Beyond the MDS: Team Approach to Falls Assessment, Prevention, & Management

by Gretchen Henkel

Mrs. Brown, an 89-year-old resident of a skilled nursing facility who uses a walker, falls in a hallway on her way to the dining room. The floor nurse and an aide first check her lower extremities for the possibility of hip fracture. When they determine there is no fracture, they help Mrs. Brown up to a nearby bench. Using a short-form checklist, they begin assessing Mrs. Brown for any additional consequences of her fall. They take her blood pressure and pulse, check for swelling, bruising, and pain, as well as change in cognition. They note their findings on the form.

Mrs. Brown says she is not dizzy and blood-pressure readings indicate that she is not hypotensive. She also does not have a history of falling. Moving to other items on the checklist, the nurse and aide check the immediate environment, noting that the lighting is fine, and that there are no spills or obstacles on the floor.

Finally, the nurse checks Mrs. Brown's walker, and discovers that one leg is missing its rubber tip. With no other apparent causes pinpointed for the fall, they determine that the damaged walker tip may have been the contributing factor. The walker is sent to maintenance for repair, and Mrs. Brown is given a replacement walker. Staff notify her physician of the fall that day, and after a comprehensive evaluation post-fall, Mrs. Brown's care plan is updated to reflect her fall and her chart tagged to include more frequent fall risk assessments. In addition, all the walkers in the facility are put on a regular schedule to be checked for repairs.

Recent data document that the rates of falls in nursing homes and hospitals are approximately three times the rates of falls among community-dwelling elderly over age 65 (Rubenstein LZ, Power C. Falls and mobility problems: Potential quality indicators and literature review (the ACOVE Project). Santa Monica, CA: RAND Corporation, 1999). And, as many Caring readers know, because of the potential for serious injury when an LTC resident falls, the Centers for Medicare and Medicaid Services mandates the reporting of all fall incidents. Marking the fall indicator on the quarterly Minimum Data Set (MDS) triggers a Resident Assessment Protocol, which necessitates a fuller investigation of the cause of the incident.

However, when it comes to falls assessment, fulfilling regulatory requirements is only part of the story, as the above example illustrates. The experts interviewed for this Special Report suggest that medical directors and facility administrators would be wise to develop and implement a comprehensive, facility-wide process for determining causes and assessing risks of falls. Otherwise, caregivers as well as practitioners may miss important diagnostic clues, thus bypassing opportunities to correct modifiable risk factors and avert subsequent falls.

"We shouldn't be looking at falls only because the surveyors ask about them, or because it's part of the [CMS] QI and we have to do it," said Jonathan Musher, MD, CMD, Corporate Medical Director for Beverly Health Care and Co-Chair of the steering committee that developed the American Medical Directors Association's Falls and Fall Risk Clinical Practice Guideline. "We should be looking at falls because we are trying to prevent them from happening again, so that patients do not have serious complications."

Assessing for fall risk "is a geriatrics task that a physician needs to do, for any patient over 65 or so," affirmed AMDA President Jacob Dimant, MD, CMD, Medical Director of Augustana Lutheran Home in New York City and a member of Caring's Editorial Board. In a nursing home, that assessment becomes even more critical because of patients' frailties and the presence of environmental risk factors.

Process Is the Message

Falls assessment and prevention are an integral part of the care process at the Augustana Lutheran Home, where Dr. Dimant--who researched falls causes and outcomes in various New York City nursing homes--has been the medical director for the last six years. It's a misnomer to call a fall an accident, he maintains. "Falls comprise one of the most important geriatric syndromes. A fall is really an interaction between an environmental factor--such as a slippery floor--and patient characteristics, such as poor visual acuity or gait problems."

For any clinical geriatric syndrome, practitioners should not rely on the MDS as the sole assessment tool, said Dr. Dimant. "Remember that the MDS is just that--a minimum data set," he emphasized. A fall is usually a symptom of other conditions and represents an opportunity to further quality-assurance initiatives in the long-term care setting.

As noted in AMDA's Falls and Fall Risk CPG, "sometimes, the actual fall is just 'the tip of the iceberg.'" Numerous risk factors are associated with falls in LTC residents. For example, a previous fall may have engendered a fear of falling, leading to reduced mobility, deconditioning, and loss of muscle strength and balance. Often, a fall can be the first visible sign of an acute illness, such as pneumonia. In addition, neurologic or cardiac illnesses, musculoskeletal problems, visual impairments, neuropathies, bowel or bladder incontinence, dehydration, and orthostatic hypotension brought on by medications all represent risk factors for falls.

The process of addressing falls prevention is similar to that for other clinical problems, and should include the following elements: assessment; diagnosis and cause identification (see "Physical Assessment Following Fall: Checklist 1"); setting the goals and objectives for care in the context of resident wishes and advanced directives; care planning; management of risks and complications (any injuries from a fall); and monitoring and periodic reevaluation of the care plan.

Dr. Musher stressed that an incomplete diagnosis of the reasons for a fall can result in repeat incidents. He recalled a female patient who fell twice, and was taken to the hospital for a syncope workup. An EKG and CT scan were normal, but when the woman returned to the facility, Dr. Musher discovered that no one had asked her about dizziness. "Sure enough," he said, "she had orthostasis. I asked her if she had been dizzy before she fell, and she said yes. If the hospital physicians had gone through a process, orthostatic hypotension would have been one of the first things to check."

Both AMDA and the American Geriatrics Society (in partnership with the British Geriatrics Society and the American Academy of Orthopedic Surgeons' Panel on Falls Prevention) have formulated guidelines for preventing falls in older adults. The AMDA CPG refers more directly to residents and care processes in long-term care facilities, whereas the AGS paper addresses both community-dwelling and institutionalized elderly (J Am Geriatr Soc 2001;49:664-672). Both present general principles of falls assessment and prevention, leaving the specifics to practitioners.

The philosophy behind the AMDA CPG, said Dr. Musher, is to provide an outline for facilities when developing their own falls prevention programs. "The practice of medicine is both an art and a science, and so we wanted to give some latitude within all the [AMDA] guidelines that would let facilities use them and also develop their own process." Consulting the CPG and its algorithm, medical directors and other members of the care team are free to devise forms and processes that fit their facility.

"We're suggesting one process, but if the facility staff go through any process, they would come up with a good conclusion," said Dr. Musher.

However, not all falls can be prevented; nor is it possible to arrive at a root cause for every fall. The assessment process may not always yield a clear-cut answer as to why the patient is falling. "But if we've gone through the process and documented that, that is the minimum that we owe the patient," Dr. Musher added (see box at right).

The CPG will likely undergo a scheduled review soon, a process that is built into the generation of every AMDA clinical practice guideline. A newer version, he surmised, might include some specific assessment tools, such as the Tinetti Gait and Balance Scale developed by Mary E. Tinetti, MD, Director of Yale University's Claude D. Pepper Older Americans Independence Center for Research, as well as the MDS quality indicators.

First, Educate

Instituting an effective care process for preventing falls requires buy-in from all levels of caregivers, from medical director to pharmacist, and from nursing to the housekeeping staff. "The [AMDA] guidelines provide general principles and current care," said Barbara Resnick, PhD, CRNP, an Associate Professor at the University of Maryland School of Nursing in Baltimore, and also a member of Caring's Editorial Board, but "not everybody practices using the current care philosophy." "Unfortunately," agreed Dr. Musher, "in some cases we look at things from an institutional standpoint versus from a patient standpoint."

Dr. Resnick views outmoded beliefs about care processes as the major barrier to instituting falls-reduction programs. "There are many people who, whether they admit it or not, still have a gut reaction that if patients fall, you tie them down--or that there's nothing that can be done, or that the people at risk shouldn't exercise. We are kidding ourselves if we think these beliefs are not still prevalent."

To counter these beliefs, Dr. Resnick presents evidence-based research in staff in-services at Roland Park Place, a continuing care retirement community operated by the University of Maryland. Studies demonstrating that exercise in the elderly can help reduce falls, for instance, help to drive home the message that restraints are not the answer, and that all falls-management programs and interventions should be patient-focused.

Dr. Dimant added that the medical director plays an important role in educating physicians about falls prevention. A thorough medical evaluation makes up a large part of any falls assessment, since a patient's inherent medical conditions, including side effects from medications or undetected acute illnesses, can contribute to falls.

For MDS compliance purposes, every nursing home goes through a process when a patient falls, said Dr. Musher, "but in many cases, the process may not be as organized as we would like." Different departments--rehabilitation, pharmacy, nursing--might be conducting separate assessments of the patient. "What we really need is to move to the trans disciplinary, in which everyone is moving toward a common goal and communicating with each other."

When to Do Assessments

Facility residents should be assessed for their risk of falling at several different junctures, said Dr. Dimant. One of the most critical is upon admission, which is a time of high risk for the resident, especially if he or she is cognitively impaired. An older person's confusion can be magnified by a new and unfamiliar environment, putting him or her at increased risk. Therefore, the admitting nurse should conduct a quick assessment of the resident to identify any immediate risk factors.

A more comprehensive falls evaluation should then be performed within seven to 14 days and incorporated into the resident's overall care plan. Does the patient have muscle weakness and gait problems? Rehabilitation can be instituted, if the patient and family are willing. The comprehensive falls assessment should be revisited on a regular basis, and repeated after a new fall.

Cause Identification

When a fall occurs, staff must immediately: assess the injury, if any; treat the injury; and identify the cause of the fall. Circumstances surrounding the fall are critical for diagnosing its cause, and many facilities generate a short form such as Checklist 1, which prompts personnel to follow a prescribed process after a falling incident.

This is usually followed by a more comprehensive report, such as "Comprehensive Evaluation Post Fall: Checklist 2." Dr. Dimant noted that causes of falls belong to one of two main categories: those inherent to the person, and those that are environmental. Accordingly, process indicators are usually be grouped according to category (as shown at bottom).

Individualized Approach

"No two older adults are the same," Dr. Resnick stressed. As part of an ongoing research effort on falls prevention, Dr. Resnick recently devised simple checklists based on the AMDA CPG for use by front-line caregivers at Roland Park Place. She urged use of the forms to promote a focus on the individual. "It's time-consuming, but that's what it takes," she said. "That's [the time of the fall] the precious moment; it helps you identify what went on." This becomes especially important when considering interventions and care plans, which must, said Dr. Dimant, be tailored to the individual.

Care plans may involve addressing factors inherent to the patient, or to the environment, or both. For example, if residents are incontinent and nonambulatory (resident characteristics), placing them on regular toileting schedules can help prevent them from trying to get up on their own to go to the bathroom (staff process and training-environmental factor).

Because falling can be an adverse drug reaction, drug regimen review is critical. Some of the biggest offenders, says Dr. Dimant, include diuretics, which can cause patients to become dehydrated and dizzy, and long-acting benzodiazepines. In the former instance, a physician might take the patient off diuretics and try a different medication for high blood pressure. In the latter example, changing to a different anxiolytic may diminish the risk of falls.

Monitoring the care plan must also be individualized. If the patient is given newer shoes to help with walking, for example, staff should check the shoes in the first few days to assure that they are not too loose (a fall risk), or too tight, (a pressure ulcer risk).

Throughout the assessment, evaluation, care planning, and monitoring process, the physician "must listen to the patient, and listen to other staff," emphasized Dr. Musher. Each proposed work-up or intervention must be weighed for its risks and benefits to the patient. For example, an end-stage patient with dementia may not benefit from being transferred to a hospital or other facility for a CT scan and invasive testing. However, for a healthier ambulatory resident, such testing may make sense.

Living with Risk

Implementing an effective falls-management program requires that LTC practitioners constantly balance the dual needs to protect the patient from harm while preserving his or her freedom and independence. "Freedom to some people," said Dr. Dimant, "is more paramount than the risk of fracture."

Dr. Dimant urged practitioners to keep in mind that not all falls result in serious injury. In a study he conducted some years ago in New York, only 15% of 310 falls in a skilled nursing facility resulted in serious morbidity, and only 4% of the falls required that the patient be admitted to the hospital.

"Sometimes it's tough to convince staff and family that we have to accept the risk that this person is going to fall, because the alternative is to tie someone down, which is worse," added Dr. Musher.

Dr. Resnick observed that nursing staff may often be guilty of instilling fear of falling into their patients. "My philosophy is, let's get back up on the horse after a fall," she said. "Nurses are the creators of the fear of falling. When someone falls, nurses are afraid of liability and tell patients not to get up by themselves." Then the remonstration becomes self-fulfilling. The patient believes he or she will fall, and so is fearful of moving around; this lack of activity can lead to muscle deconditioning and an even greater risk of falling.

Falls & Quality Improvement

The AMDA CPG also urges facility administrators to incorporate analysis of falls into quality-improvement studies. Tracking falls on a monthly basis can allow the medical director to pinpoint environmental causes of falls.

For instance, at one facility where Dr. Dimant was medical director, he noticed a rise in falls in July and August on certain units. After performing a root-cause analysis, Dr. Dimant and the facility's administrators determined that nurses were taking more vacations in July and August. Temporary nurses had not been trained adequately in falls prevention. The solution was to stagger nurses' vacations so that some "veterans" were always available to inform replacement staff of the procedures.

Dr. Musher likens following a methodical falls prevention guideline to a pilot's pre-flight checklist: "Pilots check all their gauges, they kick the tires, and go through a process. I'm sure that the pilot knows how to fly before he (or she) gets in the plane. But they still go through that same process every time. Physicians, caregivers and individuals who are taking care of elderly patients have education and the experience. But it's also important to go through a process so you don't miss some of the basics."

When countering physician objections to the time-intensive development of care processes, Dr. Musher cautions not to be "penny-wise and dollar-foolish. If you spend a little more time up front, it will really save you time in the long run."

Medical journalist Gretchen Henkel is a Contributing Writer to Caring.

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