Falls Prevention Mapping the incidents of falls as they occur throughout a nursing ltome.

facility can be used to pinpoint a specific pattern related to location, shift, time of fall, urrcl/or particular day. By using a falls mapping tool, a visual representation on tlte emerging, patterns for falls allows for more expedient and effective dissemination of falls-relutecl clata, (fucluding prevention measures), to front-line staff. Ily Janusz Kaleta, B.Sc.N. (4th year), R.P.N., C.P.T.A.

'p rofessional care staff at Ccdarvale I T"rtu." Lons-Term Care Home in

To.lnto have recognized the importance of developing a falls
dorvntor.vn prevention program that works. Analysis of past interventions used at the Cedarvale facility revealed that, while the response by staff to resident falls was prompt and prof'essional, and incident data consistently recorded. the

any emerging patterns. As a result he

correctly identified the major clusters of outbreaks in the city. He successfully

a week. it is possihle to track falls continuously ort a trtonthly basis. The

recortlecl data self-arranges into clusters (cokrur-coded on tlle tool) and leads to the intelpretalion of emerging themes.

identified a particular water pump on

Broadwick St. in the Soho district which he suspected of having water

contaminated with fecal matter. In 1854, he convinced a local London council to disable the contaminated water pump by removing the handle.

In the graphic of the Fall Analysis Tirol. one can see multiple falls occuring in the early morning hours

interprofessional communication and analysis of causes of falls was done rather poorly. Staff, therefore, developed a simple colour-coded visual tool

Within days, the deadly cholera epidemic in that area came to an end. To prove his point, Snow had mapped

the London cholera outbreak. He

visually depicted clusters of choleraoutbreak data seen in different parls

that would allow mapping of falls in real time and the recording of essential
details including the location of the fall, nursing shift (days, evening, night), and specific action plans incorporating the Plan-Do-Study-Act Quality Improvement Model. (See sidebar on the P-D-S-A
model

of

London. The mapping technique

he used is the basis of the F.A.C';|. Analy si s Kale ta To ol, whichis described below, and which is now employed at
Cedarvale Terrace.

for improvement. See page 6)

Falls analysis
The inspiration for this initiative on 'falls mapping'came from the historical approach taken by Dr. John Snow who deciphered the origins of the London cholera outbreaks in the mid-1800s. Snow carefully analyzed the map

Falls mapping Mapping the incidence of falls throughout a nursing home facility
can pinpoint a specific pattern relative

to exact location, shift, time, and/or

particular day. This visual representation

on falls allows for

expedient

and

of

London

to sort out the data of

cholera cases into identifiable clusters and locations and then focusing on
Page 4

eflective dissemination of data to frontline staff. Because nursing staff in LTC homes provide care 24 hours a day, 7 daY

Note missing hanclle ott thc walerpump at the Dr. John SIrow tnetnotial in Soho.

Canadian Nursing Home

Fall Analysis Tool

Kaleta, Janusz,20l0

Locations legend
Each coloured

Nursing Shifts
07:00 - 15:00 Study/Actions:

dot represents

afall in the
corresponding location, day, time and shift.

l.
2. 3.

Safe footwear

Assist with toileting

Use assistive devices Safety checks

4.

15:00 - 23:00 Study/Actions:

1. Communicate risk

2. 3. 4.

Assist with toileting PM hygiene care

Safety checks

23200 - 07:00

Study/Actions:
1.
Safety walkabouts beds

2. Lowering

3. Early toileting 4.
Safety Checks

between 05:00 to 06:00 in residents' rooms (red) and washrooms (yellow).

develop appropriate interventions. (See page 8 for 'Team goals').

Bibliography . OHQC - Ontario Health Quality

Rcsidents-Firsl Advaneiug Quality.

Council,

With this information,

appropriate
be

falls prevention interventions can

implemented by the night shift.

Interventions
Based on the location of the identified risk factors, suitable interventions can

in Ontario ', I-ong-Ternr eare l{-mes. SoadMap to lalls

Preyentiln = May, 2010. See: <http://www. res identsfi rst.caldoc u me nts/qi roadmap s/rfpreventingfalls-d6-may
I
1

better

Front-line staff also relate much to a visual representation of

the collected data rather than verbally reported numbers alone. The visual
representation ofevery fall is charted in

by the nursing teams, such as walkarounds by staff, early toileting

be developed

pdf>.

relation to date of the fall, time of the fall, the location [i.e., room, washroom, lounge area, recreation room, etc.],

and the specific shift [day, evening or nightl. Staff now have access to a greater understanding of the specific patterns and probable risk factors for the occurrence of falls. For example,
note the number of falls on weekends.

ofresidents, frequent safety checks, etc. Providing a visual guidance to front-line staff, such as a colour mark on the wall indicating the position a particular bed should be lowered every evening was also found to be a simple and effective way to ensure residents'safety.

. RNAO - Registered Nurses' Association of Ontario, Pr-eventiln. o*f . Ialls -and

Fall IqDqes
i-n

Lhe Older Adult.

RNAO,

:5,

Available

at:

<www.mao.org/Page. Retrieved

asp?PagelD=$24&ContentlD=810>.
on May 15,2011.

. RNAO, Falls Preventiol: _Buil=djn: the Esutdatlons lor PauEntja ly'-Self-Learnin

Paqkagc. R-NAQ Nursing Best hactrce G.uidcline

The Falls Prevention Team

also

Prograq" 2007. See: <www.rnao.org/Page.asp?P

agelD=924 &ContentlD= I 707>.

recognized that, at night, residents frequently experience reduced vision

acuity, slowed adaptation to darkness,

Ontario Injury Prevention Resource Centre,

Evidence-based

Falls Across the Lifespan;

Practrec-S-v.ntbEsts

All the locations are colour-coded in order to provide a means to identify

potential risk factors for falls and to

and reduced depth perception

colour contrast sensitivity.
(See

and

Docurnent-Ilqvembel. 2008. <www.oninjuryresources.caldownloads/misc/

FallsReview-D8.pdf>.

following

page on photo-luminescence).

Lynons, R., John, A. et a1., Modification of the

home environment for the reduction

of injuries;

The P-D-S-A quality improvement process

As a 'model for improvement,' the Plan-Do-Study-Act is a simple tool for making or accelerating change. The P-D-S-A cycle has been successfully employed by hundreds

C oc

hrane

C o I laboration,

2006.

. CNA -

Canadian Nurses Association. Back-

srounder:
I-$uas,2005.

The Built

Environment- Iniuru

Prevention-ane!-Nursing:

of health care organizations - including nursing homes - to improve many health care
processes and ensure the saftey of clients.

Summary

of

the

Wasner. L.. Rust. T.. Safetv in Lons-Term Care

Although originally designed to be used in the business environment, the P-D-S-A model is a repetitive (oi iterative) four-step process or cycle that starts off small to test
the potential effects on changes that have been made. This can lead to larger and more
targeted change(s).

Setunes.-Broadcnr@
Include Long-Term Care Services: Cdn. Patient
Safety Institute; 2008.

See

<www.patientsafetyinstitute.cal

With the right health care personnel selected for the team (i.e., a Falls Prevention Team), and the objective established (i.e., reduction in the incidents of resident falls),
the variety of possible actions to reduce the number of falls suffered by residents is then discussed in detail by team members. The team has to initially determine what it is they want to accomplish with the change(s)

English/research/commissionedResearch/
SafetyinLongTermCareSettings/Documents/
Re po rt
s

/LTC

7o

20 p ap er

Vo

20 - Vo 20 S af ety

Eo

20

inTo2lIll

CVa20 S

ettin gs%o2} - Vo20200 8.pd$.

it intends to address - the objective (i.e., reduction offalls). . The first step involves planning a test or observation (i.e., assistive devices such as using visual guides). This step also includes a plan for collecting relevant data from
various sources (i.e.,falls mapping, staffintervieu,s, incident reports, etc.).

. Zimmerman, R., Ip, I., et al., An evaluation of patient safety leadership - walkarounds;
Healthcare Quarterly; Volume 11; Special Issue; P 16-20;2008.

. . .

About the author

the change/
Janusz Kaleta, B.Sc.N. (4th year), R.P.N.,

The second step is to try out or do a test on a small scale and see

if

innovation leads to an improvement (i.e., a reduction in resident falls). The third step involves setting aside time to study or analyze the results of the test, (i.e., a test to determine the eficacy of strategically placed visual guides to reduce falls
as determined,for example,from the mapping procedure).

C.P.T.A., is a staff educator at Cedarvale Terrace Long Term Care Home in Toronto.
Author contact: <jkaleta@cedarvaleterrace.ca>.

The fourth step is the refinement, or action stage; that is, the team takes rvhat has been

learned from the test and refines or improves on it.

The author acknowledges the input of

After testing the change on a small scale, including duplicating the test and learning

the multi-disciplinary team at

Cedarvale

from each test, and refining the change or changes introduced, the team now has the
option to implement the changes to other parts of the facility. . For more infbrmation on P-D-S-A, see: <www.innovations.ahrq.gov/content.aspx?id=2398>. Page 6

Ter-race, as well as residents and families,

front-line nursing staff, the medical team,

rehabilitation/physiotherapy, administration,
housekeeping and dietary departments.

Canadian Nursing Home

To prevent falls by residents due to visual challenges - especially at night - the Falls Prevention Team at Cedarvale Terrace partnered with Gloway Solutions, a safety products company that produces night-time navigation systems suitable for institu-

tional settings. about 30 minutes

The products , which are photo-luminescent, require of natural or artificial light to

charge. The stored energy emits light in the dark for over eight hours, which is ideal for visual guidance

to residents looking for assistive devices, call bells, glasses, etc. Even holding bars can be illuminated in order to safely self toilet. (See page 8)

(Above) Safety bar

daytinrc.

(Bektw) At night witlt photo-lurnittescence.

As iliustrated adjacent, the use of photo-luminescent products has been found to be an effective

lvay of

enhancing night-time navigation for more independent and mobile residents. This is
especially important when a resident experiences a sudden voiding urge at night due to physiological impairment, i.e., poor sphincter control or earlystage incontinence.

Too often, residents will rush to the washroom without turning the lights on or looking for assistive devices, a scenario that significantly increases the

risk for falls; photo-luninescence significantly reduces this

risk.

\'s.*,'
* -

It's been known for exists between the difficulty in rising from a chair and r'valking a short distance, and the risk of falling. The simpie "Timed get up and go" test measures the time it takes for a resident to rise from a chair', walk a ferv
meters, and then return. The
across the room, and/or greater the risk of falling.

some time that a strong correlation

longer it

takes to rvalk
''':
:

the level of unsteadiness, the

(Above) Sirtk tltrrirtg tlaytiltlc

r.r.::,t i' r.::$s:r:;:;'r)'.,

(Ilelow) Gkrrvirtg cdgcs of sink rtt nigltt

-,.;.''.). ':

.)

'.:

.'.

'

Even if a resident is not physically injured in a fall, the

experience can result in psychological damage.

Fall researchers describe a "fear- of falling cycle" in rvhich after a fall, the person become so afraid of falling again they limit their activities. This in tum decreases
their fitness, mobility and balance and leads to decreased social interactions, reduced satisfaction rvith life and increased depression. This cycle the risk of another fall.

of fear further increases

Volume 22,

Nunber3, October,

2017

Page 7

Team goals in falls prevention at Cedarvale Terrace Long-Term Care Home

The Falls Prevention Team at Cedarvale Terrace strives to reduce the number of falls and fall related injuries by early identification

The Team also provided for 'residents at risk' a number of falls

prevention items such as:

of risk factors and provision of suitable interventions

evidence - while reducing the use of restraints.

based on

The Cedarvale Tenace Falls Prevention Program is focused on

inter-professional collaboration with a focus on the unique needs of
residents and families.

. Alarms with non-removable clips . Head protective soft helmets . Geri Hip Protectors . Assistive devices via Physiotherapy
. Prevention of injuries related to use of anticoagulant therapy
One of the primary goals of the Team was to reduce the number

Reduction in transfers to hospital emergency units as a result of

falls and fall related critical injuries have been set as a priority. The following additional P-D-S-A [Plan-Do-Study-Act], initiatives with
the focus on falls reduction, have been conducted:

offall-related critical injuries such as head trauma and hemorrhage.

All

residents on anticoagulant therapy, such as Coumadin, have been

Falls Prevention Brochure For New Residents and Families In an effort to improve communication and encourage a preventative approach to fall risk, the Team developed a brochure as part of
the Admission Package for new families of residents. The aim of the

identified and appropriate interventions were added to their Care Plans. INR levels are monitored as per physician order to ensure
therapeutic range. This was completed in 2001.
. Safe0 Cards
a1l

The Team designed Safety Cards intended to prompt

brochure is to share with them a knowledge of the risk factors for falls and apprize them ofthe need for items the resident should have: non-slip footwear, eyeglasses, assistive devices, belts, etc.

front-line care staff to be proactive and aware of three questions when interacting with residents, or before leaving their room. The
three questions focus on: need to void/use washroom, pain, and any other need such as having certain items close by, i.e., remote control,

Safety Champions

Last year, the Team recruited "Safety

Champions" from frontline staff who could share their expertise of falls prevention with new employees. All Champions volunteered to
act in this project and received "Safety Champions" pins.

book, dentures, tissue, phone, etc.

The card will also list "Universal Falls Precautions," an easy-

to-follow guide for front line staff. The RNAO's Nursing Best
Practice Guidelines recommends use of Universal Fall Prevention I Interventions for all patients (RNAO,2007).

In was also arranged for residents at risk to have Low Profile BedSide Mats to prevent critical injuries.

Unintended consequences An overlooked issue in falls prevention

Researchers evaluated a broad range ofinterventions to prevent falls - with a wide range of outcomes. A study from Australia

illustrates an over-looked issue about falls intervention outcomes.

Over 1200 institutionalized older adults were assigned to one of

three fall-prevention programs:

. . .

one-on-one counseling by a physical therapist using written and/or video materials; materials alone; and
a usual-care control group

Encouraged to walk
Falls were reduced 507o in the one-on-one counseling group
compared with the materials-only and usual-care groups. However, only among the cognitively intact did the intervention show

a positive outcome. Unexpectedly, falls among the cognitively

impaired were more common in the intervention group. The study has two main messages, according to the researchers. Besides being labor-intensive, prevention programs can have

unintended consequences among certain patient populations. In one study, cognitively impaired patients had more falls after intervention, perhaps because they were encouraged to walk.
Concludes the authors: Different fall-prevention interventions
may be required in different

populations.

Source: Journal Watch General Medicine, Ap.ril 12,2011.

Canailian Nursing Home

Diuretics increase risk of falls in nursing home residents

Residents who are starting on a diuretic,
and those who are already on a diuretic and are switched to a higher dose, have an acute increase in their fall risk, says a study from new prescription for a diuretic or an increase

Nursing home residents the most vulnerable to falls

There are a number of reasons why residents of nursing homes are more vulnerable to falls than community-dwelling elderly:

in the

dosage. The increased

risk

was

especially pronounced with loop diuretics which are used in cases of impaired kidney
function, i.e., hypertension, edema. It was recommended that increased surveillance for all residents take place for the first two days following a change in diuretic in order to reduce falls.

the American Geriatrics Society Annual

Scientific Meeting held

. the high level of frailty

in Baltimore this

the number of co-morbidities

past Spring. The study results show that the

. cognitive deficits are comlnon

risk for falls in residents increases more than

two-fold within one day of their receiving

. inactivity is common . the side effects of medications

o

the care giver/resident ratios

Certain antidepressants tinked to nursing home falls

In the days after they start taking nonSSRI (non-selective serotonin reuptake
inhibitor) antidepressants, such as bupropion or venlafaxine, residents are at significantly greater risk for falls, according to a new
study presented at the Alzheimer's Disease

. availability of appropriate therapies

a

"Our results identify the days following

new prescription or increased dose of a non-

SSRI antidepressant as a window of time associated with a particularly high risk of

Universal falls risks There are other reasons for falls, including the following - but these are
universal due to the natural aging process and the effects of acute and chronic health

International Conference in Paris this past

summer. Researchers found the increased

falling among residents," said study author Dr. Sarah Berry of the Institute for Aging Research at Hebrew Senior Life in Boston.

conditions.

review

of the
'

literaturex

Newer drugs. including serotonin-norepinephrine reuptake inhibitors, may also be associated with risk of falls, it was noted' I

indicates the following risk factors:

risk for falls also applies to those who had

more advanced

age

gender

dosage increase of their current prescription.

. chronic and acute illness 'vision changes

Falls may be an indication of early Alzheimer's symptoms

Falls are more common among individuals with the earliest signs of Alzheimer's, who
are twice as likely to fall as healthy people,

ment and memory loss, are important; however, the results of this study illustrate the significance of understanding that, in some people, changes in gait and balance may

.cognitiveimpairments'medications .risk+akingbehaviours'inattention . inadequate diet/exercise ' fear of falling

. physical disabiiity/muscle weakness

heavy, awkward handbags

researchers said during

a presentation at

. diminished physical fitness

the Alzheimer's Disease International Conference held in Paris in mid-July.

appear before cognitive impairment,"

spokesperson said.

. alcohol/drug use 'inappropriate footwear

Also pointed out was the growing evidence

Environmental risks
The surrounding environment can also
harbor risks that increase the probability of falling. In the nursing home environment

Gait and balance

Otder adults with Alzheimer's may also be at higher risk for falls because of balance and gait disorders and problems with visual
and spatial perception caused by the disease.

suggesting

that'silent' biological

changes

may be occurring in the brain a decade or more before the outward symptoms of AIz-

heimer's are observed. According to this

fall by an older adult, who otherwise has a low risk of falling, may signal a need
study, a

well as in the community), institutional hazards are especially lethal: inferior de(as

"Understanding the traditional hallmarks

of Alzheimer's, including cognitive impair-

for an evaluation for Alzheimer's. I

signed or maintained buildings; inadequate building codes; poor enforcement of safety regulations; lack of hand rails or grab bars; slippery floors; poor lighting; surface glare;

Multi-faceted podiatry interventions can preYent falls

Among seniors, foot problems are associated with falling, a major risk factor for fracture. In a randomized controlled trial, Australian investigators compared the effectiveness of a multi-faceted podiatry intervention, versus routine podiatric care in

however, received a multi-faceted

treat-

lack of toileting and rest areas; beds too

high; room and halhvaY clutter.

ment regimen consisting of full-length foot orthotics, the provision of

prefabricated appropriate footwear, an indepth foot and

"Prevention of Falls and Injuries Among the El-

ankle exercise program, and education in fall prevention. The control group received
podiatric care only.

derly: Special Report," Office of the B.C. Provincial Heatth Officer, 2004. See: <rvww.health.gov.

preventing falls in 305 community-dwelling

bc.callibrary/publications/yearl2004/falls.pdf>'

elders with

a mean age of 74. All

had

At one-year follow-up, the number of falls

was signilicantly lower in the intervention group than in the control group. The intervention group experienced one fracture; the control group had seven

chronic foot pain, were receiving podiatric care. and were at elevated risk for falls.

Both control and intervention

grotlps

Did you know: Falls are the leading cause of injury costs in Canada and account for $6.2 billion or 3lEa of total costs of all injuries in
a

continued with the podiatric care they were currently receiving. The intervention group,

fractures. I
,O'7

year. From: Safer Health Now, a program

Journal Watch General Medicine

l2l ,2011-

Volume 22, Number 3, October, 2077

of the Canadian Patient Safety Institute. Page 9