Annals of Long Term Care

Q: Are all falls in the nursing home preventable?

A: According to the Centers for Medicare & Medicaid Services (CMS), a fall is defined as failure to maintain an appropriate lying, sitting, or standing position, resulting in an individual’s abrupt, undesired relocation to a lower level. An episode in which a resident lost his/her balance and would have fallen, were it not for staff interventions, is also considered a fall. Both the incidence of falls and fall-related injuries increase steadily in the elderly. Incidence rate for falls in nursing home residents is two to three times greater than that in community-dwelling elderly (about 1.7 falls per bed annually). Ten to 25% of falls among institutionalized elderly result in a fracture, laceration, or need for hospital care.¹

A fall in a nursing home resident is a possible cause of citation by long-term care regulatory agencies. The long-term care facility may be cited under one or more regulatory F-tags (Table I).² Falls and related injuries are also a frequent cause of litigation in the long-term care setting.

While the majority of falls in long-term care settings should be preventable, it is not feasible to prevent all falls, even when the best possible care is provided.³ Preventing falls constitutes a significant challenge in nursing home settings and requires a substantial interdisciplinary team effort. Every facility should have a fall prevention program that, at the minimum, addresses the following three elements:³

• Assessing residents for risk of falling
• Identifying and implementing interventions to minimize risk of falling
• Identifying and implementing interventions to minimize risk of sustaining an injury as a result of a fall

ASSESSING FALL RISK
Regulatory guidelines require that a comprehensive patient assessment, the Minimum Data Set (MDS), be completed within 14 days of admission to a nursing home. Certain items on the MDS will indicate that a resident is at risk of falling (Table II). When the MDS is completed, a resident who has one or more of these items (also known as triggers) will trigger a falls Resident Assessment Protocol (RAP). Assessment instruments such as the RAP may provide clues to possible causes of falls. The assessment by the MDS and associated RAP may be too late for some residents who are at increased risk for falling from the time of admission.

In addition to the MDS, many facilities use fall assessment tools that are completed by nursing staff within 24 hours of admission, and regularly afterwards (quarterly or annually, at any time a resident has fallen, and with any significant change in resident condition). Most of these tools are composed of items that have been linked to increased risk of falling (Table III).^4-7 Such tools may help identify possible causes for falls. The Morse Fall Scale⁸ is an example of such tools that can be easily administered by nursing staff. The Morse Fall Scale is used in Veterans Administration long-term care units and in some community nursing homes. The scale is composed of six items that address history of falling, secondary diagnosis, ambulatory aids, presence of IV/heparin lock, gait/transferring, and mental status. On the Morse Fall Scale, a score of 0-24 indicates no fall risk, a score of 25-50 indicates low risk for falling, and a score of 51 or higher indicates high risk for falling.

The Tinetti Balance and Gait Evaluation instrument⁹ is a validated assessment tool that may be used to evaluate fall risk. Using this tool, individuals who scored 19 or less out of 28 had 5.7 times increased risk of falling. The Tinetti Balance and Gait Evaluation instrument is a valuable tool that can help practitioners and therapists to assess fall risk in their patients. The tool, however, may not be practical for routine implementation by nursing home staff.