Falls among long-term care residents are becoming more and more rampant, as an astounding 50% of residents experience one or more falls annually.¹ The majority of falls take place in the bedroom and approximately one-half of all cases involve falling from the bed.^1–2 Most falls occur when residents are attempting to get out of bed on their own— usually in attempts to use the bathroom to meet toileting needs.² Falls from the bedside are associated with significant physical and psychological complications. Such complications include: injury (eg, hip and other fractures), immobility resulting in muscle weakness, functional disabilities, higher risk for potential falls, and psychological distress (eg, depression, fear of falling).² The purpose of this article is to provide long-term care nursing staff with practical guidance on the utilization of height-adjustable low beds in helping to prevent injurious falls from the bedside.

CAUSES OF BED-RELATED FALLS
       There are several factors that can lead to bed-related falls.Bed falls occur most often among residents with lower extremity dysfunction (eg, muscle weakness, arthritis, sensory loss, etc.), cognitive disorders (eg, depression, delirium, dementia, etc.), and who are taking medications (eg, diuretics and sedatives), which all affect the ability to maintain a safe level of transfer activity.¹ Environmental factors that may contribute to risk of bed falls include bed heights that are too high, overly soft mattresses (resulting in poor sitting balance), and slippery floor surfaces (resulting in unstable foot placements during transfers).¹ There are several situational factors that may increase the risk of bed falls. For example, the onset of bladder dysfunction (eg, frequency, incontinence, nocturia) may lead to frequent attempts to leave the bed and fall risk. Also, newly admitted residents are at unusually high risk for bed falls because of exposure to new environmental surroundings (ie, beds of varying height and width, equipped with wheels and side rails) that a resident may not be accustomed to.

ADJUSTABLE LOW BEDS
       The essential goal of fall prevention is to reduce the risk of falls and/or injurious falls from bedsides. Adjustable low beds are often recommended for those residents at-risk from falling out of the bed. Adjustable low beds are designed to:
• Provide the safety of a lower bed (less than 9-inches above the floor), which is effective in reducing the likelihood of a serious fall-related injury. The low height allows residents to rest comfortably, eliminating the risk of serious injury caused by falls at higher heights.
• Offer the ability to adjust the height of the mattress deck for safe resident transfers on/off the bed.This helps to reduce fall risk.
• Rise to a comfortable working height for caregiver, allowing nursing, house-keeping, and other multidisciplinary staff greater ease and less strain in performing daily caregiver tasks.

LOW BED PROTOCOL
       A best practice clinical approach to utilizing adjustable low beds consists of the following:
Step 1: Assessing fall risk from bed.There are a number of risk factors that can increase the risk of falling (Table 1), several of which increase the risk of falls and injurious falls from the bed as well. In response to decreasing the risk of bed falls, caregivers often keep the resident’s bed at a low height. Keeping the bed at a low height may not always be the safest position for residents since individuals with stroke, Parkinson's disease, and arthritic knees may experience great difficulty getting up from low height beds, this can increase fall risk.
       A safe bed height is accomplished when a resident is able to sit on the edge of the mattress with both feet planted firmly on the floor and is able to transfer on and off the bed without any difficulty or loss of balance. Consequently, observing a resident’s ability to transfer safely and independently from the bed can be used to assess fall risk. Any observed impairment in bed mobility or transfers is a strong predictor of fall risk. Residents should be asked to perform a number of simple bed mobility maneuvers while the caregiver carefully observes whether or not the resident can accomplish these activities in a safe and independent manner (Table 2).
       Despite the presence of multiple risk factors, residents who are able to complete the bed mobility maneuvers independently and without difficulty are generally considered to be at a low fall risk from the bed. For these residents, the adjustable low bed should be kept at a height that supports the individual’s safe transfers.

• Conversely, residents demonstrating one or more impaired maneuvers have poor bed mobility and are at high risk. They are also suitable candidates for keeping the adjustable low bed set at a low height.
       Residents at greatest risk for injurious falls and those most suitable for a low bed include any resident with:
• Unsteady balance
• Impaired mobility
• Previous falls from bed
• Previous injurious falls from bed
       It is important to recognize that the performance-based bed mobility screen is a quick and simple evaluation of risk.Therefore, a failed bed mobility screen should be followed-up with a physical and/or occupational therapy referral for further assessment.
Step 2: Assessing need for additional injurious fall precautions.When using a low bed to prevent injurious falls, other precautions may be needed especially with frail residents. Since falling onto a hard surface can increase risk for injury, an exercise-style mat or foam-based mat placed at the side of the low bed and/or use of a hip protector, can further reduce the impact of a fall. The use of a bed exit or fall alarm will be helpful because, the alarm notifies the nurse if the resident has rolled out of bed.

PRIMESENSE^™ INTELLIGENT MIGRATION SENSING TECHNOLOGY

(Above) The Primus 4 Way Stretch Defined Perimeter Cover converts any flat mattress to a fall prevention mattress.

       Primus Medical, LLC (Boardman, Ohio) (www.primusmedical.com) has developed a product to be used in conjunction with low beds, which represents a promising solution for preventing falls. The Concord Pressure Reduction Mattress with PrimeSense^™, a reactive pressure redistribution mattress used to prevent and treat pressure ulcers, is designed to also detect a resident’s movement and alerts caregivers if the potential for a fall, entrapment, or elopement arises.The sensors and alarm box are built within the mattress. Once movement is detected, PrimeSense alerts staff though an adjustable audible tone, existing nurse call, or wireless nurse call and paging systems. In addition, PrimeSense is equipped with an intelligent reminder that alerts staff to a resident’s turning schedule (ie, when turned on to an every 1 or 2 hour schedule, the turn reminder detects if a resident has not been repositioned and reminds staff. This feature can also be used for toileting schedules).

(Above) The Concord PrimeSense™ Ready Mattress is a proactive system in preventing falls.

DEFINED PERIMETER MATTRESS COVER
       Primus Medical, LLC also offers a defined perimeter mattress cover that helps promote a safe environment without the need for side rails.The perimeter mattress cover offers a low intervention solution to many of the side rail restraint issues affecting healthcare facilities today. Wedge-shaped foam sections line the side perimeters of the mattress providing a gentle reminder to those lying in bed of the mattress edges, to help prevent accidental falls from the bed. The 15- inch openings in the mid-section allow for easy resident exit and entry and the straps with quick-release buckles easily secure the cover to the bed.
Step 3: Fall and injury risk is a dynamic process that is often subject to change, monitoring residents and their bed mobility should occur on a regular basis.