F689 Accidents – Fresh Eyes on Frequent Fallers
Falls are a critical concern in long-term care facilities, impacting resident safety, health outcomes, and compliance with regulatory standards. Understanding fall statistics, root causes, and regulatory requirements help providers to develop actionable strategies to address falls proactively…
Statistics at a Glance
- F689 ranks as the #3 most cited survey deficiency and is the #1 most cited Immediate Jeopardy citation.
- According to the CDC, falls are the leading cause of injury-related deaths among individuals aged 65 and older. Approximately one-third of older adults reported at least one fall in the previous year.
- Annually, seniors experience 29 million falls, resulting in 7 million injuries and an estimated $50 billion in Medicare costs. Over 27,000 deaths are attributed to falls each year.
Regulation/Intent
F 689 Free of Accident Hazards/Supervision/Devices
§483.25(d) Accidents. The facility must ensure that –
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility must provide an environment that is:
- Free from accident hazards
- Provides supervision and assistive devices
- This includes:
- Identifying hazard(s) and risk(s)
- Evaluating and analyzing hazard(s) and risk(s)
- Implementing interventions to reduce hazard(s) and risk(s)
- Monitoring for effectiveness and modifying interventions when necessary
According to the RAI User’s Manual, ‘Fall’ refers to unintentionally coming to rest on the ground, floor, or other lower level and is not the result of an overwhelming external force. A fall without injury is still a fall.
‘Unavoidable Accident’ means that an accident occurred despite sufficient and comprehensive facility systems designed and implemented to (1) identify risks, (2) evaluate/analyze risks, (3) implement interventions, and (4) monitor the effectiveness.
Contributing Root Causes to Consider in Preventative Action Planning
Common causes of falls in nursing homes include weakness and mobility issues such as transfer difficulty, incorrect use of walking aids and improper footwear. Environmental hazards contribute to approximately 25% of falls, and include issues such as, but not limited to wet or uneven floors, clutter, inaccessible personal items, poor lighting, incorrect bed height and improper wheelchair fit. Vision deficits and medications are other common factors in resident falls. Identifying potential risk factors for each resident is crucial to putting effective preventative interventions in place.
Fall Risk Assessment and Care Plan Development
A comprehensive fall risk assessment is the foundation of prevention efforts. Assessments should include at a minimum:
- History of falls
- Medications
- Cognitive status
- Vision patterns
- Orthostatic blood pressure
- Acute and chronic health conditions
- Balance and mobility
Tools such as the Morse Fall Scale or Hendrich II Fall Risk Model are valuable for identifying risk levels. Regardless of what tool is used to determine fall risk, the facility should have a policy with instructions for conducting assessments, and licensed nurses should be educated on thorough/accurate completion of the assessment. Assessments should also consider (1) resident’s personal preferences (bedtime routine/hours, toileting routine, bedside items, room personalization), (2) footwear (optimal footwear includes low heel, hard sole, high heel collar, non-skid sole), (3) assistive devices (good operating condition, kept within reach), and relevant environmental factors (adequate lighting, clear path).
Based on the resident’s MDS assessment, fall risk assessment and data collection findings, an individualized, resident-centered fall risk care plan should be developed and implemented.
Fall Program Systems
In addition to resident-specific assessments and care planning, processes should be in place that provide a framework for managing both facility-wide prevention efforts and management of fall events.
Considerations should include post-fall response, resident stabilization, falls team huddle or other formal fall investigation process that carefully analyzes the fall event and documents “clues” that contribute to root cause analysis. Immediate interventions should be implemented based on the established root cause of the fall and post-fall response initiated, including, but not limited to appropriate notifications, a new falls assessment, fall investigation review, plan of care revision (s), evaluate and monitor resident for 72 hours following the fall and monitor staff compliance with care plan revisions, as well as, the resident’s response.
Periodically review the effectiveness of current structured programs aimed at Fall Prevention such as Restorative Nursing Programs, Activities Exercise Programs and Walk to Dine Programs. Are these programs applying evidence-based approaches? Demonstrating effectiveness in reducing repeat falls?
Prevention of Repetitive Falls
After completing a thorough fall investigation and determining root cause(s), care plan revision and implementation is the key to reduce the risk of repetitive falls. Communicating care plan revisions to appropriate staff members and monitoring for effectiveness is an important part of the care plan revision process.
Care Plan Revision
1. Resident-specific modification involves revising the care plan to reflect the resident’s current condition and risk factors that may have changed since the previous assessment.
- Keep in mind that the past history of a fall is the single best predictor of future falls – evaluate past falls when revising the care plan.
- New intervention(s) should be based on the Root Cause Analysis of the fall
- Gather input from the resident or family/representative as well as staff in the area at the time of the fall. Also seek feedback from direct care staff about resident’s behaviors, needs, effective and ineffective strategies
2. Education is an intervention and should be included as an intervention when appropriate
- Consider, how, when, and by whom will the education provided?
- Consider whether the resident is able to understand and retain new information? If not, education or instructions will likely be ineffective.
3. The care plan should be updated after every fall
- Changes may include the addition of risk factors, change in goal, and/or revision of interventions
4. In some cases, interventions may need to be discontinued
- It may be more appropriate to remove an intervention than to add another.
- Be willing to try both new and old interventions as needs may change over time.
5. Goals may need to be adjusted
- “No falls through next review” is not met once the individual falls. Consider documenting appropriate timeframes based on the intervention(s) and/or goals that address reducing the risk of injury.
6. When new risk factors are identified, appropriate interventions should be documented to address those risk factors.
7. Determine the appropriate Supervision Level – Facilities are obligated to provide adequate supervision to prevent accidents. The type and frequency of supervision should be individualized based on each resident’s assessed needs and identified hazards.
- Supervision may include interventions such as Resident Safety Rounds/Purposeful Rounding, increased activity participation.
8. Implementation of interventions should be individualized, resident-centered, and implemented immediately.
Next Steps
Preventing falls requires a proactive, team-based approach focused on comprehensive risk assessments, individualized care planning, and continuous monitoring. Adhering to regulatory standards and re-focusing efforts on a data driven/evidence-based approach can significantly enhance resident safety and quality of care. Contact Proactive for a review and update of your falls program, targeted case reviews of residents with repeat falls and for training that can be the catalyst for improvement in your fall related quality measures.
RESOURCES
https://www.securesafetysolutions.com/cdc-fallstatistics/
https://www.in.gov/health/files/CDC_Falls_in_Nursing_Homes.pdf
https://proactiveltcexperts.com/product/winning-the-fall-prevention-battle-8-part-package/
Written By:
Angie Hamer, RN, RAC-CT
Senior Consultant
Proactive LTC Consulting
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