W

ithin long-term care facilities—ie, nursing homes and assisted living facilities (ALFs)—falls constitute the largest category of adverse events. As many as 50% of residents experience 1 or more falls, and roughly 33% will fall 2 or more times in a year.¹ As a result, falls are associated with risk of significant complications, including: injury (eg, hip and other fractures); immobility and functional disabilities; psychological distress (eg, depression or fear of falling); staff concerns about resident “safety” and risk of legal liability; family concerns about the quality of care provided by staff; and other potential problems (eg, increased levels of staff required to care for those who fall, poor regulatory survey results, high insurance premiums, etc.).²
       Falls are complex events caused by multiple internal factors (eg, acute medical conditions, chronic diseases, behavioral symptoms/unsafe behaviors, and adverse medication effects) and and/or external factors (eg, hazardous environmental conditions like slippery/wet floor surfaces, poor lighting, unstable furnishings, unsafe equipment, etc.).² In many instances, falls can be predicted. They are, therefore, preventable. Despite the best multidisciplinary efforts to prevent falls, however, some falls will occur, no matter how excellent the care. When a fall occurs, the typical response is to rule out any injury and/or life-threatening conditions that might have occurred. Many residents who fall, especially recurrently, however, have multiple underlying risk factors. By concentrating only on the consequences of falling, the causative factors responsible for falling and risk factors for further falls often go undetected. The purpose of this article is to discuss an organized approach to the post-fall assessment.

Post-Fall Assessment

       The goal of a post-fall assessment, which should occur immediately after a fall, is to identify those internal and external factors that caused the fall and discover the presence of any new or additional risk factors.³ Collecting this information can help determine “What happened?” and “Why did it happen?” and design appropriate interventions to prevent further falls. A step-by-step approach to post-fall assessment follows.³

Step 1: Reporting Falls

       The accurate reporting of resident falls represents an essential component of post-fall assessment. To ensure that falls are evaluated, they must first be reported by staff.

Table 1

If falls are not reported, the causes of the fall and needs of the resident will not be detected, and interventions to prevent further falls will not take place. The best way to ensure that falls are reported is for staff to have a clear definition of falling (see Table 1).

Step 2: Assess for Serious Injury and Urgent Conditions

       Immediately following a fall, it is important for residents to not be moved. Evaluate residents to make sure that they have not seriously injured themselves and/or they do not have life-threatening medical conditions that may have precipitated the event. Though this may frustrate both resident and staff, it is necessary to rule out serious problems and prevent complications.

Step 3: Obtain Circumstances of the Fall

       What was the resident trying to accomplish at the time of the fall? Does the resident know what caused the fall? Was he or she feeling dizzy or weak? Did he or she trip or slip? Did his or her legs give out? Was he or she feeling unsteady? Where did the fall occur? What was the resident trying to do or accomplish when he or she fell? Is this the resident’s first fall, or has he or she experienced previous falls? Obtaining a history of the fall (ie, the circumstances surrounding the fall) can help determine causes of falling and/or patterns of falling. A useful acronym for remembering the components the fall history is SPLATT (symptoms, previous falls, location, activity, time, and trauma).
       Symptoms. Ask those residents who are cognitively able to respond about their fall. Use open-ended questions like, “Tell me about your fall, can you remember what happened?” and “What did you experience?” and “How were you feeling just prior to falling?” In addition, residents should be asked about specific symptoms known to correlate with falls. For example, a brief loss of consciousness may be indicative of syncope. Palpitations or lightheadedness may occur secondary to an arrhythmia or low blood pressure. Complaints of fatigue or weakness may suggest cardiac disease, electrolyte abnormalities, or anemia. Dizziness, confusion, and/or memory problems may be due to medication side effects. Symptoms, such as pain, incontinence, or frequent urination, may point to unstable medical conditions.
       Previous falls. Is this the resident’s first fall, or has he or she had prior falls? This information is obtained from previous incident or fall reports. Finding out about past falls and their circumstances is important because many residents experience “patterned” falls (ie, multiple falls occurring for the same cause).³
       Location. Where did the fall occur? Was it in the bedroom, the bathroom, the hallway, or the dining room? This information may provide clues to potentially high-risk locations. The majority of falls occur from or near the resident’s bed, accounting for as many as half of all falls.3 Other common fall locations are the bathroom and toilet.³
       Activity. What was the resident doing at the time of the fall? Was he or she walking or transferring from the bed, chair, wheelchair, or toilet? Was the person going to the bathroom? Was he or she bending down to pick something off the floor or reaching for something, such as a call bell? This information may provide clues to potentially high-risk activities. The most frequently cited activity at the time of falling includes transferring from a bed and chair transfers.³ Other activities commonly associated with falls include toileting and getting up from bedside commodes and wheelchairs.³
       Time. What time of day and day of the week did the fall occur? This information can provide feedback on potentially high-risk situations (ie, at change of shift, after meals, times of low staff levels, etc.) Most falls occur during the early period of institutionalization (or first 72 hours of a stay), during nighttime hours, and after meal times.^1,3
       Trauma. Document any physical injury associated with the fall. Common injuries associated with falling include:
• Scrapes or abrasions
• Bumps, swelling, or bruises
• Skin cuts or lacerations
• Sprains
• Bumps or bleeding from the head.

       Editor’s note: The second part of this article, covering the remainder of the steps for the post-fall assessment, will be published in the June issue of ECPN.