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Tip of the week: Change your environment of care to manage falls

Contemporary Long-Term Care Weekly, September 18, 2008

Falls are an inevitable part of day-to-day life in a long-term care facility. Accidents happen, and CMS understands that. What the agency also understands is that there is a difference between avoidable accidents and unavoidable accidents—and that difference is how well your facility prepared ahead of time and did all it could to prevent an accident from happening.

Many of the agency’s recent regulatory efforts, including F-tag #323, accidents and supervision, are founded on this notion. A survey and certification letter, S&C 07-02, also clarified certain definitions for physical restraints and reiterated CMS’ belief that restraints should have a limited role at best in nursing home care because of their potential for causing negative outcomes.

With a better understanding of the theory behind F-tag #323—and what CMS is really getting at with both F-tag #323 and the recently clarified definitions of physical restraints—your facility can better prepare to prevent accidents and minimize the threat of survey deficiency. You can also rework your care plans to move toward the ideal scenario: a restraint-free facility.

“When you read the guidelines that CMS put out, they say a lot of the same things over and over, with seemingly no concrete guidance to the facility,” says Rein Tideiksaar, PhD, president of Fall Prevent, LLC, and a leading author on elderly fall prevention. But what F-tag #323 seems to be getting at, he explains, is that your facility needs to focus on the resident environment and then examine that environment in terms of a process.

“You need to put something in place where you identify hazards and risk for every part of the environment,” he says. “It should be multidisciplinary and include an evaluation—i.e., documentation—of what you have found.”

“What [the agency] finally said, in pages and pages of guidance, is to stop throwing up your hands and saying, ‘We’ve done everything’ in terms of falls,’ ” says Diana Waugh, BSN, RN, a long-term care consultant with Waugh Consulting in Waterville, OH, and cofounder of the Getting Residents Out of Wheelchairs (GROW) Coalition.

Remember, CMS’ definition of an unavoidable accident is one that occurred despite a facility’s efforts to do the following:

1. Identify an environmental hazard and resident risk

2. Evaluate and analyze that hazard and risk

3. Implement interventions

4. Monitor and modify those interventions as needed

When assessing accidents—potential or actual—you need to examine whether you’re really doing all you can, Waugh says. She posits the following examples:

Scenario 1: Say you have a female resident who keeps falling asleep in her wheelchair and falling out of it. Whenever she falls, the resident seems to hit her nose. Sometimes, she hits her face hard enough to cause damage.

Analysis: “I asked the facility, ‘Okay, what did you do?’ ” Waugh recalls. “And staff members said, ‘We keep trying to get her to stop doing that, but she won’t!’ ”

In this example, Waugh says, there are critical measures the facility failed to take. According to F-tag #323, those missed steps would mean the difference between noncompliance with proper accident prevention and supervision, and a surveyor recognizing that the facility did all it could to avoid an accident.

“First, did you try placing [the resident] on a couch or taking her out of the wheelchair?” she asks. The response suggests a first important measure: Change the routine.

“Then, of all the things you tried, did you document everything?” Waugh asks. That’s the piece of the puzzle most often missing, according to both her and Tideiksaar: a lack of documentation. It’s how you show CMS you did everything you could. “CMS has put the tools in your hands. [The agency has] given you the questions so you can be ready with the answers,” Waugh says. “This is a process, a structured process.”

Scenario 2: Say you have a female resident who requires technological monitoring in the form of an alarm. You purchase a $400 alarm and attach it to the resident, who warns you “not to put one of those things on me.” The resident tears off the alarm and throws it to the floor and later has an accident because she is unmonitored.

Analysis: In this case, says Waugh, the facility ignored the resident’s wishes, and an accident happened because the resident wouldn’t wear an alarm. The facility blamed the accident on the resident’s refusal.

“Why would you scapegoat the resident?” Waugh asks. The salient point was that the resident indicated she didn’t want to wear an alarm, but the facility assumed that was the only solution available because it seemed to be an easy fix. “And on top of that, you have a $400 alarm in pieces on the floor!” Waugh adds.

Scenario 3: You have residents who get hurt because you don’t have enough staff to monitor them.

Analysis: First of all, says Waugh, dispense with any care-plan entry that describes one-on-one supervision. That’s rarely possible, especially if it means sitting the resident near the nurses’ station so a staff member can keep an eye on the resident while the staff member works.

Staffing shortages are problems that aren’t going to subside any time soon, and blaming accidents on a staffing shortage is only going to lead, except in extraordinary circumstances, to a survey deficiency. It’s up to you to allocate staff the best you can so that you at least have a record to show CMS that you tried to use as many staff members available as possible—especially at night.

“We’re dealing with a population that’s awake 24/7,” Waugh says. “Yet we are still convinced that we need more people during the day and not at night.”

Your survey begins at minute one

“What CMS is doing, I think, is addressing the issue of fall prevention and restraint avoidance from the environmental perspective,” says Tideiksaar. The agency is “looking at the same old issues with a new spin in the hope [that] facilities will try new things. In a sense, the environment is what it is—static. The difference is that the risk factors change according to the host and the activity.”

How your facility maintains its environment says a lot about its operations, note Tideiksaar and Waugh. The minute a surveyor walks through the door, his or her goal is to make a professional, informed evaluation of your policies and procedures and file a report indicating his or her findings.

But that impression doesn’t start when you, the administrator, sit down with the surveyors and prepare to give them what they need. What might surveyors think about your environment of care, Waugh suggests, if they notice one or more of the following?

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