Root Cause Analysis for Unwitnessed Falls in the Nursing Home

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. RCA or root cause analysis is an investigative process for us to find out what happened, why it happened and to determine what can be done to prevent it from happening again.

The CDC 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% of them are thought to be unwitnessed. So, if no one saw it happen, how can you get to the cause? Learn what to look for, what questions to ask, and how to use documentation to support an effective root cause analysis in this useful, bite-sized article.

What is an unwitnessed fall?

According to the WHO, 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 falls:

• 70% of resident falls occur in the bedroom
• $50 million is spent on non-fatal fall injuries each year
• $754 million is spent each year in relation to fatal falls
• Fall death rates increased in the US by 30% from 2007 to 2016
• 36,508 older adults died from preventable falls in 2020

It’s clear that due to the aging population and higher life expectancies, that falls are more of an obstacle to delivering quality care and resident well-being than ever and the problem will only 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.

Risk assessments

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

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. You should also perform a risk assessment upon transfer or re-admission of residents.

Risk factors for falls to consider in your risk assessments

• Historical - Does the resident have a documented history of falls? How many of those were injurious falls? 
• Physical - do they need assistance to walk or have any physical disabilities?
• Cognitive – are any conditions affecting their cognitive functions?
• Pharmacological – Perform a medication review to be aware of 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 care plans which could indicate a fall risk?
• Environmental – factors such as changes to that person’s environment and items brought in from home.
• Other medical comorbidities – include 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?

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

First responder steps upon discovery

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.
2. Assess and observe the environment for clues – while attending to immediate needs, take in details about the environment such as lighting, obvious obstacles, clutter, potential purpose, or direction of movement. Also observe the equipment within reach such as call bell, walker, wheelchair, and reacher.
3. Document the facts of the incident in EMR.
4. 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 factor, but we could not have learned this without involving non-clinical staff. Similarly, housekeeping might notice that the resident’s water jug remained untouched from one day to another which could indicate dehydration. Don’t be afraid 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 injuries gained from it. Performing a drug review at this time may be logical.
6. Notify providers and resident representatives about the event and changes to their care plan including subsequent interventions put in place for the management of 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 cure requires a heck of a lot more resources.

Not all falls are preventable but as a part of a facility-wide overall fall prevention strategy, 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.

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 detective work:

• Did this person hit their head?
• Are they cognitively 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 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 for 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. This is our commitment 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. It even promotes change in 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.

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 be alerted 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.
• 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 loss of subsequent income. Accora offers two FloorBeds for nursing homes, the lowest of which goes to just 2.8” from floor level, around the size of a tennis ball. Both our FloorBeds are available with even plane 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 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

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 your building and not place blame unnecessarily. Thorough RCAs and making a constant drive toward excellence in care a top priority 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 our elders?

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