Falls Reduction Betsy Willy MA, PT, CWS Pathway Health Services January 2012.
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Transcript of Falls Reduction Betsy Willy MA, PT, CWS Pathway Health Services January 2012.
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: [email protected] Betsy Willy: [email protected]