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esidents in long-term care facilities may exhibit some common characteristics, traits, and health issues that indicate their potential for falls leading to serious injury. Programs to successfully control the falls rate cannot, however, be based solely on such generalizations. To provide ultimate care and ensure the safety and dignity of each resident, he or she must be continually assessed, observed, and monitored—before and after a fall—to determine root causes and adjust the care plan.
       The Long Island State Veteran’s Home (LISVH) is a 350-bed long-term care facility affiliated with Stony Brook University in Stony Brook, NY. The resident population of 318 men and 32 women includes veterans and spouses of veterans. There are 238 employees in the nursing department. The facility probably has a higher percentage of residents who use wheelchairs than do many other nursing homes because 91% are male, many of whom served in the armed forces. These individuals tend to have been more accustomed to being active their whole lives and display highly independent characteristics. They tend to want to assist with chores and to help fellow military members and frequently seek to rise from their chairs to assist, whether the need is real or perceived. The challenge for staff to accommodate patients’ needs to be as mobile as possible is to do it in a way that protects against injury.

Addressing Safety

       Interventions implemented as part of LISVH’s quality improvement (QI) process during the past 3 years have consistently reduced falls and injuries from incidents associated with exits from beds and wheelchairs. In 2001, the rate of falls by residents exceeded the New York State benchmark, but the impact of the new program became evident late in 2002.
       Fall events reported in 2001 ranged from 160–180 reports per month. In 2002, they declined from 100 in the early part of the year to a range of 50–80 per month in the last quarter. The quarterly average in 2002 was 190 falls. That declined to an average of 162 per quarter in 2003 and 129 per quarter in 2004. The quarterly rate of major injury from falls declined from an average of 14 in 2002 to 7 in 2004.
       We identified the falls rate as a quality-of-care issue. A nursing QI committee had previously addressed falls as part of the overall accident/incident reporting process. Committee members functioned as consultants rather than as part of a process to prevent falls. Nurses felt that many serious falls could be averted with a different approach. The nursing department developed and implemented a program that has succeeded because it is an interdisciplinary approach based on identifying and addressing root causes of falls.
       Planning began with the formation of an ad hoc committee for accidents and incidents. The committee included 2 assistant directors of nursing (ADONs) representing day and night shifts, a staff nurse, the director of education, and the administrative assistant to nursing services. The director of nursing (DON) served as an advisor.
       The committee was tasked with developing a comprehensive fall safety program to meet the following objectives:
1. Reduce incidents of falls and injury
2. Identify root causes for fall events
3. Implement programs to improve resident care
4. Analyze recurring root causes that impact quality of life or care.
       In developing the initiative, the committee emphasized the use of existing research that demonstrated clear evidence of the effectiveness of various interventions and practices to minimize injury and enhance safety. It became clear from the research that:
1. Fall intervention programs focused on individuals most at risk can reduce fall rates substantially and are the most cost-effective¹
2. Fall prevention programs must focus on resident-specific risk factors and target interventions to the individual, while demonstrating that the most cost-effective strategy for preventing falls is to identify high-risk individuals²
3. It is important to develop and implement a comprehensive, facility-wide process for determining causes and assessing risks of falls; otherwise, caregivers may miss important diagnostic clues.³
       People fall for a variety of reasons. The committee analyzed the root causes of falls from a sample of 24 documented incidents in 2001. The results correlated to the risk factors identified in the research. The major root causes identified in 5 areas studied included:
1. Clinical profile (ie, tremors, rigidity, stiffness, impaired vision, Parkinson’s disease, agitation, dementia)
2. Polypharmacy (ie, cardiac drugs, diuretics, psychotropic medications, sleeping pills)
3. Recurring trends (ie, toileting issues, previous falls, dizziness while standing, self transferring without waiting for staff assistance)
4. Mobility factors (ie, poor balance, impaired gait, reduced mobility)
5. Human factors (ie, noncompliance, response time to call light, awareness of safety issues).

Positive Changes

       Look closely at the clinical links associated with falls and develop measures that can impact those links to reduce fall incidents and identify areas of education needed for staff. In analyzing root cases, it is critical for an investigation to be done as soon as possible after an incident, with information collected from staff members who witnessed and/or responded to the fall.
       Positive culture change, education, training, and the use of bed and chair alarms to alert staff to potential incidents all combine to contribute to the success of the program. Change cannot be dictated; it is an evolutionary process. Open communication with all departments through committees and directly with caregivers is an essential part of the process. All departments are actively involved in observing and responding to the factors within the facility that might create an unsafe environment and provoke a fall or injury. Sharing information is valuable in integrating changes into the daily practices of all departments, not just nursing.
       Facility-wide educational programs introduce the staff to various facets of responsibility, including:
1. Root cause determination and documentation, using accepted analyses
2. Elimination of waist-belt restraints, which research and our own analysis had shown to actually increase falls⁴
3. Use of non-skid surfaces in chairs
4. Reliance on reports to identify residents who fell, recording detailed information about the resident to inform caregivers about problem areas and strategies to address them
5. Proper installation and operation of alarm monitoring units.
       The bed and chair monitoring and alert system is a first line of defense in 2 ways. Foremost, it is a safety mechanism. Incidents are averted when staff is alerted when a resident may be inadvertently falling or deliberately attempting to rise from a bed or chair. If not for an alert, the resident might have already been on the floor before anyone knew it. When alerted, staff members must respond immediately. That requires proper attitude and close proximity to residents.
       The system is also a planning tool. Every alert is recorded as part of the ongoing evaluation process to determine cause, aiding caregivers to adjust attention and care based on the individual’s habits. Our facility first employed alarm units in 2001. By 2004, there were 3 different systems in use. That created operational inefficiencies; each system had different functions and requirements. Efforts to properly check and maintain the various types of units proved time-consuming and confusing and required too much training and supervision.
       Our solution in 2005 was to standardize by installing a single system. Working with Meseron Sales Corp., a distributor of medical equipment, we installed the Bed-Check^® monitoring system, which was shown to help reduce falls by more than 50%.⁵ It uses a pressure-sensitive strip positioned under a bed sheet or placed on the seat of a wheelchair that senses movement by the patient. If the patient’s weight on the strip is lessened, the alarm is activated, signaling a possible fall or attempt to rise. Bed alarms are connected to the call bell system, the room’s call light, and a nurse’s station. Nurses test each alarm for proper operation during the first hour of each shift.

Conclusion

       Reducing falls and the serious injuries that they can cause, especially with an active resident population, requires an interdisciplinary approach. Quality improvement processes must rely on accurately identifying and addressing root causes of falls on the basis of an individual resident. The entire staff, not just nursing, must participate in the effort, and alert systems help staff members respond more quickly to incidents in progress.