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Falls are a leading concern in older people residing in assisted living facilities (ALFs)*; up to 50% of residents fall annually. As a result, there is an urgent need to address fall prevention and to improve safety practices for people living in ALFs.
*Assisted living facilities (ALFs) are residential settings designed to provide supportive housing for individuals who need extra help in their day-to-day lives but do not require nursing home care. Definitions used to describe supportive housing differ from state to state. As a result, there are many different terms for similar facilities: personal care homes, sheltered housing, homes for adults, board and care, domiciliary care, adult foster care, senior group homes, residential care facilities, adult congregate living, continuing care retirement communities, and life care facilities are some that are used. The term assisted living facilities is used in this CD-ROM to cover all current definitions of supportive housing. Most ALFs offer various levels of service. Basic service typically includes only room, board, and organized activities, while the highest service level includes assessment of physical and mental conditions, multidisciplinary care planning, medication administration, and nursing care (including assistance with basic activities of daily living).
ALFs often struggle to achieve best practice in their efforts to prevent falls. Any successful fall prevention program is highly dependent upon two things: 1. Education. It is crucial that all staff members have: An awareness of the extent and consequences of falls A knowledge of the conditions under which falls occur and what factors are associated with fall risk An appreciation of available multidisciplinary strategies or interventions to reduce fall risk Most important, an understanding of the process of fall prevention and its essential components (i.e., conducting fall risk and post-fall assessments, designing targeted interventions based on identified causes and fall risk factors, and evaluating the effectiveness of interventions for reducing falls)
2.
Resources, tools, and guidelines. These are necessary to help the staff effectively prevent falls.
Both education and resource support are important ingredients in promoting consistency of knowledge and practice among staff members and in achieving best practice. This CD-ROM provides a wealth of materials essential to beginning or improving a fall prevention program.
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.
. . . must implement a fall reduction program and evaluate the effectiveness of the program. As appropriate, this program should include an assessment process, risk reduction strategies, transfer protocols, in-services, involvement of patients/families in education, and evaluation of environment of care issues.
without access to Microsofts PowerPoint software, simply log onto www.microsoft.com and download the free PowerPoint Viewer 2003. This allows any user to view and print the presentations. In addition, the CD-ROM contains all of the decision-making guidelines and assessment tools that the staff needs to begin or maintain a consistent fall prevention program. These files are presented in PDF format and can be viewed using Adobe Reader, which is included on this CD-ROM. All documents on this CD-ROM can be accessed from the current document. Links embedded in the Table of Contents below will take readers directly to the section or form indicated.
TABLE OF CONTENTS
Falls in Assisted Living Facilities Here is a concise overview of the importance and consequences of falls, the causes of falls, intervention strategies aimed at reducing falls, and an organized approach to fall prevention for ALFs. Reducing the Risk of Falling in ALFs (in Microsoft PowerPoint) This PowerPoint presentation includes instructional notes and is designed for staff education. The presentation reviews the extent and complications of falls in ALFs, the causes and risk factors for falls, preventive strategies aimed at reducing fall risk, the essential components of a fall prevention program, and a step-by-step approach to implementing a program. Understanding Fall Risk Describes specific internal and external risk factors for falls in ALFs. Injury Risk Factors Provides a list of common factors that increase the risk of injury from falls. Risk of Falls in Alzheimers Disease Describes fall risk and management strategies as they relate to Alzheimers disease. Fall Prevention Guidelines This one-page guide provides both a summary of the fall prevention process and a standard to follow for fall prevention in ALFs.
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.
Fall Prevention Protocol This protocol is a detailed description of all the appropriate steps to take to reduce the chances of resident falls. Fall Prevention Program Policy The policy describes a proactive, standardized approach ALFs can take to preventing falls. Fall Risk Intervention and Screening Tool This screening tool assesses all risk factors for falls and recommends targeted strategies for responding to identified fall risk factors. Assessing Medications and Fall Risk Medications can be a particularly complex factor in falls, so here is a simple approach to assessing medications and fall risk. Post-Fall Assessment This comprehensive post-fall assessment form helps identify treatable causes of falls for the purposes of reducing the risk of future falls. A Basic Fall Risk Screening and Prevention Program Presents a simple approach to fall risk screening and prevention. Canes, Walkers, and Wheelchairs This basic review of canes, walkers, and wheelchairs is designed to help ALF staff troubleshoot common problems with these mobility aids. Environmental Safety This handy checklist helps staff members spot and correct common environmental hazards. Environmental Precautions This handout describes hazards associated with pathways, lighting, floor surfaces, stairways/steps, storage areas, seating, bathrooms, and tables, and recommends appropriate modifications. Exit Alarms This review of exit alarms describes the types available and the indications for using each type.
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.
CAREing About Falls (fall-prevention poster) Use this educational poster to increase staff awareness of simple fall prevention strategies. Facts About Preventing Falls (family education handout) Use this educational handout to inform families about fall prevention for their loved ones. You Can Prevent Falls! (resident guide) This educational booklet helps inform residents about fall prevention. Components of a Successful Fall Prevention Program Provides a list of the major clinical and organizational factors needed to achieve a successful fall prevention program.
This practical guide includes all of the information needed to implement a successful fall prevention program. While all the material, including the PowerPoint presentation, can be used as is, it is recommended that each facility adapt the material to meet its own individual needs. The information given is general. Be sure to consult your states specific regulations and guidelines governing supportive housing.
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press. All rights reserved.
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.
CIRCUMSTANCES OF FALLING
The majority of falls occur when residents are going about their usual activities of daily living. Most falls occur in activity rooms, dining rooms, hallways, bathrooms, and outdoors. The most frequent activities at the time of falling include walking up or down stairs and steps; getting out of a bed, a chair, the bathtub or shower, or off a toilet; getting on and off buses and vans; falling from ones chair or wheelchair; tripping over objects on the floor; slipping on water or urine on the floor; and rushing or hurrying, particularly without using canes or walkers.
Falls in ALFs can be reduced by understanding Why falls occur What factors are associated with fall risk Which strategies reduce fall risk And most important, taking action to prevent falls
CAUSES OF FALLING
Falls have many different causes, and residents may have several predisposing risk factors. The relative contribution of each risk factor differs according to the individuals underlying medical condition, functional level, and environmental circumstances. Some ALFs care for all older people, including those with dementia and Alzheimers disease, while others may only care for individuals with Alzheimers disease. As for any aging person, falls associated with Alzheimers disease are often precipitated by a host of internal and external risk factors. Individuals with Alzheimers disease may have more cognitive risk factors for falls than the older person who is cognitively intact, but the approach to fall prevention in both populations is similar. Falls are caused by a combination of internal factors (e.g., acute and chronic disease states, adverse medication effects) and/or external factors (e.g., environmental hazards and obstacles interfering with mobility). The likelihood of falling increases with the number of risk factors a resident has (see Understanding Fall Risk).
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.
Internal factors resulting from the residents physical or mental condition that contribute to the risk of falls include Poor vision and hearing Unsteady gait and balance Parkinsons disease/other neurological disorders Cardiac or heart abnormalities Muscle weakness Arthritis Foot problems Low blood pressure Cognitive/mental impairment (see Risk of Falls in Alzheimers Disease) Medication side effects Dizziness Pain Fatigue Urinary frequency/incontinence Behavioral problems
External factors associated with fall risk consist of environmental obstacles and design features that interfere with safe mobility. Some of these include Floor spills and clutter Slippery floor surfaces Throw rugs Wet outdoor walking surfaces Unstable or low-seated chairs Poor/dim lighting Lack of bathroom grab bars Low toilet seats Inappropriate bed height Faulty stairs/steps Improper footwear Improper utilization or poor repair (worn tips, structural defects) of canes, walkers, and wheelchairs
The risk of the environment contributing to falls is greatest for individuals who have mobility problems because hazardous environmental conditions can interfere with safe mobility.
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.
It is important to recognize that fall risk prediction is imprecise. Some lowrisk residents may fall and some high-risk individuals may not. Effective risk assessment should enable staff to anticipate risks correctly more often than not, however.
Medical Strategies
Because falls and fall risk factors may be caused by underlying diseases, adverse medication effects, and resulting disabilities, all residents should be referred to their primary care provider for evaluation. Diagnosing and treating risk factors such as visual disorEssential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.
ders, gait and balance impairment, muscle weakness, cognitive impairment, postural hypotension, and cardiovascular irregularities can greatly reduce fall risk. Also, discontinuing inappropriate or excessive medications and managing existing chronic diseases is important. Last, diagnosing and treating osteoporosis (i.e., weak bone strength caused by calcium deficits and prolonged periods of immobility or reduced weightbearing activity) can help to reduce the risk of injurious falls such as hip fracture.
Among older people in ALFs, acute diseases and side effects of drugs are important precipitating factors for falls. Falls should therefore be regarded as a possible symptom of disease or a drug side effect until proven otherwise. Timely correction of precipitating and predisposing factors will help prevent further falls. See A Basic Fall Risk Screening and Prevention Program and Assessing Medications and Fall Risk, both of which offer a simple approach to communicating about fall and medication risk with residents doctors.
Rehabilitative Approaches
Residents with impaired mobility may benefit from one or more rehabilitative strategies. These consist of exercise programs, proper footwear, and ambulation devices to assist with mobility. Exercise programs can be grouped into two broad categories: general physical activity (e.g., walking, aerobic movements, other endurance exercises) and specific physical activity (e.g., training geared specifically toward increasing balance and strength). To be effective, exercise needs to be tailored to the residents physical capabilities and needs. The National Institute on Aging offers information about exercise programs for older adults on its web site (http://www.niapublications.org/ engagepages/exercise.asp). All shoes and slippers worn by residents should fit properly (i.e., not too tight or loose) and their soles should be slip resistant. Balance is generally better with shoes that have thin, nonslip soles rather than footwear such as sneakers or running shoes with thicker soles that actually interfere with balance. Shoes and slippers with rubber or crepe soles provide adequate slip resistance on slippery floor surfaces such as linoleum. If foot problems (e.g., hammertoes, bunions, calluses, nail disorders) prohibit wearing proper footwear, individuals should be referred for podiatric care. Residents who have gait and balance disorders should be using canes or walkers to maintain or improve balance and mobility. Canes and walkers also furnish residents with a visual presence of support that instills confidence during ambulation, which can help reduce their fears of instability. As with canes and walkers, wheelchairs should be tailored to meet the specific needs of the individual and be evaluated routinely to ensure they are being used safely. It is important for staff to
5 Falls in Assisted Living
Essential Falls Management Series: Managing Falls in Assisted Living, by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.