Lodge has significantly reduced the rate of falls in their long-term care home
from 16.7% in 2012/13 to 9.9% in 2017/18, but the improvement didn’t happen
overnight. Their quality journey began in 2012 and has evolved to include a
multi-pronged approach to this complex issue. Their falls prevention program
has even expanded to measure its potential impact on emergency department (ED)
Quality Ontario had a chance to catch up with Margaret Holst, RN, Quality Lead,
and RAI Coordinator at Knollcrest Lodge to find out more.
you identify that falls was a quality issue that needed to be addressed?
Knollcrest was part of a group of nine homes in Huron Perth county that was
selected by Huron Perth Non-Profit Homes and Services for Seniors (HPNHSS) to
receive enhanced education and training in quality improvement.
Department Managers and RAI MDS Coordinator attended a Quality Education Day
offered as part of this initiative. As a result of this education, we
identified fall prevention as a high priority area to begin our quality
journey. Our falls rate in 2012/13 was
16.7%, which was above the provincial average.
initial steps did you take to reduce falls in your long-term care home?
started our work in 2012, we used the Registered Nurses Association of
Gaps Analysis Work Sheet (Preventing Falls and Reducing Injury
from Falls, Fourth Edition 2017) to compare our current practice to
identified existing gaps in our workflow, including assessing for risk,
comprehensive post fall assessments, documentation, and follow up preventative
actions. We also used quality improvement tools such as fishbone diagrams and
the 5 whys to determine the root causes of our high falls rate, and
Plan-Do-Study-Act (PDSA) cycles to test change ideas.
We set a
falls rate target of 8% and implemented the following change ideas:
- Falls Risk
Assessment: Within 48 hours of admission and routinely thereafter, a falls risk
assessment is completed, and a plan of care with individualized interventions
is implemented to address the identified areas of risk.
Star' program: When a resident’s falls risk assessment indicates “high risk,” a
logo with a star is placed outside the resident’s room as a cue to notify staff
to increase monitoring of the resident.
The resident’s fall risk scoring is also taken into consideration by the
Physician and Pharmacist with medication changes, quarterly medication reviews
and during annual medical physical examinations.
Assessment (UDA) Tool in PointClickCare®: We developed a Post Fall
Assessment/Incident Reporting tool with a section for analysis. It is designed
to capture specific details and direct front-line staff members to follow a
consistent course of action after every fall. The format of the UDA encourages
staff to ‘think outside the box’ and to determine what the resident was doing
prior to the fall. Were they cold, or hungry? Did they need to be toileted?
What could have been done differently? What can be implemented to prevent
- Fall and
injury prevention equipment: We increased the amount and types of equipment
available (such as bedside/floor fall mats, bed and chair fall monitor alarms,
grippy socks, high/low beds, and hip protectors) and provided education on
their appropriate use. Staff felt empowered to promptly implement interventions
such as rearranging the room or changing the resident’s plan of care (i.e. to
address continence issues).
- Tracking and
posting data on our Quality Improvement bulletin board: This was implemented to
increase staff ‘buy-in’ and motivate the team to strive for improvement.
implementing these initiatives, our falls rate was reduced from 16.7% in
2012/13 to 16.4% in 2013/14. We determined that more needed to be done.
further steps did you take?
multidisciplinary team identified gaps within our Nursing Restorative Care
Program. We recognized with the current staffing levels and existing workload,
some residents were not receiving optimal time and opportunity for functional
rehabilitation (strengthening, tolerance, and balance) to maintain or improve
safe transfer and ambulation status.
the program included:
- Creating a
well-defined role for a Restorative Care Aide (RCA) to become the champion for
the Restorative Program. The RCA’s daily routine includes dressing programs,
walking, gym, and group active range of motion exercise programs for
strengthening, tolerance and balance work. It also includes 1:1 passive range
of motion to prevent contractures, and eating programs at breakfast and lunch
for residents who have potential for functional rehabilitation (to become more
independent) or experiencing recent losses in functional abilities.
- Completing an
assessment upon admission to determine the potential for functional
rehabilitation and at least quarterly thereafter. Each resident’s program is
reviewed and updated as necessary to address any changes or losses in level of
independence. Monthly multidisciplinary meetings to address resident needs in a
timely manner has also been of benefit as our resident population’s complexity
In 2015, a
Quality Lead role was created to organize and move Knollcrest’s Quality
Improvement planning forward. The Home’s Falls Prevention Program remained in
the spotlight as a priority focus.
to change our processes based on small change ideas, evaluating and evolving
our Falls Prevention Program, using PDSA cycles as our main ‘go to’ tool. Some additional changes include using a 'post
fall huddle tool' with staff at the scene of the fall, and initiating
orthostatic blood pressures to be completed after a fall for those residents
who are ambulatory. As a result, orthostatic and postural hypotension have been
identified as a contributing factor to falls for several residents.
Interventions have been put into place to address these risks.
years of implementing these additional initiatives, our falls rate decreased
from 16.4% in 2013/14 to 12.4% 2015/16.
you today with your fall prevention efforts?
rate has consistently decreased since 2012/2013. We have been successful in
maintaining a rate of 9.9% since 2017/18 compared to the 16.4% provincial rate
(Data source: Health Quality Ontario - System Performance).
been your biggest undertaking?
past six years, we have completed over 1200 Post Fall Assessment/Incident
Reports. And today, after 30+ versions of this tool (UDA), we continue to
evolve to perfect the process.
of work with falls prevention as a priority focus in our strategic quality
improvement plan, we have witnessed a culture change in staff approach to
falls. The team has become more proactive in recognizing high risk scenarios
for fall prevention and empowered to implement injury prevention strategies.
impact has your work on fall prevention had on your emergency department (ED)
In 2018, we
began to look at our avoidable ED visits rate. We decided there may be benefit
to increasing the efficiency in tracking and analyzing ED visits and hospital
admissions. We successfully implemented PointClickCare’s® functionality for
Hospital Tracking to collect data on the Home’s ED visits. We are able to track
ED visits by day of the week, reason for transfer and by visit outcome (i.e. ED
visit only or hospital admission).
October, 2018 to September, 2019, 16 residents had ED visits for a variety of
reasons. 44% of these ED visits were the result of falls (see below). Further
analysis of this data may indicate a relationship between the rate of falls and
the number of ED visits.
our rate for potentially avoidable ED visits is well below the provincial
average. We will continue with use of the Hospital Tracking Portal in
PointClickCare® to track and analyze root causes of ED visits and hospital
advice to you have for other long-term care homes who want to tackle fall
difficult to prevent among residents in long term care. Our Quality Improvement
has been a journey. Our advice would be to:
- Ensure you
have a quality lead who has insight into the workflow and roles of the
multidisciplinary team. Start with small, measurable goals and complete ongoing
Plan-Do-Study-Act (PDSA) cycles.
- Involve all
members of the team (including the resident/family members/community) in your
improvement plan. Understand and use the strengths of all team members to
maximize their skills in quality improvement.
- Seek out
input and feedback to create ‘buy-in’, empowering and engaging everyone in the
process of change.
- Use tools
such as the PointClickCare® Hospital Tracking portal and the Post Fall
Assessment/Incident Report UDA. Quality improvement is contingent on good data
and analysing the numbers, looking for patterns and trends. Data has been
instrumental in our success.
- Use best
practices such as RNAO’s fall prevention toolkit.
- Network with
other Homes to troubleshoot and learn together. "Unity is strength. . .
when there is teamwork and collaboration, wonderful things can be
achieved." --Mattie Stepanek.
work in long term care?
Indicators & Change Ideas page for more information
on potentially avoidable emergency department visits.
You may also
be interested in our quality improvement stories featuring the work
long-term care homes across Ontario.
Read more posts in the fall prevention series on Quorum.
How do you prevent falls in primary care? Share your advice and lessons learned by clicking on “ADD A COMMENT” below.