Falls ReductionFalls Reduction

Betsy Willy MA, PT, CWSBetsy Willy MA, PT, CWS

Pathway Health ServicesPathway Health Services

January 2012January 2012

Falls Management

Goal

Eliminate Restraints and alarms

without increasing falls

or injuries from falls

We all know:We all know:Alarms Do Not Alarms Do Not Prevent FallsPrevent Falls

Alarms are scaryAlarms are scary Alarms are humiliatingAlarms are humiliating Alarms annoy roommatesAlarms annoy roommates Folks with alarms are Folks with alarms are

afraid to moveafraid to move Staff become immune to Staff become immune to

alarmsalarms Alarms add to auditory Alarms add to auditory

clutter and chaosclutter and chaos Alarms create agitation Alarms create agitation

which leads to poor safety which leads to poor safety judgmentjudgment

Why do we use them??Why do we use them??

No one wants to be No one wants to be restrainedrestrained

MDS: Coding DefinitionMDS: Coding Definition

A restraint is any A restraint is any device that prevents device that prevents

you from doing you from doing something you could something you could do without the device do without the device

or from accessing or from accessing your body partsyour body parts

Examples for Examples for Correct CodingCorrect Coding

Deciding if a device Deciding if a device is a restraint is a restraint depends on the depends on the effect it has on this effect it has on this individualindividual

A dependent A dependent resident with a seat resident with a seat belt or lap buddy is belt or lap buddy is not restrainednot restrained

A seat belt is a A seat belt is a restraint when used on restraint when used on a resident who rises a resident who rises unsupervised from the unsupervised from the wheelchair - if he wheelchair - if he cannot open it cannot open it independentlyindependently

A lap tray is a restraint A lap tray is a restraint if it prevents a capable if it prevents a capable resident from resident from scratching their thigh.scratching their thigh.

Hierarchy of RestraintsHierarchy of Restraints

From least to From least to most safe:most safe:

– Seat belt loosely Seat belt loosely appliedapplied

– Lap TrayLap Tray– Lap BuddyLap Buddy– Snug seat beltSnug seat belt– Tilt in space seatTilt in space seat

From least to From least to most dignified:most dignified:

– Lap BuddyLap Buddy– Lap TrayLap Tray– Seat BeltSeat Belt– Tilt in space seatTilt in space seat

Death by Entrapment: Death by Entrapment: Seat Belt, Side rail, U Bar Seat Belt, Side rail, U Bar

Fireman’s Pole Fireman’s Pole

Recent Colorado Recent Colorado DeathsDeaths

Eliminate side Eliminate side railsrails– Lower bedLower bed– Fall matFall mat

Eliminate seat Eliminate seat belts except for belts except for individuals with individuals with severe extension severe extension tonetone

Recommendations: Recommendations: – Fireman’s pole and U Fireman’s pole and U

Bar placement Bar placement No further then 4 No further then 4

inches from mattressinches from mattress OR no further then half OR no further then half

the width of the thoraxthe width of the thorax

– Tie down Mattress to Tie down Mattress to prevent slippageprevent slippage

When reducing or When reducing or eliminating restraint eliminating restraint useuse First - put effective First - put effective

alternatives in placealternatives in place– Gravity assisted Gravity assisted

seatingseating– Visual supervisionVisual supervision– Opportunities Opportunities

Alternative Alternative positioningpositioning

– Fix root cause Fix root cause UTIUTI Medication issues etcMedication issues etc

Second – progressive Second – progressive reduction with family reduction with family participation, care plan, & participation, care plan, & documentation of resultsdocumentation of results

– Off when visually Off when visually supervisedsupervised

Meals and activityMeals and activity

– Off during most Off during most coherent time of daycoherent time of day

Not when “sun-downing”Not when “sun-downing”

– Increase off time till Increase off time till device is eliminateddevice is eliminated

Managing Family Managing Family ResistanceResistance

Are you treating the Are you treating the family’s needs or the family’s needs or the resident’s needs?resident’s needs?

On admission – provide On admission – provide pamphlet and explain policy pamphlet and explain policy “We are a restraint free “We are a restraint free facility”facility”– Don’t wait for the issue Don’t wait for the issue

to become urgentto become urgent Explore their fear with themExplore their fear with them Create a safe planCreate a safe plan Explain safe plan to family Explain safe plan to family

showing them how it can showing them how it can workwork

When eliminating a When eliminating a restraint - Do not take restraint - Do not take restraint off until safe plan restraint off until safe plan is in place and workingis in place and working

Do a gradual progression Do a gradual progression with good family feedbackwith good family feedback

When all else fails, do 30 When all else fails, do 30 day notification, so family day notification, so family can find a facility which can find a facility which agrees with their agrees with their philosophyphilosophy

Prevention of FallsPrevention of Falls

Stable staffingStable staffing– UnitsUnits– NeighborhoodsNeighborhoods

RelationshipsRelationships– Knowing them so Knowing them so

well, you can well, you can predict behaviorspredict behaviors

Ownership of Ownership of resident’s safetyresident’s safety– Caring for your ownCaring for your own

Overwhelming Overwhelming Sense of Responsibility Sense of Responsibility

for Resident’s safetyfor Resident’s safety Awareness of where Awareness of where

they are and what they are and what they are doingthey are doing

Visual supervisionVisual supervision– Mobile work stationsMobile work stations– Common areasCommon areas

Engaged in Engaged in relationships and relationships and activity – in life!activity – in life!

Auditory monitorsAuditory monitors

Hand off - Hand off - CommunicationCommunication

– AdmissionAdmission– Shift changesShift changes– Transfer unit Transfer unit

to unitto unit– Transfer to Transfer to

EDED– Discharge to Discharge to

homehome

Physical FitnessUse it or Lose it

Muscle strength– Sit to Stand– Transfers to dining

chair Balance – obstacles

and reaching– Over, Under,

around and through

Endurance– Walk across America

Integrated in Integrated in all activityall activity

How are we Supporting Hydration?

Preventing Injury:Preventing Injury:HelmetsHelmets

Ambulatory Ambulatory

anti-coagulated anti-coagulated residents with residents with poor balancepoor balance

Hip Protectors Hip Protectors

Prevent Impact that Prevent Impact that fractures osteoporotic fractures osteoporotic hiphip

VISN8: Hip protection VISN8: Hip protection implementation tool kitimplementation tool kit

Falls from BedsFalls from Beds

Sitting on edge of Sitting on edge of bed and reachingbed and reaching– Slippery Slippery

incontinence pads incontinence pads or bed spreadsor bed spreads

– Overinflated low Overinflated low air loss mattressesair loss mattresses

– Bed higher then Bed higher then knee heightknee height

Falls Related to Falls Related to SeatingSeating Unlocked BrakesUnlocked Brakes Over reachingOver reaching Sliding Sliding Tipping chairTipping chair Unassisted Unassisted

transferstransfers

Failure to lock brakes: Failure to lock brakes: Anti-rollback brakesAnti-rollback brakes Advantages: Advantages:

– prevents roll back prevents roll back

during attempts to during attempts to independently independently transfer transfer

Disadvantages:Disadvantages:– Must be carefully Must be carefully

adjusted to adjusted to prevent excess prevent excess pressure on ischial pressure on ischial tuberositytuberosity

Over ReachingOver Reaching

Center of gravity Center of gravity must remain must remain within the base within the base of supportof support

Leaning forward Leaning forward will tip this guywill tip this guy

Increase seat Increase seat depth and length depth and length of wheel baseof wheel base

Why DO folks attempt to get out of their chairs? Uncomfortable

– Pain– Fatigue

Boredom– Lack of engagement

with others– Left for long periods in

front of TV or in their rooms

Confusion– Agitation/anxiety

Need to move !!

Provide Alternative Options –

YOU don’t sit in one chair all day long!

Fit The Chair to ResidentFit The Chair to Residentand keep it well and keep it well maintainedmaintained

CNA’s and Nurses must be CNA’s and Nurses must be able to identify poor W/C fitable to identify poor W/C fit

Correct FitCorrect Fit– Thighs levelThighs level– Feet flat on floorFeet flat on floor– Back of chair comes Back of chair comes

up to mid shoulder up to mid shoulder bonebone

– Elbows rest on Elbows rest on armrests without armrests without leaning and without leaning and without tucking them inside tucking them inside armrestsarmrests

Two Finger RuleTwo Finger Rule

Width: Width: – Two fingers of Two fingers of

space between space between hip and side armhip and side arm

Seat depth: Seat depth: – Two fingers of Two fingers of

space behind space behind back of calf and back of calf and edge of seatedge of seat

Most common causes Most common causes of falls from chairsof falls from chairs Due to knees lower Due to knees lower

then hips putting then hips putting resident on a sliding resident on a sliding board to the floorboard to the floor– Lower seatLower seat

Seat not deep Seat not deep enough causing enough causing chair to tip when chair to tip when resident leans resident leans forwardforward

Rises unsafely Rises unsafely from chairfrom chair– Tip seat using dual Tip seat using dual

axel adjustment axel adjustment – Meet need to move Meet need to move

with frequent with frequent position changesposition changes

– Keep engaged in Keep engaged in activity and activity and visually supervisedvisually supervised

Sliding from Sliding from chairchair Pulls self from chair propelling Pulls self from chair propelling

down the halldown the hall Slumped sitting - oozes from chairSlumped sitting - oozes from chair Effect is worse if seat is too high Effect is worse if seat is too high

and knees are lower then hipsand knees are lower then hips

Gravity Assisted Gravity Assisted Seating – Eliminate Seating – Eliminate

Restraint NeedRestraint Need Let gravity help keep Let gravity help keep

the individual in the the individual in the chair - not slide them chair - not slide them out of the chairout of the chair

Tip chair using dual axel Tip chair using dual axel placementplacement– Lower back of seat Lower back of seat

and raise frontand raise front– May need to start May need to start

with lower chair with lower chair frameframe

What’s wrong with this picture?

Tall lean folks: deeper Tall lean folks: deeper seat, higher off seat, higher off ground, taller background, taller back

Seat or Cushion DepthSeat or Cushion Depth

Cushion or seat too short – Cushion or seat too short – folding forwardfolding forward

Cushion or seat Too long – Cushion or seat Too long – slides into sacral sittingslides into sacral sitting

Bariatric SeatingBariatric Seating

Large buttocks push Large buttocks push pelvis forward in chairpelvis forward in chair– Extra depth wheelchair Extra depth wheelchair

seat seat – Support low back Support low back

above buttocks above buttocks – Tip chair by lowering Tip chair by lowering

back of seat and back of seat and raising front (dual axel raising front (dual axel chairs)chairs)

Extra widthExtra width Heavy duty chairHeavy duty chair

Sacral sitting – high Sacral sitting – high pressure points and pressure points and painpain

Kyphotic Back – molded back, Kyphotic Back – molded back, extra depth seat and tipped extra depth seat and tipped

seatseat

Moldable back – Total Moldable back – Total ContactContact

Recessed deep Recessed deep surround backsurround back

Exhaustion: COPD or Exhaustion: COPD or CHFCHF

Use Lightweight ChairUse Lightweight Chair Average Average

Wheelchair weighs Wheelchair weighs 35-50 pounds plus 35-50 pounds plus weight of oxygen weight of oxygen tanktank

Rugs create Rugs create resistanceresistance

Wheels don’t turn Wheels don’t turn equally pulling wc equally pulling wc to sideto side

Habitual RockingHabitual Rocking

Elder with Dementia Elder with Dementia Pacing in a sitting positionPacing in a sitting positionSelf Stimulation through movementSelf Stimulation through movement

Solutions: Provide opportunity for Solutions: Provide opportunity for movementmovement

Stationery gliderStationery gliderFrequent opportunities to walk with staffFrequent opportunities to walk with staffStimulation classStimulation classAnti-tipping devices - front and rearAnti-tipping devices - front and rear

Sounds good but how Sounds good but how do we pay for it??do we pay for it?? Federal Regulations require facilities to meet the needs Federal Regulations require facilities to meet the needs

of residents it admits of residents it admits Reshuffle current wheelchairs Reshuffle current wheelchairs

– Wheelchair RodeoWheelchair Rodeo Utilize dual axel component on chairs already Utilize dual axel component on chairs already

owned by facilityowned by facility Prioritize - meet needs of frequent fallers firstPrioritize - meet needs of frequent fallers first Prioritize - acquire chairs with deeper seatsPrioritize - acquire chairs with deeper seats Therapy assessments and reassessments are Therapy assessments and reassessments are

reimbursablereimbursable Delegate: Tracking orders – purchasingDelegate: Tracking orders – purchasing Delegate: Maintenance of chairs – maintenance Delegate: Maintenance of chairs – maintenance

Resources - GoogleResources - Google Joann RaderJoann Rader

– Rethinking Personal AlarmsRethinking Personal Alarms– Individualized Wheelchair Seating for Older AdultsIndividualized Wheelchair Seating for Older Adults

CMS – MDS 3.0 Resident Assessment Instrument (RAI) CMS – MDS 3.0 Resident Assessment Instrument (RAI) manual for examples of Restraint codingmanual for examples of Restraint coding

Mountain Pacific QIO web site: Seating ideasMountain Pacific QIO web site: Seating ideas– Falls tool box: Betsy Willy PT, MAFalls tool box: Betsy Willy PT, MA

VISN – 8 Hip protector implementation tool kitVISN – 8 Hip protector implementation tool kit VISN – 8 Falls conference - May 2012, Tampa FloridaVISN – 8 Falls conference - May 2012, Tampa Florida Family Pamphlet - Reducing Restraint Use in Nursing Family Pamphlet - Reducing Restraint Use in Nursing

homes: A guide for Residents and Families – Colorado homes: A guide for Residents and Families – Colorado Foundation for Medical Care web siteFoundation for Medical Care web site

Email Betsy Willy: Betsy.willy@pathwayhealth.comEmail Betsy Willy: Betsy.willy@pathwayhealth.com