In 2013 approximately 23 million older adults were treated in emergency departments

In 2013, approximately 2.3 million older adults were treated in emergency departments and more than 662,000 of these individuals were hospitalized (Falls, 2013). Among older adults, falls are the leading cause of both fatal and nonfatal injuries (WISQARS, 2013). According to the Centers for Disease Control and Prevention (CDC), 20% of deaths related to falls occurred in residents who live in nursing homes (Falls, 2013). Typically, nursing homes are occupied by residents 65 years and older who are admitted because they no longer have the ability to live independently and manage tasks such as taking medications, overseeing households, and managing finances. However, nursing homes also care for patients who are not permanent residents but are in need of medical services that include post-operative care, rehabilitative therapy, or intravenous therapy. Risk factors that affect mobility after knee, hip or other surgeries and generalized weakness from hospitalizations or other medical conditions, make thispopulation vulnerable to falls. The cost of fall injuries for both nursing homes and patients can be staggering. Facilities can incur large financial penalties following notices of severe deficiencies from regulatory agencies and will incur substantial legal fees in the event of a wrongful injury or death lawsuit. In addition, legal costs can range from $100,000 to $1 million dollars and juries have awarded judgments of thousands to millions of dollars to plaintiffs (Nursing Homes, 2010). Patients injured in falls are at risk of increased financial costs for care in the nursing home as well as a lower quality of life. They are likely to incur co-pay or coinsurance costs for care by physicians and other professional services, and costs for rehabilitative services, out of pocket expenses, medical equipment, prescription drugs, and hospitalization fees. They are at risk for symptoms of depression, fractures, and need for increased pain medications; some may develop a fear of standing (Jorgensen, 2011). Not all risk factors for falls and fall related injuries in the elderly can be changed. However, there are risk factors that can be modified. Evidence based fall prevention programs that include individualized interventions and the participation of all nursing home staff are needed to effect these changes and reduce falls. The purpose of this project was to implement comprehensive evidence based falls program in a nursing home. Information was gained from an assessment at Liberty Village long term care facility in January 2019 and was used in the development of interventions throughout this paper. The Director of Nursing agreed to partner and meet with me during my project shadowing over a course of 4 days at Liberty Village. Our first meeting was to determine areas within the facility that need improvement and which could benefit from implementation of a proposed project. The need to reduce falls was identified as a major concern within the facility. The facility workers were all very receptive and opening to allow me to interview them over the next couple of days that I would be at their facility. In order to determine appropriate interventions for this facility, current practices were examined. Current processes for falls prevention, staff perceptions, and identification of residents at risk for falls were reviewed. Review of the falls risk factors was compared with staff interventions. During the 12 month period from December 2017 to December 2018 there were 290 falls in this facility which had an average daily census of 118. There were two residents who sustained fractured hips. Other injuries reported were bruises and skin tears. In reviewing the incident reports along with the schedule of employees, 50% of the falls occurred during the hours of 7 a.m. to 3 p.m. when there are many staff members working including support staff who regularly walk through the hallways. Thirty percent of falls occurred on the 3 p.m. to 11 p.m. shift when there is a reduction in nursing and support staff. Falls occurred around the evening mealtime and before 10p.m. The remaining 20% percent of falls occurred on the 11 p.m. to 7 a.m. shift which is also a period of reduced staffing. The majority of falls on this shift occurred between 1 a.m. and 3 a.m. Reasons given for 60% of the falls were related to getting to or from the bathroom or wanting to get out of the bed or chair. The remaining 40% of the incident reports indicated possible causes of the fall but many did not explain exactly what the resident was doing. Seventy percent of falls occurred with residents who were physically or cognitively impaired. Fewer than 10% of residents were able to explain how they fell. A need exists to identify residents who are at risk for falls. Hospitals that use intentional rounding have shown that fall rates can be reduced by as much as 60% (Prevention of Falls, 2012). During rounding, staff will be able to address the needs of patients, such as repositioning, toileting and making items more accessible in order to prevent residents from risking falls while attempting to retrieve articles. Nursing homes have implemented programs such as ‘Falling Stars’ or ‘Falling Leaves’ to identify residents at risk for falling. These programs use stars or leaves on the doors or wheelchairs of the residents to identify those who are a fall risk. This intervention can cue staff to pay close attention to what the resident is doing in order to intervene and assist should the resident attempt to get up and walk. Falling Stars/Leaves have been used as early as 1997 and have shown a 19% reduction in falls (Ray, Taylor, & Meador, 1997). Although assessment tools are important in addressing risk factors which can lead to the underlying cause of falls, interventions must be developed to correspond with these risk factors. When plans of care are targeted to potential causes, individualized interventions can be identified (Gray-Miceli & Quigley, 2012). Hendrich (2013) believes that post-fall assessments are equally as important as pre-fall assessments. Post-fall assessments of patients using evidence based guidelines can help staff create individualized plans and interventions to prevent future falls (Moreland, Richardson, & Goldsmith, 2004). Multidisciplinary and multi-interventional approaches can decrease falls. Falls are challenging, but a thorough assessment of risk factors and interventions to address each factor, along with education and involvement of all staff, can contribute to reducing falls of nursing home residents. Lewin’s change theory (Change Theory, 2011) was chosen for use in the nursing home. The process includes the stages of unfreezing stage, change, and refreezing. In the unfreezing stage, factors that resist change are called restraining forces, and positive forces that can drive change must be identified. Lewin points out that organizations must recognize these different forces and then strive to strengthen the positive forces in order to facilitate change. It is also important in this stage that people feel supported as they go through the idea of changing. The change stage is also called the movement process which requires staff to change the way they think, feel, and behave in regards to the process undergoing change. In this stage staff begin to feel more liberated and can become more productive. The final stage is refreezing, in which changes made become the new and consistent habit. The continued support of staff must be maintained in order for them to be comfortable with evaluating the change and making any further adjustments. If this stage is not accomplished, the change will not be sustained. Lewin’s theory promotes acceptance from staff by involving them in all aspects of the planning and implementation. In using this theory for residents living in nursing homes, staff must be aware that there are changes in practices that must be made to increase the safety of residents. In the nursing home used as the site for this project, new practices are frequently sent down from the corporate office to the facility without input from facility staff. This practice often leads to emotional changes in the staff such as frustration, anger and confusion. This does not empower staff to own change nor does it sustain practice change. During several conversations identified was the perception that nursing assistants and supporting staff did not feel they were an important part of the facility. In order to obtain positive change, it is important that administration talk with staff and find out how they view current practices in dealing with falls. In applying Lewin’s theory to the nursing home, the first stage of unfreezing involved identifying ways for administration and staff to let go of old patterns and behavior. The existing fall prevention plan in the facility needed to be modified to strengthen specific components. A multi-disciplinary approach was used as part of the falls prevention program to ensure its success. This type of approach was needed to ensure that all disciplines were represented and their ideas were included, which is important in changing old patterns. During the change stage, staff are allowed to express their ideas and are supported by all those involved. Change is not sustainable if staff do not feel supported. To gain ownership of change, Lewin (Change Theory, 2011) notes that staff must feel they have value and believe that others see their value. In doing this, every staff member will feel capable of being a part of a team and will acquire ownership for their own actions. In the refreezing stage the process involves changing the new habit in order for it to become permanent. Lewin noted that the goal of refreezing was to make the change the ‘standards operating procedure’. During my conversations with different staff I found that although staff completed the incident reports most interventions did not address the risk factors and a gap remained in identification of the root cause of the fall. Also, interventions were not individualized, but rather the interventions used were the same regardless of the various reasons identified. The assessment was reviewed and education of appropriate interventions that addressed the risk factors was done in this stage. Currently staff are required to answer the questions on a Falls Risk Screen on admission with every resident. Educating staff to understand the importance of addressing the risk factors and identification of the root cause will increase understanding of how important their role is in reducing falls. The challenge of getting all staff actively involved in the falls program is an approach that is critical in implementing positive changes that will last. Staff education is needed to involve several components, one of which is a comprehensive understanding of the nature of falls in nursing home residents. This included potential causes, consequences for patients and families, related costs, and financial penalties to the facility. Staff needs current data within their own facility in order to understand the scope of the problem and to invest in the changes that would be asked of them. A second education component is the range of interventions that can be used with nursing home residents. Alarms and reminders to patients about the call light is the only interventions recognized. Along with this is the need to help staff develop ways to individualize interventions to address identified risk factors. A third component is to educate all staff regarding their role in the project. All staff needsto have an understanding how they personally contribute to fall reduction, how the new processes would be incorporated in their facility, and their part in contributing to the success of the changes. It isimportant that the education sessions include all staff within the facility in order for everyone torealize this as a facility-wide initiative. Education sessions need to be conducted for each shift and department and included use of the huddle board, medication alerts, post-fall huddles, and rounding. Ideas were generated about how to use each resident’s risk factors to determine interventions helpful in reducing falls. Scenarios need to be utilized to illicit discussion from staff regarding how they would choose appropriate interventions. A program will be added to the new hire orientation which will include: causes of falls, consequences of falls for families and residents, assessment of risk, identifying root causes, interventions to prevent falls, individualizing interventions according to the risk factors, interventions for each discipline within their scope of practice, and family involvement in prevention strategies and their role in the processes. The newly hired employees, regardless of position, received this education before going to work on their units. Support from upper management need to be available to all staff via phone or in person for all shifts. This facility has the support within to make a good start in implementing a fall prevention program. Continued emphasis and support will need to be continued for sustained change. The presenceof management with expertise and long term care experience played a key role in introducing change,demonstrating effective approaches, and championing staff efforts. This role needs to be continued not only to sustain this program but also for other initiatives that are needed to bring safe practices to this facility. Additional steps that are needed toward sustainability include conducting quarterly reports oncompliance with interventions and recognition of the units with the best compliance rate. This would maintain awareness of falls and the interventions that need to be used by all staff members. Quarterly reports involving all staff and their contribution would sustain awareness. Additional emphasis needs to be placed on the interventions with lowest compliance. For example, staff training could include videos or role play of post-fall huddles; case studies could be used to increase understanding of addressing risk factors in care plans.ReferencesCDC. Falls in elderly (2013).Retrieved from:www.cdc.govChange theory. (2011). Retrieved from www.currentnursingtheory.comFalls in nursing homes. (2013). Retrieved from www.cdc.gov/falls/nursingFriedeman, M., Montgomery, R., Maiberger, B., & Smith, A. (1997). Family involvement in nursing home: Family oriented practices: staff-family relationships. Research Nursing Health, 20, 527-537. Retrieved from www.mcknight.comGray-Miceli, D., & Quigley, P. (2012). Evidence-Based Geriatric Nursing Protocols for Best Practice (4th ed.). New York: Springer.Jorgensen, J. (2011). Reducing patient falls: A call to action. Retrieved from American Nurse Today: www.americannursetoday.comNursing home compendium 2010 Edition. (2010). Retrieved from www.cms.govPrevention of falls, (acute care). Health care protocol. (2012). Retrieved from www.guidline.gov(WISQARS). (2013), Retrieved from www.cdc.govYoder-Wise, P. S. (2015). Leading and managing in nursing. St. Louis, Mo: Mosby.

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