By Tamala Sammons, M.A., CCC-SLP, Senior Therapy Resource
Part 1: Fall Reduction: Focus on Strategies for Prevention
How do we identify who is at risk for a fall? Generally, we assess a resident’s physical and cognitive performance to determine who is a fall risk. However, many residents score as a fall risk, so how do we really sort it out? Do we really know who is most likely to attempt to move and why? That is a key difference.
The Challenge: Identify fall risk residents by finding out who is motivated to move and then find out what that motivating factor is. Give the residents a voice … give the CNAs a voice. Ask the resident and CNA about any changes, challenges and unmet needs.
Complete fall rounds on the floor, not in a meeting room! Assess the environment. How is the resident room set up? How is the bathroom set up? Where is the bed in relation to heating/cooling systems? How is the closet designed? What is lighting like at night? Ask the resident about their environment: how it is set up, temperature preferences, access, lighting, etc.
Provide the nurses with a tool kit based on activity prescriptions: Complete a thorough evaluation, determine who is motivated to move, determine what activities they enjoy being engaged in, determine what they can do alone and with caregivers, create activity-based prescriptions based on eval and treatment findings. Have this information and the supplies in the tool kit for nurses to easily access.
Create a Falls IDT with Nursing, Activities/Rec Therapy, RNA, and Therapy. Re-think how to really identify who’s at risk (motivated to move). Do rounds together. Have daily huddles to review the 24-hour report. Share interventions. Keep building the tool kits.
Part 2: Fall Reduction: Focus on Strategies Post-Fall
Partner with clinical to determine the cause of the fall. Ask the resident what they were doing/wanting. See if they can re-enact what they were doing prior to the fall. When reviewing a fall, ask: Is it cursory, perfunctory with the same approaches/interventions? Or are we creative, thorough and using great detective work to truly develop individualized interventions?
Complete a comprehensive evaluation. If currently on caseload, consider a re-evaluation … head to toe! Engage all therapy disciplines. Leave nothing out of the investigation to the root cause. It may take a few days to figure it all out.
- Vital signs: Review blood sugars and check orthostatic BPs
- Standardized tests: Assess strength and muscle performance; aerobic capacity; gait and locomotion; range of motion; ADLs; cognition; pain scales; vital signs!; sensory impairments; footwear; seating and positioning/support surfaces; modify their environment — remove hazards, modify the bathroom, modify closets; review medications
- Toileting/Incontinence: Was the resident attempting to toilet? Were they incontinent at the time of the fall? How is the bathroom set up? What adaptive equipment is in place/needed?
- Positioning: Does the resident have difficulty maintaining good positioning and is it different in bed versus in a wheelchair? Were all positioning devices in place at the time of the fall? What is needed now?
- Pain: Were they motivated to move due to pain? Was there a pain treatment in place prior to the fall? Does there need to be one now?
- Cognition/Communication: Is there any difficulty using the call light? Any difficulty expressing needs? Can they understand and follow requests? Can they explain what happened and why they fell?
- Strength/Balance mobility: What are the safety concerns with physical movement or use of current devices? Was there sudden weakness or dizziness reported? Can they demonstrate what they were doing when they fell? Complete muscle and sensory testing.
- Low vision assessment: Can they see the things they need? How is the lighting? Does there need to be color contrast in the room or bathroom?
Provide skilled interventions to address:
- Difficulty with transfers in/out wheelchair/standard chair/bed
- Inability to accurately position wheelchair when transferring
- Inability to safely reach objects in near/far proximity
- Difficulty crossing midline
- Losing balance when challenged outside base of support
- Inability to lift/carry objects
- Difficulty with ambulation while multitasking (e.g., walking and talking)
- Losing balance with overhead activities
- Poor body alignment or losing balance when bending
- Gait deviations when ambulating
- Loss of balance with direction change or varying surfaces when ambulating
- Shortness of breath with increased mobility distance/ambulation distance
- Confusion or misuse of assistive device(s)
- Difficulty climbing stairs/curbs
- Poor recognition of safety hazards with mobility tasks
- Impaired mobility
- Impaired vision/hearing/sensation
- Impaired cognition
- Modify the environment: lighting, grab bars, raised toilet seats, bedside commodes, add color for low vision or other visual impairments; what about the closet?