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alls constitute the largest category of adverse events in long-term care facilities, and as many as 50% of residents experience at least one.¹ Falls are associated with significant physical and psychological complications, including injury (eg, hip and other fractures), immobility resulting in muscle weakness and functional disabilities, and psychological distress (eg, depression and fear of falling).² Resident falls are equally distressing for caregivers and management, often leading to concerns about resident safety and legal liability. Family members may also become troubled when their loved one falls and, as a result, may question the quality of care provided—especially if the fall results in injury.
       Facilities must take a number of steps to reduce falls. First, facility staff must understand the conditions under which falls occur and the most common factors associated with fall risk.

Table 1

An increased knowledge of why residents fall and factors that are associated with fall risk can help staff easily identify at-risk residents and explore appropriate solutions. Second, facilities must have a formal fall prevention program in place that identifies at-risk residents and employs interventions aimed at reducing risk. This article will provide a framework for developing a best practice approach to fall prevention.

Where and When Falls Occur

       Falls from or near the resident’s bed account for nearly half of all falls.³ Most falls occur during the early period of institutionalization (ie, the first 72 hours), during night hours, and after meals. Bed and chair transfers are the most frequently cited activities that cause falls.³ Other activities commonly associated with falls include toileting and getting up from bedside commodes and wheelchairs.

Why Falls Occur

       Falls are complex events caused by multiple internal factors (eg, acute and chronic diseases and adverse medication effects) and/or external or hazardous environmental conditions (eg, slippery floor surfaces, poor lighting, elevated bed heights, unstable or inappropriate furnishings, bed rails, unsupportive footwear).² Although they happen frequently, not all falls are expected—as many as 10% occur as a result of acute medical events, such as fainting and dizziness.² In most instances, these falls cannot be predicted and, therefore, are not preventable. The overwhelming majority of falls, however, are due to a host of underlying risk factors (see Table 1), which are potentially preventable.

Fall Prevention Process

       The success of a fall prevention program is dependent upon following a process of care that includes the following steps:
       Assessing risk. Assessing fall risk is an important starting point in attempting to reduce falls, since many falls are related to anticipated or predictable causes or risk factors. The main purpose of risk assessment is to identify those residents who are most likely to fall. The rationale for this assessment is that if residents at high risk for falls can be identified, then appropriate interventions can be instituted to minimize risk. A number of fall risk assessment tools, including the Morse Fall and Conley scales, are available to assist staff. These tools are sensitive (ie, they correctly identify high risk residents) and specific (ie, they correctly identify residents not at risk). Aside from identifying resident risk, assessment tools may also help target where the need for intervention is most urgent as well as the types of interventions required. The tools can also help raise staff awareness of resident risk.
       Baseline fall risk assessments should be completed within 2 hours of admission. Since residents are subject to “a change of condition,” (eg, acuity of illness, medication and comorbidity changes affecting mobility, cognition) risk factors for falls are subject to change as well. As a result, reassessment of fall risk needs to be ongoing. A reassessment should be completed whenever a resident experiences a change of condition or medication. High-risk residents (eg, those experiencing recent confusion, taking sedatives, or suffering from recent falls or temporary acute illness) should be assessed at every shift change and immediately after falls.³
       Communicating risk. Once a resident’s risk of falling has been identified, it is crucial that their risk status is communicated to the nurses, nursing assistants, occupational and physical therapists, physicians, and other relevant staff members. Fall risk status can be communicated by placing colored decals on the resident’s chart and/or bedroom door, using color-coded wristbands, and/or documenting adverse events on daily shift reports. Formalizing and incorporating the process of risk communication into policies or protocols can be helpful. For example, everyone in the facility would know that a resident wearing a colored wristband, is “at risk of falling” or has a “potential for injury.”
       Multidisciplinary evaluation. After risk assessment, an attempt should be made to identify the cause(s) of all identified risk factors. Since most residents will have multiple risk factors, multidisciplinary referral and evaluation is necessary. The risk assessment and subsequent multidisciplinary evaluations will serve as the basis for selecting appropriate interventions.
       Care planning. A fall prevention program is only useful if an effective treatment or intervention is available. For at-risk residents, interventions need to be targeted toward identified risk factors. It is important to remember that, as risk factors change, interventions may have to change as well. For those residents at risk for falls (ie, those with an absence of any fall risk factors), the concept of universal precautions may be used. This concept acknowledges that all residents are at a certain risk of falling and require universal precautions, such as setting the bed at the lowest level, ensuring residents have necessary items, placing nurse call bells within reach, and eliminating potential environmental hazards.
       Post-fall assessment. All residents who fall should receive a post-fall assessment. The purpose of this assessment is to discover what caused the fall and to prevent another fall from occurring. Key components of the post-fall assessment include identifying all internal and/or external factors that contributed to the fall and determining the presence of any new or additional risk factors. This information is helpful for conducting an analysis of the fall (ie, “What happened?” and “Why did it happen?”) and designing appropriate interventions to prevent further falls.
       Monitoring. Monitoring or follow up of the resident’s care plan should occur on a regular basis. The purpose of monitoring is to evaluate the effectiveness of interventions in reducing falls and/or fall risk and determine what the next steps should be if the interventions failed to reduce risk.

Summary

       An effective fall prevention program can be achieved by adhering to an organized clinical approach. This consists of carefully assessing fall risk on a regular basis and implementing interventions based on the needs of each at-risk resident.

Got a Question?

       Dr. Tideiksaar provides answers to any fall-related questions in the SAFE-T-NET^TM Clinical Resources forum by Nurse Assist, Inc. E-mail your questions to askdrt@nurseassist.com. Selected questions will also be published in ECPN.