Annals of Long Term Care

This article is the first in a three-part series from the author on environmental falls.

Falls by older nursing home residents are common, estimated at 2.6 falls per person per year.¹ To adequately address the problem requires a concerted effort and team approach by all healthcare professionals and providers who enter the healthcare setting, consistent with the creation of a culture of patient safety,² and as required by federal regulations³ and national accrediting bodies.^4,5 Although not under federal mandate, administrative management of facilities, such as residential homes or those comprising a Continuing Care Retirement Community (CCRC), have the responsibility to provide due diligence in preventing falls among their residents.

Of all of the multifactorial etiologies linked to falls in older adults, those due to environmental hazards are probably the simplest type of falls to recognize and prevent. According to the Consumer Product Safety Commission and National Safety Network Report (1991-2002), consumer products found in the environment are responsible for many falls among older adults who enter the Emergency Room for fall-related injuries.⁶

This three-part series focuses on some of the more commonly observed environmental-type falls, drawn from anecdotal patient reports from practice experience, to illustrate their contribution, if at all, to fall development. If at all is emphasized, as falls in older people may appear to be due to an environmental factor, when in fact they may occur from other significant events, unbeknownst to the observer. Because falls are observed and recorded to occur in a recognized “place” (eg, down the step, off the bed, in the bathroom), it is easy for the untrained observer, and a mistake, to attribute where the fall occurred as an explanation for why it occurred.

Healthcare professionals trained to assess the older adult ask decisive questions of underlying events and precipitating causes. This line of inquiry is essential, as an untrained provider or the older adult him/herself may attribute the fall to an “accident” or maybe old age. The case presented here illustrates this point. Only through a focused, comprehensive post-fall assessment of the person and the environment can likely underlying causes be identified. Complementing the post-fall assessment is the practice of “due diligence” by all healthcare professionals and providers of healthcare to avert additional falls.

Application of due diligence in the healthcare setting embraces both healthcare providers (staff) and professionals. Healthcare professionals and healthcare facilities that adopt national and professional guidelines for fall prevention (American Geriatrics Society [AGS]/British Geriatrics Society [BGS]⁷; AMDA⁸) in their practice and follow standards of care provide tangible examples of due diligence. Due diligence belies the professional code of ethics, professional accountability in the healthcare setting, and is an integral component of patient safety. It is also an unspoken expectation of the care recipients, our patients.

Interdisciplinary Team Member and Patient Perspectives of a Fall
The following excerpt conveys a resident’s personal account and the team’s account of a fall assumed to be due to environmental hazards. Plans of care were developed accordingly and were revisited when falls unexpectedly continued.

Case Presentation

Footing and Footwear Issues: Reports from One Older Adult
An 89-year-old, cognitively intact, married female residing in a two-bedroom apartment in the residential section of a CCRC reports in response to her fall, “I tripped over my own foot!”

RN assessment: Resident found lying on the kitchen floor near a puddle of water, dazed, vital signs stable.