AHRQs Safety Program for Nursing Homes OnTime Falls Prevention Facilitator Training Introduction to Falls Reports Falls Prevention Electronic Reports Electronic Reports Falls HighRisk Report Summary of Fall Risk Factors by Unit or Facility ID: 773482
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AHRQ’s Safety Program forNursing Homes: On-Time Falls PreventionFacilitator Training Introduction to Falls Reports
Falls PreventionElectronic ReportsElectronic ReportsFalls High-Risk Report Summary of Fall Risk Factors (by Unit or Facility) Contextual Factors Report (by Unit or Facility) Postfall Assessment Report (by Resident) October 2017 On-Time Falls Prevention 2
Teaching the Falls Prevention Electronic ReportsThe teaching sessions for each report should include the following content: Purpose of the report Content of the report Calculation detailsQuizzes and exercises October 2017 On-Time Falls Prevention 3
Postfall Assessment Data ElementsRequired data elements include: The date and time of the fall.The name of the person who witnessed the fall, OR the name of the person who found the resident (if the fall was not witnessed).The location where the resident fell. The position the resident was found in. The activity the person was engaged in when he or she fell, if the fall was witnessed. October 2017 On-Time Falls Prevention 4
Postfall Assessment Data ElementsAdditional data elements include:Suspected cause of the fall. Description of any injury and treatment. Physician notification and examination. Family notification.Physical therapy evaluation, if indicated. October 2017 On-Time Falls Prevention 5
Postfall Assessment Data ElementsThese data are typically collected and documented in a facility’s EMR by staff immediately after a resident’s fall. Facilities should work with their EMR vendors to determine how and when these data are currently documented. October 2017 On-Time Falls Prevention 6
Falls High-Risk ReportProvides a weekly snapshot summary of facility residents at highest risk of fallingEnables staff to be more proactive, consistent, and accurate when identifying residents at risk Helps clinicians see changes in resident status earlier, and identify residents at risk before they fall October 2017 On-Time Falls Prevention 7
Falls High-Risk ReportHow many residents triggered for highest risk of falling?What are the most common risk factors? Which acute change was seen most often? Least often? How many residents at highest risk are cognitively impaired? Have no cognitive impairment? How many residents at highest risk had a change in status during the report week? October 2017 On-Time Falls Prevention 8
Falls High-Risk Report:High-Risk CriteriaRisk criteria identified based on: A review of the literature Fall elements and scoring from existing instruments Input from an advisory panel of leading experts and nursing home users October 2017 On-Time Falls Prevention 9
Falls High-Risk Report:High-Risk CriteriaRisk determined based on a combination of the following elements: Presence of existing conditions considered high risk A change of condition of one or more risk elements New contributing risk factors October 2017 On-Time Falls Prevention 10
Rules for Determining High RiskRule #1: High Risk Based on an Existing Condition Within 90 Days:Residents will be flagged as “high risk” using this criterion if they have at least 3 of the 4 following conditions: Severe cognitive impairment or unsafe behaviors Gait and balance instability A history of falls within the last 180 daysUse of psychoactive medications October 2017 On-Time Falls Prevention 11
Rules for Determining High RiskRule #2: High Risk Based on a Change of Status Within 7 Days: Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition and one of the following changes in status: Acute mental status change New unsafe behaviors New gait/balance problem or mobility device New fall New medication or dosage change Orthostatic hypotension/ dehydration Vertigo/dizziness Syncope fainting Hypoglycemia Possible infection New seizure activity New admission October 2017 On-Time Falls Prevention 12
Rules for Determining High RiskRule #3: High Risk Based on New Contributing Risk Factor Within 7 Days:Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition and one of the following new contributing factors: New or uncontrolled pain New or increased urinary incontinence Increased independence in mobilityRoom change October 2017 On-Time Falls Prevention 13
ADL Changes and Additional InfoSupplementary information about activities of daily living Included in the Falls High-Risk Report but not used in calculations of high risk October 2017 On-Time Falls Prevention 14
ADL Changes and Additional InfoIncludes changes in last 7 days:Decline in bed mobility, transfer, or toileting Symptoms of depression Low body mass index Significant weight changeAn active physician’s order for vitamin DOsteoporosis DiabetesVisual impairment October 2017 On-Time Falls Prevention 15
Sample Falls High-Risk Report Resident Within 90 Days Within 7 Days Name Room High-Risk Existing Conditions High-Risk Change in Condition New Contributing Risk Factors ADL Decline and Other Clinical Information Mental: Unsafe Behaviors Mental: Cognitive Impairment Gait and Balance Instability Fall: 8-30 Days Fall: 31-180 Days Psychoactive Medications Other High-Risk Medications Acute Mental Status Change Behavior: New Unsafe New Gait/Balance or Device Order New Fall Med: New Med or Dose Change Orthostatic Hypotension/Dehydration Vertigo/Dizziness Syncope/Fainting Hypoglycemia Possible Infection New Seizure Activity New Admission Pain: New or Uncontrolled Chronic Urinary Incont : New or Increased Mobility: More Independent Room Change Bed Mobility Transfer Toileting Depression Score Increase Monthly BMI <22 kg/m 2 Significant Weight Change Vitamin D Order Osteoporosis Diabetes Visual Impairment Resident A 122 X X X X X X 25* X Resident B114 XX X X X X Resident C103XX X X X 21 Resident D142 X X X XResident E112 X X Resident F133X X X X XTotal3122111 1 111 2 3 111 2 12 12 Unit: Date: ___/___/___ October 2017 On-Time Falls Prevention 16 * If current score higher than prior score, then display score and asterisk (*).
Falls High-Risk Report Calculation DetailsDisplays the following data for Existing Conditions: Mental: Unsafe Behaviors Mental: Cognitive Impairment Gait and Balance InstabilityFall Within 30 DaysFall Within 31-180 DaysPsychoactive Medications Other High-Risk Medications October 2017 On-Time Falls Prevention 17
Falls High-Risk Report Calculation DetailsDisplays the following Change in Condition data: Acute Mental Status Change Behavior: New Unsafe New Gait/Balance or Device OrderNew FallMedication: New Medication or Dose Change Orthostatic Hypotension/DehydrationVertigo/DizzinessSyncope/Fainting HypoglycemiaPossible Infection New Seizure Activity New Admission October 2017 On-Time Falls Prevention 18
Falls High-Risk Report Calculation DetailsDisplays the following New Contributing Risk Factors: Pain: New or Uncontrolled Chronic Urinary Incontinence Mobility: More IndependentRoom Change October 2017 On-Time Falls Prevention 19
Falls High-Risk Report Calculation DetailsDisplays the following contributing ADL Decline and Other Clinical Information: Bed Mobility Decline Transfer Decline Toileting DeclineDepression Score (PHQ-9 or PHQ-90V) IncreaseMonthly BMI <22 kg/m2 Significant Weight ChangeVitamin D Order OsteoporosisDiabetesVisual Impairment October 2017 On-Time Falls Prevention 20
Check Your Understanding:Falls High-Risk Report Quiz A resident who wanders according to his most recent MDS assessment has met which of the following high-risk existing conditions (HRECs)? HREC 1: Mental Instability HREC 2: Gait and Balance Instability HREC 3: Fall History HREC 4: High-Risk Medication Profile October 2017 On-Time Falls Prevention 21
Check Your Understanding:Falls High-Risk Report Quiz High-risk changes of condition data elements are captured from multiple data sources within the facility’s EMR and represent changes in a resident’s clinical condition within how many days of the report date? 5 days 7 days 10 days 14 days October 2017 On-Time Falls Prevention 22
Check Your Understanding:Falls High-Risk Report Quiz Which of the following sources are used to determine changes in levels of urinary incontinence and activities of daily living? Nurses’ notes MDS assessments Nursing assistant documentation Therapy notes and evaluations October 2017 On-Time Falls Prevention 23
Summary of Falls Risk Factors ReportProvides information regarding the number and percentage of falls that have occurred for residents with each risk factor included in the Falls High-Risk Report Note that a fall may be associated with multiple risk factors. Can be used by nursing and QI teams to identify trends, support root cause analysis, and target areas for improvement October 2017 On-Time Falls Prevention 24
Summary of Falls Risk Factors ReportReport displays falls information at the unit or facility level.Report can be used to monitor overall prevalence and trends of risk factors associated with falls on a specific unit or facilitywide . Data may be trended for 1 month or 3 months. October 2017 On-Time Falls Prevention 25
Summary of Falls Risk Factors Report Calculation DetailsDisplays the following data: High-Risk Existing Condition High-Risk Existing Change of Condition Within 7 Days of Fall New Contributing Risk Factor Within 7 Days of Fall Additional InformationInjuryFalls With Major Injury Falls With Minor Injury October 2017 On-Time Falls Prevention 26
Sample Summary of Falls Risk Factors Report High-Risk Existing Conditions High-Risk Change in Condition New Contributing Risk Factor Additional Info Within 30 Days Injury Totals Mental: Unsafe Behaviors Mental: Cognitive Impairment Gait and Balance Instability Fall: 8-30 Days Fall: 31-180 Days Psychoactive Medications Other High-Risk Medications Acute Mental Status Change Behavior: New Unsafe New Gait/Balance or Device Order New Fall Med: New Med or Dose Change Orthostatic Hypotension/Dehydration Vertigo/Dizziness Syncope/Fainting Hypoglycemia Possible Infection New Seizure Activity New Admission Pain: New or Uncontrolled Chronic Urinary Incontinence: New or Increase Mobility: More Independent Room Change Bed Mobility Transfer Toileting Depression Score (0-27) Diabetes Monthly BMI <22 kg/m 2 Significant Wt Change Vitamin D Order Osteoporosis Diabetes Visual Impairment Fall With Major Injury Fall With Minor Injury Total Residents who Fell Total Residents With >1 Fall Total Falls Unit A # falls1721211011181430015417460405374120307510143181661330741% (of Q total falls)4151512427443470037104110150100127171029070171224210744391532 Unit B # falls9963121251462021102921113030773231311342431437% (of Q total falls)2424168323214311165453005245333808019198583833511511 Unit C # falls57720661001401422910111230242000111641422327% (of Q total falls)19262670222240052052773340444711071570004142215415 Facility Quarterly TOTALS# falls31373415233625546496426101871751161803012710118337249218314105% (of Q total falls)3035321422342454647640610177175106170301171011733523920 On-Time Quarterly Summary of Falls Risk Factors by UnitNursing Unit: Date: ___/___/___October 2017On-Time Falls Prevention27
Check Your Understanding: Summary of Falls Risk Factors Report QuizEach resident fall will only be linked to one risk factor on the Summary of Falls Risk Factors Report. True False October 2017 On-Time Falls Prevention 28
Check Your Understanding: Summary of Falls Risk Factors Report QuizIn order for a high-risk change of condition to appear on the Summary of Falls Risk Factors Reports, it must have been noted within how many days of the fall? 14 days 5 days 7 days 10 days October 2017 On-Time Falls Prevention 29
Check Your Understanding: Summary of Falls Risk Factors Report Quiz A resident’s postfall assessment documents a hematoma on his head, a dislocated hip, and a laceration on his thigh. Which of the following best represents how these injuries will appear on the Summary of Falls Risk Factors Report? Fall with major injury=1 and fall with minor injury=0 Fall with major injury=2 and fall with minor injury=1Fall with major injury=1 and fall with minor injury=2 Fall with major injury=2 and fall with minor injury=0 October 2017 On-Time Falls Prevention 30
Contextual Factors ReportDisplays facility trends by contextual factorEnables comparison of trends across nursing units and aids understanding of the cause of variance Improves the timeliness of root cause analysis and audit process October 2017 On-Time Falls Prevention 31
Contextual Factors ReportDisplays information on day of the week, shift, time of day, and location of fall and if the resident had a room change in last 30 days Uses information collected during resident postfall assessments Can be generated for a single unit or for the facility as a whole Can show data trended for 1 month or 3 months October 2017 On-Time Falls Prevention 32
Sample Contextual Factors Report Day of Week Shift Time of Day Location Other Fall totals Monday Tuesday Wednesday Thursday Friday Saturday Sunday Days Evenings Nights 7 a.m . - 9:59 a.m. 10 a.m. - 11:59 a.m. 12p.m. to 1:29 p.m. 1:30 p.m. to 2:59 p.m. 3p.m. - 4:59 p.m. 5p.m. - 7:59 p.m. 8p.m.-10:59 p.m. 11p.m.- 12:59p.m. 1 a.m.- 4:59 a.m. 5 a.m. - 6:59 a.m. In room Bathroom Hallway Dining Room Activities Therapy Beauty/Barber Shower/Tub Nursing Station Out of Facility Other Room Change Within 30 Days of Fall Date Total Residents Who Fell Total Residents With >1 Fall Total Falls Unit A # falls 0 0 2 0 0 1 1 1 2 1 0 0 0 1 1 1 0 0 1 0 1 1 0 0 0 0 0 20003314% (of total falls)0050002525255025000252525002502525000005000075 Unit B# falls12112102 142000111110321000020005628% (of total falls)1325131325130251350250001313131313038251300002500063 UNIT C# falls00111001200030000000000111000000303% (of total falls)003333330033670001000000000000333333000000 FACILITY TOTALS# falls124232145522 3122112043111104000812315% (of total falls)71327132013727333313132071313771302720777702700053 Note: Percentages may not add to 100 due to rounding.Monthly Contextual Factors Report Date: ___/___/___October 2017On-Time Falls Prevention33
Contextual Factors Report Calculation DetailsDisplays the following data: Day of Week: Monday–Sunday Shift: Days, Evenings, Nights Time of DayLocationOther: Room Change Within 30 Days of Fall Date Total Residents Who FellTotal Residents With >1 Fall Total Falls October 2017 On-Time Falls Prevention 34
Sample Contextual Factors Graph Day of Week Shift Time of Day October 2017 On-Time Falls Prevention 35
Check Your Understanding: Contextual Factors Report Quiz Which of the following is the source for the day of the week, shift, and time of a fall on the Contextual Factors Report? Nurses’ notes Resident Care Plan Postfall AssessmentPhysician Progress Notes October 2017 On-Time Falls Prevention 36
Check Your Understanding: Contextual Factors Report Quiz For the Contextual Factors Report to display the shift on which the fall occurred, the Postfall Assessment must include a field labeled “shift.” True False October 2017 On-Time Falls Prevention 37
Check Your Understanding: Contextual Factors Report Quiz Within how many days of a resident fall must a room change occur in order for it to be associated with a fall in the quarterly Contextual Factors Report? 7 14 30 90 October 2017 On-Time Falls Prevention 38
Postfall Assessment Summary ReportDisplays a single resident’s fall details as recorded on the postfall assessment Can display trended data for up to six postfall assessmentsCan display more columns if the facility’s EMR vendor has the ability to display additional data October 2017 On-Time Falls Prevention 39
Sample Postfall Assessment Summary Report Resident Name: Date of Fall Fall Date Date 10/4/13 1/16/14 2/11/14 2/27/14 3/6/14 4/17/14 Fall Day Day of week Saturday Thursday Tuesday Thursday Thursday Thursday Fall Time Time or “not known” 6:35 a.m. 5:35 a.m. 7:15 a.m. 6:50 a.m. 6:10 a.m. 5:15 a.m. Shift Shift N N D E N N Fall Witnessed? Yes/no N N Y Y N N If yes, who witnessed? Staff, family, visitor, volunteer, other Staff Staff Family Staff Staff Family Name of person who witnessed the fall . text text text text text text If no, who found the resident? Staff, family, visitor, volunteer, other Staff Staff Family Staff Staff Family Name of person who found the resident.texttexttexttexttexttextFall LocationFall location: room; bathroom; hallway; dining room; activities; therapy; beauty parlor; shower/tub; nursing stations; out of facility; otherBathroomBathroomRoomRoomBathroomBathroomResident Position When FoundPosition when found: supine, lying left, lying right, sitting, otherSupineSittingLying rightSupineSittingSittingResident Activity at Time of FallActivity prior to fall: walking; transferring; toileting; in bed; in chair; otherToiletingToiletingWalkingWalkingToiletingToiletingPotential Causes of Fall Unknown Behavior – agitation/other Loss of balance (reaching, turning, sudden movement, other) Gait/balance instability XX Bowel/bladder: trying to get to bathroom on ownXXXXXX Personal device or equipment or attached appliance (cane, walker, crutch, O2) – improper use XX Equipment failure, bed, chair, floor mat alarms Potential medication issue: new med/dose change/suspected reaction Resident chooses not to follow recommendations: alert and oriented Resident unable to follow recommendations: cognitively impaired Other, please describe October 2017On-Time Falls Prevention40
Sample Postfall Assessment Summary Report: Injury Section Fall Comments Free text Fall Injury? Yes/no N N Y Y Y N I f yes, what type of injury? Injury Type: Major Fracture: hip X Fracture: other Joint dislocation Closed head injury with altered consciousness Subdural hematoma Injury Type: Minor Skin tear X Abrasion X Laceration X Superficial bruises, hematomas X X Sprain Other injury that causes pain Injury SiteHeadUpper extremity (UE)Lower extremity (LE)LELELELELEUEInjury AssessmentROM upper: full/decreasedFullFullFullFullFullDecr ROM lower: full/decreasedDecrDecrDecrDecrDecrFull Loss of consciousness: yes or noNoNoNoNoNoYes Neuro status: usual or not usual (changes noted)UsualUsualUsualUsualUsualNot usual Bleeding: none, minor, significantNoneNoneNoneNoneNoneNone Other Free text Where Resident Was TreatedFacility, ER, hospital admitFacilityFacilityERERFacilityFacilityOctober 2017On-Time Falls Prevention41
PCP Notified ? Yes/no Y Y Y Y Y Y MD Notified Physician name Brewer Brewer Cannon Jackson Brewer Brewer PCP Notification Date Date 10/4/13 1/16/14 2/11/14 2/27/14 3/6/14 4/17/14 Family Notified ? Yes/no Y Y Y Y Y Y Family Notified Family name/relationship Daughter Daughter Son Son Son Son Family Notification Date Date 10/4/13 1/16/14 2/11/14 2/27/14 3/6/14 4/17/14 Family Notification Time Time 8:00 a.m. 8:00 a.m. 8:30 a.m. 7:30 a.m. 8:00 a.m. 8:00 a.m. PCP Exam Performed ? Yes/no Y Y Y N Y YPCP Exam DateDate10/6/141/17/142/12/14 3/6/144/17/14PCP Exam TimeTime8::00 a.m.8:00 a.m.8:30 a.m. 8:00 a.m.8:00 a.m.PT Notified?Yes/noYYYNYYPT Consult Date10/4/131/16/142/11/14 3/6/144/17/14 Sample Postfall Assessment Summary Report: Notifications SectionOctober 2017On-Time Falls Prevention42
Postfall Assessment Summary ReportFall Date Fall Time Fall Witness Witness TypeWitness NameFound By Fall LocationPosition When Found Activity at Time of FallInjury Assessment Notes Bleeding Suspected Cause of Fall Fall Comments Fall Injury Injury Type Major Injury Type Minor Injury Site ROM Upper ROM LowerLoss of ConsciousnessNeurological Status Displays the following data: October 2017 On-Time Falls Prevention 43
Postfall Assessment Summary Report Treatment Location Physician Notified Physician NamePhysician Notification Date Physician Notification TimeFamily Notification Family Relationship Family Notification Date Family Notification Time Physician Exam PT Consult Displays the following data: October 2017 On-Time Falls Prevention 44
Check Your Understanding: Postfall Assessment Summary Report QuizUp to how many falls are displayed on the Postfall Assessment Summary Report? 34 5 6 October 2017 On-Time Falls Prevention 45
Check Your Understanding: Postfall Assessment Summary Report QuizUp to three residents can be displayed in a single Postfall Assessment Summary Report. True False October 2017 On-Time Falls Prevention 46
Check Your Understanding: Postfall Assessment Summary Report Quiz Suspected Cause of Fall will display one causative factor for each fall. True False October 2017 On-Time Falls Prevention 47