Does this sound familiar? Mary, an 87-year-old memory care resident and recurrent faller, has another fall in her room. A housekeeper spots her lying on the floor. Staff members rush to help. Alarm, floor mat, low bed? What will it be this time? The nurse completes an incident report and an intervention is care planned. The same scenario with Mary repeats itself over and over. She falls, a new intervention fails, her family grows concerned, staff members become frustrated, and the resident and facility are at risk.
Ask the Right Questions
Organizations tend to spend a significant amount of time and resources putting interventions in place for residents like Mary before they investigate the root cause of the fall. Why exactly did Mary fall? What was she trying to do right before it happened? How can additional falls be prevented? One method of ensuring that root-cause analysis is completed is to ask: how does the intervention that has been put in place relate to the cause of the fall?
The first step in root-cause analysis (RCA) is to gather clues, evidence, and data about what may have contributed to the fall. Observe the physical environment around Mary and assess her physical and cognitive status. Next, ask why questions. All staff familiar with the resident, including social service, activities, housekeeping, maintenance, and dietary, should be involved in asking the following questions:
1. Ask the resident, Are you OK? Resident safety is a number one priority.
2. Ask the resident, What were you trying to do? If you ask what happened, he will say he fell. We want to know what specific action led to the fall—going to the bathroom, reaching for an item, standing up, etc.
3. What was different this time? If she usually gets up to go to the bathroom at night without a fall, what was different that caused a fall this time?
4. What was the position of the resident when found? Did he fall near a bed, toilet, or chair? How far from it? Was he on his back, front, left side, or right side? What was the position of his arms and legs? This may offer clues as to weakness, orthostatic hypertension, injuries, etc.
5. What was the surrounding area like: noisy, busy, poorly lit, cluttered? If in a bathroom, what are the contents of the toilet? Was there poor visibility? What’s the position of furniture and equipment?
6. What was the floor like? Wet? Shiny? Uneven? Carpet or tile? Was there urine on the floor?
7. What was the resident’s footwear? Shoes, socks (non-skid), slippers, bare feet? Was it appropriate for the floor surface?
8. Was the resident using a walker, cane, wheelchair, or other assistive device? ? Was the device in her visual space (aging adults tend to lose peripheral vision and may not see items)?
9. Did the resident have his glasses and/or hearing aids on? Are they clean and in working order?
10.Who was in the area when the resident fell? Any staff, residents, or visitors? If so, could they provide possible clues to the cause of the fall?
11. Ask the resident, How did you sleep last night? Research indicates that poor sleep patterns can contribute to falls.
Most falls are caused by one or more of the following:
· Extrinsic falls are related to the physical environment: wet floors, excessive noise, or placement of furniture.
· Intrinsic falls are caused by resident conditions such as orthostatic hypertension, acute infection, pain, sleep deprivation, or delirium.
· Systemic causes can be related to inconsistent staffing, use of bed alarms, boredom, or shift-change activity.
These questions guide staff members conducting the investigation and serve as a tool for the post-fall huddle. Observation skills of staff are a key component in the investigative process. It is easy to miss something you are not looking for. Gather the clues by looking, listening, and touching. Secure the immediate surrounding area, including equipment, until the incident has been documented.
One of the initial challenges when conducting RCA is teaching staff how to use critical thinking skills to solve problems. With the RCA approach, staff are trained, coached, and mentored to look for clues. They need to know what questions to ask and must apply critical thinking skills that help them recognize patterns, make predictions, and connect the dots from the evidence.
The most important level of RCA is a review of systems and processes at the facility level. The pattern of Mary’s recurrent falls should be reviewed by the interdisciplinary team. What time did they occur? Did they occur around shift change? How long since she had been toileted? What meds were given in the previous three hours? Have other residents had similar falls? Many clues can be found in this data.
Falls related to system factors will continue if RCA is not done facility-wide. In one facility, for example, RCA of a monthly fall log indicated that nurses were not identifying and proactively treating pain. When facility leaders reviewed an analysis of the facility’s process for orientating nursing staff, they discovered that pain management had been removed from training due to budgetary constraints. The pattern of falls related to pain had begun shortly after the change in training had been made. The appropriate intervention was to provide pain management training to all nurses and follow up with audits to ensure that both pharmacological and alternative therapies were being used to treat pain proactively. With these measures enacted, there were no more reports of falls resulting from unidentified pain.
Falls pose a risk to resident safety as well as facility liability. F-Tag 323 is one of the most frequently cited tags on annual surveys. An appropriate response to residents with recurrent falls will improve quality of care and quality of life, refine systems and processes, and reduce regulatory risk and liability.
CMS’s performance improvement framework promotes the use of RCA. The Plan of Correction requires facility leaders to conduct RCAs, correct defective actions related to residents, identify others at risk, identify systemic changes, put a plan in place, and monitor to ensure that deficient practices are corrected.
The problem of falls in nursing facilities is multifaceted and difficult to resolve. If RCA is not a key component of a comprehensive fall program, facility leaders may miss what they are not looking for.
Linda Shell, DNP, MA, RN, DNS-CT, serves as Chief Learning and Education Officer at lindashell.com, and is a nurse leader and consultant/educator with a passion for developing strong, resilient leaders, effective teams, clinical quality, and healthy work cultures in the field of aging services. She has inspired thousands of leaders to discover their Leadership DNA through her SurTHRIVELeadership platform. For more information on nurse leadership and other topics, visit lindashell.com.
For permission to use or reproduce this article in full or in part, please submit a permissions form.