Falling is one of the biggest worries of nursing home residents and their families. That fear comes with good reason.
Just a few years ago, Oklahoma was ranked 48th in the nation for nursing home falls with major injury. Nearly 50 percent of nursing home residents fall within the first 12 months of being there. If a person has fallen once, they’re twice as likely to fall again. Life as they knew it is over for many people after a fall.
Those statistics were simply unacceptable to several groups of Oklahomans invested in creating a better quality of life for nursing home residents. The University of Oklahoma College of Nursing is a leader in that work, and it recently was awarded a $1 million federal grant to launch the implementation phase of its falls prevention program, “It’s Not OK to Fall.”
The program is a partnership with the Oklahoma State Department of Health through funds from the Centers for Medicare and Medicaid Services.
“I’m very pleased this successful program will be able to continue,” said Gary Loving, Ph.D., RN, interim dean of the Fran and Earl Ziegler College of Nursing. “Falls are a significant risk for elderly individuals, particularly those with disabilities and chronic illness. Through this program we can expand our efforts to decrease those risks.”
The pilot phase of “It’s Not OK to Fall” began three years ago. OU College of Nursing staff members Teri Round, M.S., RN, and Diana Sturdevant, Ph.D., RN, led a group that combined several evidence-based falls intervention strategies. During the testing phase, nursing homes that incorporated the new strategies decreased their rate of falls by 50 percent. Round is executive director of clinical operations for the college, and Sturdevant is co-principal investigator for the falls project.
The falls prevention program focuses on three primary areas: better sleep, hydration and strengthening for residents.
Traditionally in nursing homes, employees check residents every two hours during the night, positioning and changing as necessary, prompted by the belief that it will prevent skin breakdown. However, that also means people can’t sleep more than two hours at a time. Prevention of wounds is often linked to better nutrition, and modern mechanics can accomplish the same task as physically turning someone.
“The evidence shows that if you let people sleep six or more hours a night, they don’t fall as much,” said Round, a registered nurse. “There are other benefits as well: When people sleep better, they tend to eat better during the day because they’re not falling asleep over their meals. And they’re more engaged in their activities, such as physical therapy.”
Hydration is another important component. The program worked with nursing home staff to encourage residents to drink adequately from 8 a.m. to 4 p.m. That not only prevents dehydration, but it lessens the amount they drink at night, thereby decreasing the number of times they have to go to the bathroom overnight. Nursing homes have been encouraged to fill water dispensers with fruit or vegetables to flavor the water.
Strengthening the muscles is important because it improves a person’s balance. The program introduced a form of Tai Chi to nursing homes so that residents could participate in a low-impact exercise that has been demonstrated to improve balance. Strengthening also involves teaching “toilet squats,” which is raising and lowering oneself over the toilet. This decreases their fear of falling, as well as the urinary tract infections that can occur when a person goes to the bathroom infrequently.
“When people feel like they might lose their balance and fall, that makes them exercise less, which then makes them more likely to fall,” Round said. “Everything works together negatively.”
However, the strategies must be used in connection with a comprehensive falls assessment of each nursing home, and a root cause analysis when someone does fall. The assessment takes into account the physical layout of the nursing home, from the parking lot to the individual rooms. The root cause analysis teaches staff to investigate the specific cause of a fall, rather than simply keeping track of the number of falls.
In one example, a nursing home decreased its use of alarms on the residents’ beds. In some cases, a new medication or an infection was causing residents to become dizzy and fall, so the installation of an alarm was not addressing the root cause, Sturdevant said. In another case, a nursing home resident was drinking a full pot of coffee in his room during the evening hours, resulting in restlessness and falls because he couldn’t go to sleep at night. Realizing that, and convincing him to switch to decaf, helped him sleep and stopped the falls.
“You have to personalize the situation for each resident. It is a person-centered care model,” said Sturdevant, an advanced practice registered nurse who also holds a doctor of nursing degree.
The Oklahoma Department of Health administers the grant, which is funded through the Civil Money Penalties (CMP) program. When nursing homes are fined, that money goes to the Centers for Medicare and Medicaid Services, and part of it returns to the Oklahoma State Department of Health, where it can only be used for quality improvement projects that help residents of nursing homes.
“‘It’s Not OK to Fall’ is a great project that has continued to evolve through a series of improvement cycles,” said Julie Myers, DrPH, who manages the Oklahoma CMP Fund Program for the Oklahoma State Department of Health. “The CMP Fund is pleased that the OU College of Nursing has been awarded funding to continue the delivery of the project to at least 60 nursing homes in Oklahoma over the next three years.”