likelihood. These types of medications are frequently referred to as Falls Risk Inducing Drugs or FRIDs.16 And as we’ve mentioned, the use of multiple medications at once can significantly increase the risk for falls as a risk factor in and of itself.
Dr Canterbury suggested that performing regular medication reviews and actively looking for opportunities to deprescribe high-risk medications is one of the most impactful elements to address in your fall prevention strategy.13
Assessing environmental risks periodically is advisable as part of a successful fall prevention program. Compliance expert, Rebecca DeRousse advised that environmental rounding should be a cornerstone habit in your weekly leadership activities in her webinar on the Top 10 cited F tags and how to avoid them.17
“You can look for any hazards or risks on a routine basis with your interdisciplinary team. I suggest that you do this on a weekly scheduled basis. Set it up for 30 minutes a week and have representation from all your departments […]. Look at different areas of your building, have a checklist that you follow and within a certain amount of time you’re going to cover your whole building.”17
Further extrinsic fall risk factors could include ineffective communication between caregivers at shift handoff or and a lack of caregiver support or resources including appropriate medical devices.
F 689 pertaining to accident hazards, supervision and devices states that the resident’s environment remains as free of accident hazards as possible and also that each resident received adequate supervision and assistance including assistive devices to prevent accidents.17
This means that as the healthcare provider, it is up to you to balance the availability and suitability of assistive devices as well as to maintain a safe environment. Both of these come down to a matter of policy and investment from the leadership team as well as buy-in and commitment from the nursing staff.
If you’re particularly interested in best practices in fall prevention in terms of design elements then you’ll love this whitepaper, Falls Prevention by Design, which gives an in-depth look at specific design implications as a means to preventing falls in nursing homes.18
Now that we’ve covered several notable fall risk factors inboth the extrinsic environment and the intrinsic factors that are individual to each resident, we can move on to strategies and methods of preventing and managing falls in the nursing home.
New innovations in assistive devices are being thought up all the time to help prevent the burden of falls for older adults. We all know the staple Durable Medical Equipment (DME) pieces that you'll find in long-term care settings: walkers, bed and chair levers or assist bars, height-adjustable beds, handrails, grab bars, fall mats and lift chairs to name a few. But just like the field of fall prevention technology is developing all the time, the DME industry is still finding better ways to assist residents with increasingly complex needs.
From height-adjusting power toilets to floor-level beds, there are all manner of assistive devices for falls prevention available on the marketplace. Key questions you may wish to observe when considering different types of DME are:
1 - Is it user-friendly? No matter what innovative, cutting-edge features the equipment can provide, it won't be very useful without your residents and staff being comfortable with using it.
2 - Is it adjustable? Individualized care is a big thing now and rightly so. Humans come in all sorts of shapes and sizes and so what works for one, shouldn't be assumed to work for another. Looking out for DME that is easily adjustable for the use of different people is advisable. Pat Quigley recommends implementing an "individualized bed height program" in nursing home settings to assist with safe bed transfers and urges caregivers not to forget about seat height and toilet height too.19
3 - Is it visually appealing? We understand that for some items, functionality is going to trump aesthetics. However, if there is a choice about whether to choose an item that is residential-looking, homey and non-clinical without loss of clinical functionality then this will no doubt assist your marketability as well as contribute to your resident's sense of well-being. No one wants to be in a hospital, especially those with cognitive impairment who can't remember why they are there. Sometimes ugly DME equipment can really ruin the peaceful ambiance of a residential nursing home and make it feel clinical, uninviting and even alarming for the residents.
4 - Is it cost-effective? At the end of the day, even not-for-profit nursing homes have to break even so cost has to be considered. Cost doesn't always equal the price point, though. Checking with facilities that already use the items you're considering will help you get a clearer picture of the efficacy, durability and quality of the item. Sometimes it's better to buy nice rather than buy twice so considering long-term value, not just the immediate cost, and elements like warranties is vital to get a big picture of value.
As well as providing physical durable medical equipment (DME) and hazard-proofing your building as much as possible, here are other things you can incorporate into your fall prevention program.
Increasingly it seems, health care providers are opening up the conversation about technology and how it can impact on the prevention of falls and breaking the cycle of recurrent falls.
Legacy technology devices such as bed exit alarms. chair alarms and noisy nurse call systems may have been ditched due to evidence regarding noise at the bedside and alarm fatigue that caregivers experience but some of these may be useful to repurpose.
Some providers, as one example, have repurposed bed exit alarms to repositioning alarms, to alert caregivers to the person moving in bed, which could indicate that they need to get up, or are close to the edge of the bed.20 As long as these don't disturb the resident's sleep through sound or light disturbance, these may prove to be a useful tool in alerting nurses to the resident's needs in a timely fashion and hopefully preventing injuries in patients from bed falls.
"Look at the technology that's available to you. To be able to use sensor technology, surveillance technology, motion sensors, silent sensor technology. Many of these technologies, they don't have to alarm at the bedside."2 - Patricia Quigley
In recent times, AI and sensor surveillance technology for fall reduction have been growing in popularity in some long-term care communities.21 Privacy can be a key objection to these so opt-in by the resident or their power of attorney is crucial to the implementation of these systems. They can also be expensive, yet many have proven to be demonstrably effective at detecting falls which can aid in your root cause analysis in the case of unwitnessed falls. This then allows future care planning to include more informed and accurate data to prevent future recurrent falls.
The routines and care plans that you implement for residents with a high risk of falls are vital to successfully preventing avoidable falls. Ensuring that leadership and the wider team have a working knowledge of how to effectively care plan based on specific fall risk factors for falls and not just the knowledge that there is such a risk is so important.
We know that not all falls are preventable so when a fall does occur, root cause analysis and on going care planning in light of the new information recorded is key to preventing future falls. There are many elements of post-fall documentation that the first responder and clinical team are responsible for completing including the incident report, updating the EMR, recording findings from the first responder head-to-toe assessment, creating a new fall risk assessment and updating the resident's care plan.22
Of course, it goes without saying that the immediate priority is to ensure any injuries are dealt with and urgent needs are met after a fall but it is also vital to implement efficient routines for documenting fall events, performing your root cause analysis for a fall and care planning accordingly in light of the new information.23
Regarding preventing falls in the nursing home as a functional team, continuous improvement and a commitment to excellence in the quality of care provided are core elements of an effective fall prevention strategy.
Ensuring that there is a system of continuous staff education and training for team members in long-term care settings is an excellent way to ensure your staff have a working knowledge of best practice fall prevention interventions and fall prevention programs in nursing homes.
Also, in cases where recurrent falls are an ongoing issue in your facility, it may be wise to involve the QAPI team for recommendations for large-scale improvements that could benefit your current fall prevention program.
There are many free or inexpensive staff training programs available to help nurses and caregivers to improve the quality of care that they deliver to residents. Accora, as an example offers regular webinars on fall prevention and written content to help long-termcare professionals prevent falls and fall-related injuries at no cost to providers.
Communication is also a key pillar of successful fall prevention measures. If important information and data get lost between shifts, then this is potentially disastrous to continuity of care and effective care coordination. Dr Quigley explains the importance of staff communication in the prevention of falls in a recent learning session.24
"At the point of care, the elements of a fall prevention program does include communication. And that's communication about the care plan. How is it working? We don't oftentimes know how the care plan is actually working. So, this includes your handoffs, how you do your rounds to make sure you're keeping eyes on those residents who really need to have increased surveillance, your whiteboard communication, what's communicated in team meetings.
"Handoff communication is such an integral part of care coordination and delivery of safe patient care. So, your handoff efforts are so important, and they have multiple functions - it's about transferring responsibility and accountability for our resident's care to the next person."25 - Patricia Quigley
Training on effective communication between caregivers and documentation processes is key to ensuring that quality care is being delivered consistently.26 In addition, effective and proactive communication with family, their power of attorney and other stakeholders in that resident's quality of life is key to ensuring the best outcomes for that person.
There was a lot to unpack in that article but the key elements for you to take away with you are that assessing a risk for falls must go beyond simply establishing a yes/no answer via a risk assessment tool as to whether the resident is a high fall risk. Get specific and ensure that all caregivers are recognizant of the individual factors that make up this perceived risk for falls, be that cognitive or visual impairment, comorbidities, the presence of high-risk medications, history of falls or gait and balance challenges. Ensure the interdisciplinary team is aware of the specific risk factors for falls.
In terms of fall prevention programs in nursing homes, it's best practice to try and accommodate for mitigating those risk factors that are modifiable through means of assistive equipment, devices, technology, care planning, medication reviews, effective communication between the team and other stakeholders or other fall prevention interventions.
While many elements are covered in this article, it is important to note that fall prevention and the associated risk factors for falls is a multifaceted topic that would be impossible to cover thoroughly in one article. This is intended to serve as a comprehensive overview but is by no means a complete or in-depth account of every element of fall prevention. We also wish to note again that not all falls are preventable, but there is no doubt more we can do to avoid preventable falls.
So, stay curious, pursue staff training opportunities and share knowledge with others and residents. One way you can stay curious about innovations in fall prevention is by joining our Accora Cares community.
If, like many other long-term care professionals, you’re concerned about the three “never events” that LTC providers strive to avoid: Falls, pressure injuries and F-Tags then Accora Cares is the monthly newsletter for you.
1 - https://www.cdc.gov/falls/data-research/index.html
2 - https://us.accora.care/blog/fall-prevention-for-nurses-and-caregivers-lets-get-clinical
3 – https://us.accora.care/webinars/5-tangible-ways-to-prevent-falls-in-dementia-care
6 - https://us.accora.care/webinars/reducing-fall-risk-in-older-adults-beyond-just-gait-and-balance
7 - https://us.accora.care/blog/a-physical-therapists-perspective-on-reducing-fall-risk-in-older-adults
8- https://youtu.be/xCwP6sf5g3A
9 – https://us.accora.care/blog/design-for-an-aging-population
10 - https://us.accora.care/blog/the-connection-between-sarcopenia-and-falls-and-how-to-manage-it
11 - https://us.accora.care/webinars/the-role-of-nutrition-hydration-in-fall-prevention
14 - https://us.accora.care/blog/polypharmacy-and-falls-risk-in-the-older-adult-population
15 - https://www.deprescribingnetwork.ca/medications-and-falls
17 - https://us.accora.care/webinars/top-10-cited-f-tags-and-how-to-avoid-them
18 - https://us.accora.care/whitepaper/how-design-can-help-reduce-and-prevent-falls-in-senior-communities
19 - https://us.accora.care/blog/10-tips-for-safer-bed-exits-in-long-term-care-with-dr-pat-quigley
20 - https://us.accora.care/webinars/strategies-to-maximize-safe-and-assisted-bed-exits
22 - https://us.accora.care/webinars/fall-documentation-and-root-cause-analysis
23 - https://us.accora.care/blog/best-practice-fall-documentation-and-root-cause-analysis
24 - https://us.accora.care/webinars/fall-and-injury-prevention-lets-get-clinical
25 - https://youtu.be/faSISz0JUqc
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