Root cause analysis for unwitnessed falls in nursing homes

Adverse consequences of falls lead to decreased quality of life, increased risk of death, decreased function, injuries and an increase in the fear of falling for nursing home residents. RCA, or root cause analysis, is an investigative process for the primary care provider to find out what happened, why it happened and to determine what can be done in terms of preventive measures to stop it from happening again.

The Centers for Disease Control states that around 36 million falls are reported among older adults each year, resulting in over 32,000 fall-related deaths. Of these falls, 94% are thought to be unwitnessed. So, if no one saw it happen, how can you get to the root cause? Learn what to look for, what questions to ask, and how medical professionals can use documentation to support an effective root cause analysis in this useful, bite-sized article.

What is an unwitnessed fall?

According to the World Health Organization, a fall “is defined as an event which results in a person coming to rest inadvertently on the ground or floor, or other lower level.” If the fall was not seen by a care professional or witnessed by a resident with the sufficient cognitive ability to give an accurate account of the event, then this is typically considered to be an unwitnessed fall

The fall facts

Some relevant statistics around the prevalence of falls:

• Older adult falls cost the U.S. healthcare system $50 Billion each year
• 70% of resident falls occur in the bedroom
• Falls are the most common cause of traumatic brain injuries
• In 2019, 83% percent of hip fracture deaths and 88% of emergency department visits and hospitalizations for hip fractures were caused by falls
• Each year, nearly 319,000 older people are hospitalized for hip fractures.

It's clear that due to the aging population, higher life expectancies and consequent higher acuity of nursing home residents, falls are more of an obstacle to delivering quality care and resident quality of life than ever and the problem could worsen as this trend continues. So, what are senior care professionals to do about it? Well, when considering the management of falls, start with the humble risk assessment to identify patients at risk of falling.

Fall risk assessments

Fall risk assessments are pivotal to proactivity in fall risk mitigation. This is a holistic approach to evaluating the potential and actual risk of falls and should never be underestimated in your strategy for fall prevention.

When to carry out fall risk assessments

You should routinely carry out initial fall risk assessments or update existing ones upon admission, quarterly, annually and whenever a resident's condition or medication changes. Proper fall-precaution documentation dictates that you should also perform a risk assessment upon transfer or re-admission of residents.

Risk factors for falls to consider in your risk assessments

• Physical: Do they need assistance to walk or have any physical disabilities/mobility challenges?

• Cognitive impairment: Are any medical conditions affecting their cognitive functions?

• Pharmacological: Perform a medication review and note any medication that could affect their balance, vision or otherwise lead to falls. Has their medication     changed recently?

• Behavioral: Is this person typically impulsive or experiences unpredictable behavioral changes?

• Compliance with care plan: Are there any factors in their existing care plans that could indicate a fall risk?

• Environmental: Environmental factors such as changes to that person's environment and items brought in from home.

• Other medical comorbidities: Including conditions like Parkinson's, orthostatic hypotension, etc.

• Clinical risk factors for falls: Does the resident suffer from sleep disturbances, vestibular dysfunction, visual field cuts, or dehydration?

• Historical: Does the resident have a documented history of falls? How many of those were injurious falls?

By identifying these risk factors and potential hazards, long-term care communities can implement individualized safety interventions and prevention measures to prevent falls and fall-related injuries. Not only will this aid in your ability to deliver excellent care, but it will also have a positive effect on your survey results and marketability.

First responder steps upon discovery of an unwitnessed fall

The purpose of a post-fall assessment is to assess injuries from falls and determine what action might be needed to stabilize a resident.

1. Before a resident can be moved, a RN must assess them for an injury to the spinal column, obvious fractures, significant bleeding and their level of     consciousness. Provide first aid, if necessary, perform a physical examination, get vital signs and assess pain levels, respiratory status, skin integrity and signs of circulation. If there are obvious signs of spinal column damage, fracture or change in the level of consciousness, determine if Emergency Medical Services are warranted from the physical examination.
2. Assess and observe environmental hazards for clues. While attending to immediate needs, take in details about the environment such as poor lighting, obvious obstacles, clutter, the potential purpose, or direction of movement. Also, observe the assistive equipment within reach such as the call bell, walker, wheelchair and reacher.
3. Document the facts of theincident in EMR.
4. Prepare the incident report. Involve all personnel in the collection of data for the incident report, not just clinical staff. For example, the dining staff might have noticed that the resident ate less than usual for their last meal. This tells us that low blood sugar could have been a contributing risk factor. Similarly, housekeeping might notice that the resident's water jug remained untouched from one day to the next, which could indicate dehydration. Don't beafraid to play detective and involve all who are intrinsic to the resident's daily living.

5. Update their fall risk assessment and care plan according to the fall event and any broken bones or other injuries gained from it. Performing a drug review at this time may be advisable.
6. Notify healthcare providers and resident representatives about the event and changes to their care plan, including subsequent interventions put in place for the management of recurrent falls.

Incident reports for effective root cause analysis

Benjamin Franklin said, “An ounce of prevention is worth a pound of cure.”

It's a consideration we highly value here at Accora. Prevention is harder to measure, but a cure requires a lot more resources.

Not all falls are preventable, but as part of a facility-wide fall prevention program, an efficient and detailed incident report is vital. A good incident report will aid in future fall prevention not just for that resident but potentially for others, too. They also serve as evidence that you followed procedures and adapted the resident's care plan according to changes in circumstance or risk. When it comes to survey time, this documentation will serve to demonstrate the facility's competency inimplementing timely and appropriate fall prevention measures based on the circumstances of fall incidences.

A good incident report should guide us to ask and answer questions that lead us to ask further questions. Use your findings in combination with what you and others already know about that person to create an effective incident report.

Here are some questions that you can use to start the process of your root cause analysis detective work:

• Did this person hit their head, and if so, what is their level of injury?

• Do they have a cognitive impairment? Are they able to report on what happened?

• Are there any dangers in the immediate environment?

• Were there signs of injury or abnormal vital signs in the initial head-to-toe physical examination?

• What were they doing or likely to be doing prior to the incident?

• Was their care plan followed and were all appropriate interventions in place?

• Is the person incontinent?

• Where did the fall occur and at what time of day?

• Were staffing levels normal?

• Anything noticeable from a system/operational concern?

• Was the resident's routine that day typical for them?

• Any changes in medications that could increase their risk of falls?

• Did they feel dizzy or weak?

• Was the floor wet?

• What was the surrounding area like? Busy, loud, cluttered?

• Were they using an assistive device?

• Did they have their glasses on/hearing aids functioning?

• Were they reaching for something?

• Did they use the call bell? Was it within reach?

• Where were they trying to go?

• Are they in pain?

What a successful root cause analysis looks like in practice

We can prevent future falls or injuries through a deep dive RCA in many cases. This is our commitment as medical care professionals: that we can always do better for our residents. This is key to a holistic approach to a fall prevention program. Think of it as a tool for quality improvement. It engages staff in analyzing why events occur collaboratively. It even promotes change in facility culture by encouraging a non-punitive approach. Ultimately, this approach allows us to individualize the care of our residents and deliver a constantly improving level of quality care to the people in care facilities.

Solutions and innovative strategies for reducing unwitnessed falls

• Technology – AI-powered smart surveillance equipment can aid in root cause analysis as well as lower overall fall rates in long-term care communities. A system such as that offered by Safely You begins recording when a fall or unusual movement is detected so you can get an accurate picture of the cause of the fall, as well as alerting nurses to it instantly. Safely You can boast a 94% accuracy rate at detecting falls, which is, in our opinion, rather impressive. Find out more about their unwitnessed fall solutions.
• Design with care – Reducing falls in general (and therefore also reducing unwitnessed ones) can be achieved by ensuring that your care facility is optimally designed to be easily navigable by seniors. Choosing appropriate color contrasts and placing strategic task lighting and perfectly positioned assistance equipment can help in reducing overall fall rates. You can find more about how to adapt care environments to best support fall prevention in our recent blog post, Design for an aging population.
• Assistive equipment – Since the majority of falls occur in the bedroom, ensuring you have the right equipment to guard against preventable falls from the bed is vital to reducing fall rates. Residents are typically less frequently observed in the privacy of their bedrooms, so any fall-prevention methods you can employ in that room can save on injuries, falls and the loss of subsequent income. Accora offers three FloorBeds for nursing homes, the lowest of which goes to just 2.8” from floor level, around the height of a tennis ball. All our FloorBeds are available with level-plane fall-safety mats that create an even surface on which to roll. This means that should the resident experience an unplanned exit from the bed, the mat effectively prevents a reportable fall because there is no change of plane and also significantly reduces the frequency and severity of fall-related injuries.

View our FloorBeds here or access our recent case study showing how FloorBed technology reduced falls from the bed by 100% in an Illinois nursing home.

Final thoughts on managing unwitnessed falls

A well-executed Root Cause Analysis can be an effective tool for your facility to reduce falls and connected injuries. Ongoing education and review of your fall prevention program can also assist in identifying gaps in care planning and interventions. It's key to promote a culture of safety amongst all staff in aged care settings and not place blame unnecessarily. Thorough RCAs and ensuring that the constant drive toward excellence in care processes are top priorities can help with this. What's more, we know that a decrease in falls can help maintain the quality of life and overall functioning of our residents, and what else are we here for if not to improve the lives of older adults in aged care settings?

Sources

https://us.accora.care/webinars/fall-documentation-and-root-cause-analysis

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/steadi/pdf/STEADICostOfFallsPostcard_508.pdf

https://www.cdc.gov/falls/data-research/facts-stats/index.html

https://www.safely-you.com/falls-behind-the-numbers/

FAQs

What proportion of falls are unwitnessed?

One large cohort study found that "75% of fall events occur when patients are not supervised by staff". While this was in a study regarding hospital falls, this study of falls is likely to translate with reasonable accuracy to the staff-poor senior living industry. Safely You identified a greater chance of falls being unwittnessed in nursing homes, up to 94%.

Determining a procedure to identify and track the circumstances of fall events in your long-term care facility will allow fall trends to be identified, and this documentation will hopefully then be instrumental in preventing the number of injurious falls.

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