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Running Head: DECREASING FALLS IN LONG TERM CARE FACILITIES 1
Decreasing Falls in the Elderly Population Living in Long Term Care Facilities
Brianna Griffin, Anna Kessler, Katie Luckraft, Hailey Monroe, Amelia Richardson, Anna
Smisek, Hannah Wohletz
College of St. Benedict St. John’s University
April 27th, 2020
FOCUS
DECREASING FALLS IN LONG TERM CARE FACILITIES
2
An increased prevalence of falls is the primary problem faced at a long term care facility
in Minnesota. Some of the areas that the facility’s nurse case manager identified as needing
improvement at the nursing home included: reducing falls, improving sleep, and increasing staff
safety. Reducing falls was chosen because this long term care facility previously had the highest
rates of resident falls in the state of Minnesota. It is recognized that falls can be extremely
detrimental to the well-being of elderly individuals and can often cause injuries such as fractures
and head trauma. Not only do falls increase physical complications, they can also cause elderly
residents to develop low self esteem, exhibit increased caution when performing daily activities,
and can also restrict their daily activities to keep themselves safe. This can lead to a decline in
physical functioning and even depression in the elderly population (de Araújo, 2016, p. 2). This,
along with the fact that the rates of fall related injuries have been rising in the United States,
motivated us to pursue an intervention that could help this long term care facility prevent falls
(Galet, 2018).
Currently, falls are the number one cause of fatal injuries within the elderly population,
and nursing home residents are at double the risk to have a fall than those who live in the
community (Botwinick, 2016). Because of these statistics, it is important for nursing home staff,
specifically, to be implementing procedures for the prevention of falls among all residents. Many
factors cause nursing home residents to be at an especially high risk for falls such as a higher
level of dependence among care center populations, the fear of falling, and environmental
hazards ( Martins, 2018). Because of the research suggesting the danger and increased risk of
falls among nursing home residents, hourly rounding was chosen as an intervention to help
prevent falls for all residents residing in this long term care facility.
DECREASING FALLS IN LONG TERM CARE FACILITIES
3
ANALYSIS
Falls are not only a concern in specific long-term care facility sites, but in nursing homes
nationwide. On average, individuals that reside in long term care facilities fall three times more
than the average adult their age that resides in the community (Oliver, 2007) and are ten times
more likely to sustain a significant injury from falling (Cooper, 2017). According to BMC
Family Medicine, 50% of older adults living in a long term care facility will fall each year,
compared to 30% of older adults living in the community (Cameron, 2018). Many factors have
an impact on an individual’s risk of falling. According to the Centers for Disease Control and
Prevention, having previous fall history in fact doubles an individual’s chances of falling again
(CDC, 2015). Factors that increase an individual’s fall risk can either be intrinsic or
environmental/extrinsic. Examples of intrinsic factors include age, gender, having a history of
falls, musculoskeletal or neurological conditions, depression, and balance instability (Noureldin
et al., 2017). Examples of environmental or extrinsic factors include safety issues, high risk
medications, and impaired ability to complete ADLs (Noureldin et al., 2017). These factors are
common for many older adults and, therefore, impact their overall risk. A cross-sectional study
completed in Canada collected data related to resident health history and care using the CBD or
Care by Design study. This study introduced a new model of healthcare to 395 residents residing
in long term care facilities. This study collected relevant data prior to and following the
implementation of the new model. The results showed that 56.7% of the residents in the long-
term care setting fell at least once in the months prior to the study and 56.2% fell within the
period the study took place (Cameron, 2018). This observational study found a strong
relationship between frailty and falls in the long term care setting. While the study’s population
was not random, the results show an accurate picture of the real clinical practice (Cameron,
DECREASING FALLS IN LONG TERM CARE FACILITIES
4
2018). These sources and studies combined emphasize the major concern of falls and the risk
they impose on residents’ health in the long term care setting.
Additionally, falls lead to many injuries which negatively impacts residents' health along
with costing the healthcare system millions of dollars. More than 50 billion dollars was spent to
cover the cost of fall related injuries in 2015. Furthermore, Medicare and Medicaid were
responsible for covering 75% of that cost (Florence, 2018). According to documents provided by
the facility, Medicare and Medicaid covers care for many individuals that reside in long term
care settings. Therefore, falls and frequency of falls affects costs of long-term care and insurance
for their residents. All these variables put into perspective the severity of the issue for residents'
health and the cost of treatment following a fall.
Resident falls are a primary concern for many long term care facilities across the nation.
Specifically, at this long term care facility, during one quarter, there were 115 resident falls
identified facility wide. Further, 75 of those 115 falls occurred by residents that are identified as
high risk. Thus, the data indicates that 65% of the falls in the facility during this time period were
repeat residents. These high risk residents have a history of falls or other factors that the staff
have identified as high risk individuals. Additionally, the facility uses a fall risk assessment that
is completed upon admission and as a resident’s care changes. Despite preventative measures
such as identifying fall risk, repeat falls are common among the long-term resident population.
According to the Cambridge Journal, around 40% of long-term care residents fall more than
once annually (Oliver, 2007). To identify additional fall trends for high risk residents, more
specific facility fall data was collected using the facility fall reporting system. Each fall report
details a comprehensive summary of the event and new interventions that were implemented
following the fall. Various details of the event include: where the fall took place, was the fall
DECREASING FALLS IN LONG TERM CARE FACILITIES
5
witnessed, was the resident continent or not, were there any injuries, and any relevant details or
statements related to the event. To categorize the data, each event was analyzed and common
root causes related to the event were identified. By analyzing these events, trends specifically for
high fall risk individuals were identified. The data indicated that the majority of facility falls
during that quarter occurred when the resident attempted to self-transfer. Specifically, around
70% of the 75 falls by high risk residents were self-transfers. Additionally, the overwhelming
majority of the falls occurred in resident rooms, where residents are out of the staff’s visual field.
Thus, indicating an increase in supervision could prevent future falls and decrease their
frequency. Intentional rounding by RNs, LPNs, and CNAs could have a positive influence on
decreasing the number and frequency of falls at the long term care facility.
DEVELOPMENT
Falls occur frequently in the nursing home setting. There are several possible solutions
that could decrease the number of falls that occur. Considering the negative consequences of
serious injury and fatality, it is essential to brainstorm and implement possible solutions. A post
fall huddle is one solution that was researched. Post fall huddles were used as an educational tool
to reduce errors and, therefore, reduce the number of falls that occured. In addition, post fall
huddles can provide an opportunity for self reflection. This may increase team effectiveness by
expressing patterns, areas of improvement, and personal pieces of advice. There are three
prominent questions that must be addressed during the post-fall huddle. This includes identifying
what happened, why it happened, and how to prevent future incidents. This serves as a valuable
leadership opportunity, as well, by contributing to a common outcome. This study promoted the
idea that reliable and effective organizations engage in some sort of retrospective practice in
DECREASING FALLS IN LONG TERM CARE FACILITIES
6
order to improve outcomes. During this time the individuals can analyze the potential changes
they may need to reduce the error which is the increase in falls (Reiter-Palmon, Kennel, Allen,
Jones, & Skinner, 2015). The problem with this solution is that it is reactive. It does not
guarantee that the number of falls will decrease. Negative components associated with this
solution involve the limited time allowed to actively participate in a post-fall huddle. The staff in
a nursing home facility are constantly adjusting their time management skills in order to
complete the designated tasks in a timely manner. Therefore, it may not be possible to engage in
a reflection when the nurses have other impending tasks awaiting completion. A post-fall huddle
could also inflict blame which could cause intergroup conflict. It must be stressed that the
purpose of the discussion is to facilitate improvement.
There are numerous studies that attempt to correlate the response to call lights and the
number of fall occurrences. One evidence based research study correlated that nurses responded
to call lights faster with residents who have fallen in the past compared to non-fallers but only
for 24 hours after the fall occurred. This short period of time is a preventive measure to reduce
the number of falls. The use of call lights are a vital communication technique between the
resident and the nursing staff. Some assume that nurses perceive call lights as an annoyance and
interruption to other nursing tasks. This disparity has led residents to become inpatient and more
prone to attempting activities that conflict with their safety (Tzeng, H.M., & Yin, C.Y., 2010). A
solution to this issue is to tape over the “HOLD” button located on the call light machine at the
nurses station. This inhibits the function of quieting the beeping sound associated with call lights.
This signals nursing personnel to answer the call light in order to stop the noisy interruption to
their charting instead of merely pausing the response. This solution is not beneficial to the
facility considering that the call light data sheets indicated relatively fast call light responses. The
DECREASING FALLS IN LONG TERM CARE FACILITIES
7
registered nurses at the facility agreed that lowering the response time would not be the most
effective means of decreasing the fall prevalence.
A third solution to decrease the number of falls happening at the long term care site,
based on research, is to implement exercise and strength programs. Research suggests that older
adults are at higher fall risks due to poor postural balance and inappropriate fall related
behaviors. Unfortunately, many older adults do not comply with the programs provided and
therefore effectiveness is not guaranteed (Punlomso, Srimuang, & Tudpor, 2020). A similar
study explained how physical activity not only affects physical health but also mental health and
well being. Safety is the most significant factor to consider while the residents are performing
these exercises. A trained professional must be with the resident at all times to facilitate proper
mechanics. This may be costly to hire another staff member especially if the facility is strict on
budget adjustments. This method is also time consuming for the residents and not cost effective
when looking at the cost benefit analysis. Motivation was a key issue during this study. The
researchers recommended the nursing staff to be assertive yet respectful. Other barriers included
the location of the fitness center/area, fear of injury, and lack of knowledge about the specific
exercises (Palmer, 2020). Therefore, the group has decided the most practical and cost effective
solution to implement is intentional rounding.
Evidence based research has suggested that intentional rounding can be beneficial at
reducing the number of falls in care facilities. Intentional rounding is doing regular and
standardised checks on residents at set intervals to manage their fundamental care needs. That
way a variety of interventions can be packaged into one. For example, many models use the
process of the “four P’s”: pain, positioning, potty (elimination), and proximity of personal items.
This process gives a set four topics staff can check on when making their rounds with each
DECREASING FALLS IN LONG TERM CARE FACILITIES
8
individual resident (Peate, 2020). Assessing these four things, patient satisfaction can increase,
pressure sores can decrease, and it can also lead to a decrease in falls. Falls are the number one
cause for injuries and death among older adults. Falls can lead to serious financial consequences,
physical injuries, psychological trauma, and increased costs by lengthening their stay in a
nursing home or a hospital (Jenko, Panjwani, & Buck, 2019). Therefore, decreasing falls should
be a priority in long term care sites.
Most of the falls happening at the long term care site are due to self-transferring.
According to Activities, Adaptation & Aging, most falls (67.8%) occur in resident personal areas.
The most common locations of these falls were in the resident’s room and the most common
resident activities at the time of a fall was ambulating (49.1%) and transferring (36.8%) (Struble-
Fitzsimmons, Oswald, & DiPersia, 2019). This data aligns with what the group found in the long
term care site. In addition, a study compared two wards, one that initiated intentional rounding
and another that did not. In this study, there was a 50% reduction in falls on the ward that
initiated intentional rounding. On the ward that did not initiate intentional round there was
actually an increase in falls (Morgan, et al., 2019).
There are several factors to consider before choosing an intervention to implement at a
long term care facility. Some of the factors that impacted the decision to choose hourly rounding
included cost effectiveness, intervention effectiveness, perceived staff workload, and dignity
issues. Nursing homes may not have the funds for costly projects because they have budget
constraints that limit them. The group chose hourly rounding because it is cost effective and does
not require much use of the budget other than paid time to train nursing assistants about the
effectiveness and importance of it. Other fall prevention plans can include costly alarms or
signage. Another factor that played a role in the decision was the effectiveness of the
DECREASING FALLS IN LONG TERM CARE FACILITIES
9
intervention in comparison to other interventions. There is a vast amount of research about
hourly rounding effectiveness in reducing falls in nursing homes. The overwhelming amount of
research that suggested hourly rounding is effective as a fall prevention strategy lead us to
choose it as the intervention to implement at the long term care site. Additionally, a contributing
factor that was considered before choosing hourly rounding was staff workload. If the staff
believe the intervention is too time consuming or unimportant, it would lead to noncompliance
by the staff and there would be no benefit for the residents and no reduction in falls. Staff have
had previous experience with hourly rounding and were satisfied with it. Because of this
previous experience, it was found to be an appropriate intervention. Due to the staff’s familiarity
with the intervention of frequent rounding, the staff were more likely to follow through with the
intervention, leading it to be successful. Finally, the last factor considered was the dignity of
residents. High fall risk signage outside of the resident's rooms was considered. This signage
would include either a different color call light or a distinct indicator of a residents high fall risk
status. This idea was met with resistance from the long term care center because it poses a
dignity issue. Indicating to other residents or visitors who is a high fall risk lacks privacy that the
resident rightly deserves. The group did not want to make the high risk patients feel like they
were a burden or that they had any shame in being a high falls risk patient. Hourly rounding is
one way to maintain dignity while also ensuring that the resident remains safe.
The intervention chosen incorporates frequent rounding on high fall risk individuals in
the entire facility. High fall risk individuals would be identified by using the Hendrich fall risk
assessment (Campanini, 2018). There will be a chart that is assigned to each high fall risk
resident with specific times listed. The nursing assistants will be consulted about where this sheet
should be kept to make charting easy and to increase staff compliance with documentation.
DECREASING FALLS IN LONG TERM CARE FACILITIES
10
Nursing assistants will need to check in on the resident at the assigned time and use the checklist
to inquire about resident needs. The checklist will include possible needs that the resident may
require at any time including going to the bathroom, having their call light near the resident,
position changes, pain interventions, personal item needs, or anything else they may require.
Before implementation there will be a staff education session in the morning huddle that includes
an information pamphlet for any questions throughout the day. The day shift workers will be
responsible for educating the evening shift, and the evening shift will be responsible for
educating the night shift. The plan is to implement the intervention over the course of a month to
analyze how fall rates decrease. In the future, it is a hope that frequent rounding can be expanded
to include all residents in the facility, especially within the short stay unit. This would help to
reduce falls facility wide for a longer period of time.
Objectives:
● An informational pamphlet will be distributed during the morning huddle to the day shift
staff members.
● Nursing students will respectfully answer all questions that the nursing staff have.
● The long term care facility will decrease the prevalence of fall rates by 10% during a one
month timeframe.
● The nursing staff at the long term care facility will demonstrate compliance of the
intervention by completing at least 75% of the resident’s checklist.
● The nursing students will gain feedback by asking the staff to complete a post-study
survey.
EVALUATION
DECREASING FALLS IN LONG TERM CARE FACILITIES
11
It was important to gain staff trust when implementing the plan in order to increase staff
compliance with frequent rounding and decreasing falls. The trust of nurses was gained by
inquiring about areas that need improvement within their facility. The problem chosen was falls
because it was the most pertinent area of concern for the nurses in the care center as this facility
had previously had the highest fall rates in Minnesota. Nurses and nursing assistants then gave
input for possible interventions to correct the high fall rates. By asking both the nurses and
nursing assistants, support for this intervention was gained facility wide. While considering a
few interventions, one of the nurses explained that a nursing assistant had been in favor of the
frequent rounding plan because it had been part of their policy many years ago. Once a proper
intervention was selected and was supported by both the literature and the staff, the facility was
consulted on the fine details of how this intervention would start. The nurses explained that they
do not want this frequent rounding to be put on their Point of Care online documentation system
because it would be at risk for audit by the Department of Health. For this reason paper
documentation was selected and would be kept at the nurse’s desk per the nursing assistant’s
preferences. Proper education would be done to maintain the staff’s commitment to frequent
rounding. There would be potential backlash with the time commitment that the frequent
rounding would require, but education would be provided to the nursing assistants about how
frequent rounding actually decreases call light usage in nursing homes (Williamson, 2018, p. 4).
In order to sustain the frequent rounding schedule the facility would post the monthly fall rates
and fall reduction percentages near the nurse’s desk so that all staff are able to see the progress
being made. This would help to maintain the motivation of all staff to continue the practice of
frequent rounding. Evaluation will be done each month to assess staff compliance and
DECREASING FALLS IN LONG TERM CARE FACILITIES
12
effectiveness of the intervention. This evaluation would include a facility audit on all rounding
worksheets to ensure proper documentation is being completed. The facility will also observe
staff during rounding times to ensure that documentation of completion is accurate. Without the
commitment of the nurses and nursing assistants, frequent rounding will not be successful. For
this reason, it is important to include staff in the planning process and keep everyone educated on
the outcomes of the intervention.
Unfortunately, due to unforeseen circumstances the facility was unable to implement the
planned intervention.For this reason, the comparison between the planned intervention and the
actual implementation was not able to be evaluated. It is the hope of the facility and the students
that this plan could be implemented at a future date to assist in the reduction of falls within the
facility.
Due to the inability to implement the plan, an extensive literature review was used to
determine how hourly rounding would affect resident fall rates. Three peer-reviewed,
experimental studies implemented hourly rounding schedules at care facilities. Morgan et al.
(2017) implemented “Customized Intentional Rounding” on a neuroscience ward. This project
was designed by staff and included team training, staff-led systems redesign, and frequent check-
ups on progress (p. 115). Falls decreased 50% on the experimental ward compared to the
incidence of falls in 50 other wards of the facility (Morgan et al., 2017, p. 115). The fact that the
program was staff-created increased the likelihood of compliance. Asking the nursing staff at the
long term care facility which intervention and form of rounding is most practical will prompt the
staff to feel they contributed to the decision.
Mitchell (2017) found similar results in a long-term care facility. His study noted a 55%
decrease in falls for a three-month trial period (p. 48). The nursing team at the facility developed
DECREASING FALLS IN LONG TERM CARE FACILITIES
13
a system of hourly rounding that used acronyms to dedicate what the resident was doing at the
time. This intervention is similar to the designated areas on this intervention regarding pain,
position, and additional needs. The facility in Mitchell’s (2017) study used:
“C for call bell and identified personal possessions being within reach;
P for pain
R for repositioning addressed comfort measures;
A for alarms addressed safety measures in place; and
T for toileting addressed assistance with bowel/bladder elimination” (p. 44).
These codes were added to the legend of the checklist. Staff compliance for the three
months was 90%, and they participated in in-service education and ongoing evaluation of the
new policy (Mitchell, 2017, p. 44). Additionally, the study revealed positive outcomes with
patient satisfaction and decreased call bell usage (Mitchell, 2017, p. 43). An interpretation of this
result is that the residents anticipated the hourly check-up, so they would not ring their call light
as much. This result would save the nursing assistants additional time because one of the
complaints of the long term care center staff was residents’ frequent call light use.
Lastly, Sanyi (2018) discovered a 71% decrease in patient fall rates after initiating hourly
rounding for 6 weeks on a 34-bed unit (p. 35). However, the intervention only targeted four high-
fall risk residents. Likewise, the intervention at the long term care facility would only include the
residents deemed high-fall risk by the Hendrich Fall Risk Assessment. The template in this study
also included assessing pain, position, toileting needs, proximity of call light, and additional
activities performed (Sanyi, 2018, p. 26-27). Though this study determined the greatest decrease
in falls, the sample size is small.
DECREASING FALLS IN LONG TERM CARE FACILITIES
14
Based on the average success rate of these studies, the expected results would be a 58.6%
decrease in falls during the experimental month. Since September 2019, the care center has
experienced an average of 19.16 falls per month. After the intervention, there should be roughly
7.94 falls in that month. The initial goal was a 10% decrease in falls. According to the literature,
the expectation is a greater decrease.
This study does come with some limitations. Since the intervention could not be
implemented, there is no certainty of results since each facility is different. There could be issues
with staff compliance since the staff complains of low staffing ratios. They may be resistant to
adding another task to their daily work. Facility roles also pose an obstacle. Due to state
limitations, hourly rounding cannot be a part of the facility charting system: Point of Care.
Having the charting in the facility system would eliminate the issue of where to place the hourly
rounding document, since every staff member has access to Point of Care. Another obstacle is
resident dignity. The nursing management staff was hesitant to place a fall risk identifier in the
patient's room or on their door.
Nurse compliance could be improved by providing education on the importance of fall
reduction and the prevalence of falls in the facility before starting the intervention. It is important
to note that hourly rounding was shown to decrease call light usage, which is a major concern of
the nursing staff. Additionally, the time consumed post-resident fall is much more substantial
than the time it takes to check on a resident every hour. After a fall, the staff must take vital
signs, conduct neurological checks, and fill out an incident report. Further implementation would
include all residents on the unit. The hourly rounding trial should also span greater than one
month to acquire more accurate data.
DECREASING FALLS IN LONG TERM CARE FACILITIES
15
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