F

alls are a major problem in long-term care facilities. Up to 75% of residents experience 1 or more falls associated with significant physical complications ranging from minor bruises and sprains to more serious events (eg, hip and other fractures and spinal cord and brain injury).¹ Given the extent of and consequences associated with resident falls, it is important for facilities to address the problem.
       In order to reduce the risk of falls, caregivers need to understand the conditions under which falls occur and the most common factors associated with fall risk. Approximately 10% of falls occur because of sudden medical illness (eg, fainting or dizziness) or “accidental” trips and slips.² In most instances, these falls cannot be predicted and, thereby, are not preventable. The majority of falls, however, are due to a host of underlying internal and/or external factors (see Table 1), which can be anticipated.

Table 1

They are, therefore, potentially preventable.¹ With an increased knowledge of which factors are associated with fall risk, caregivers will be able to more easily explore appropriate multidisciplinary solutions aimed at reducing fall risk. Therefore, a basic starting point for reducing falls and/or fall-related injury is to assess each resident’s risk of falling.
       While assessing fall risk will enable caregivers to anticipate risk correctly more often than not, it is important to recognize that fall risk is not static but a dynamic and ongoing and changing process—one that is dependent on acuity of illness, medication changes, and/or unsafe environmental conditions affecting mobility, physical status, and cognition. So aside from implementing an organized program to assess fall risk, having a method of monitoring residents who are at risk is a central component of efficient fall prevention. The purpose of this article is to provide long-term care facilities with guidance on strategies for monitoring fall risk.

Monitoring Strategies

       Since many falls occurring in long-term care facilities are foreseeable and preventable, monitoring or observing residents at risk of falling is based on the principle that risk can be managed (ie, that the early detection of risk activities and/or conditions can facilitate efforts to prevent falls). There are many strategies that can be used to monitor residents and reduce the risk of falls.

Safety Rounds

       The purpose of safety rounds, in which caregivers conduct walking rounds every 30 minutes or so, is to visibly check on the safety of residents at risk for falls. Adjustment of staffing levels may be necessary to increase supervision during times of day when many residents are carrying out activities of daily living (ADLs) and are, therefore, at a higher risk of falling. While observing “at-risk” residents may be limited by both the number of staff (since caregivers can quickly become overloaded by monitoring too many residents simultaneously) and the design of many long-term care facilities (eg, resident rooms being located far from the nursing station, necessitating increased travel times for caregivers), there are several options to ease the burden, including:
• Targeting rounds to those residents with high-risk conditions and/or circumstances, such as change in medication routines, noncompliance with nurse call systems, and reduced staffing levels
• Maintaining a continuity of caregivers who are already familiar with a resident’s care and routines and are more likely to detect unsafe conditions and intervene in a timely fashion than are caregivers who are unfamiliar with that resident
• Facilitating observation by placing residents in a high-traffic areas, such as near a nursing station or in a multipurpose day room or dining room
• Educating families about their loved one’s risk of falling and using them to help monitor risk. Family members who have been educated about the risk of falling can tell staff if their loved one is experiencing any physical or behavioral changes that might increase the risk of falling. When involving families, it is important to formalize a reporting system for them; families need to have an established staff member, such as the head nurse, with whom they can share their observations.

Eyes and Ears Program

       From a risk management viewpoint, having an insufficient number of caregivers available to watch over and anticipate the needs of residents at risk of falling can undermine the best of plans to prevent falls. One solution to the problem of caregiver shortages is to utilize all facility staff and employees (eg, nursing assistants and housekeeping, dietary, laundry, clerical, maintenance, and administrative staff, etc.) who are in regular contact with residents and/or their environments to assist with monitoring residents. The purpose of this monitoring strategy (sometimes referred to as a “falling leaf” or “falling star” program) is to prevent falls by increasing staff and employee awareness of residents at risk for falls and training them to detect changes in residents that may lead to falls.
       In essence, this program serves as another set of eyes and ears for the nurses to help monitor fall risk. The more eyes available to watch over residents at risk and observe warning signs (eg, unsteady balance or a change in condition, such as agitation, confusion, weakness or fatigue, needing help with daily activities, etc.), the better. The more ears available to listen to resident complaints (eg, dizziness, weakness, unsteady balance, etc.), the better.
       Changes reported often serve as an early warning system, allowing clinical staff to evaluate residents for an underlying cause, disease, and/or drug reaction that may result in a fall. Residents most likely to benefit from an eyes and ears program are frequent fallers, wanderers, and individuals with dementia and gait/balance impairments. It is important to limit the number of residents participating in this program. Identifying too many individuals who require monitoring may desensitize staff from paying attention to those most at risk for falling.

       Editor’s note: The second part of this article, focusing on sitter programs and fall alarms as monitoring strategies, will run in the January/February 2007 issue of ECPN.