Falls are a leading cause of injury, morbidity, and mortality in older adults. MDS 3.0 Fall guidelines look to help providers minimize fall risk while treating fall injuries with the goal of achieving the best quality of life for residents.
A previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls. Persons with a history of falling may limit activities because of a fear of falling and should be evaluated for reversible causes of falling.
Providers need to determine the potential need for further assessment and intervention, including evaluation of the resident’s need for rehabilitation or assistive devices. And the physical environment and staffing needs for residents who are at risk for falls need to be evaluated as well.
Definition of a Fall
According to the Centers for Medicare and Medicaid Services MDS 3.0 Guidelines a fall is: the unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person – this is still considered a fall.
Steps for Assessment
- Ask the new resident and family or significant other about a history of falls in the month prior to admission and in the 6 months prior to admission. This would include any fall, no matter where it occurred.
- Review inter-facility transfer information (if the resident is being admitted from another facility) for evidence of falls.
- Review all relevant medical records received from facilities where the resident resided during the previous 6 months; also review any other medical records received for evidence of one or more falls.
Note any fractures related to falls that is any documented bone fracture (in a problem list from a medical record, an x-ray report, or by history of the resident or caregiver) that occurred as a direct result of a fall or was recognized and later attributed to the fall. Do not include fractures caused by trauma related to car crashes or pedestrian versus car accidents or impact of another person or object against the resident.
Falls are a leading cause of morbidity and mortality among nursing home residents. Falls result in serious injury, especially hip fractures. The fear of falling can limit an individual’s activity and negatively impact quality of life.
- Identification of residents who are at high risk of falling is a top priority for care planning.
- A previous fall is the most important predictor of risk for future falls.
- Falls may be an indicator of functional decline and development of other serious conditions such as delirium, adverse drug reactions, dehydration, and infections.
- External risk factors include medication side effects, use of appliances and restraints, and environmental conditions.
- A fall should stimulate evaluation of the resident’s need for rehabilitation, ambulation aids, modification of the physical environment, or additional monitoring (e.g., toileting, to avoid incontinence).
Steps for subsequent assessment of residents after the initial one are similar to those outlined above. The review period is from the day after the Annual Review Date (ARD) of the last MDS assessment to the ARD of the current assessment.
- Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment.
- Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes).
- Ask the resident and family about falls during the look-back period. Resident and family reports of falls should be captured here whether or not these incidents are documented in the medical record.
Fall Prevention Tips
The American Geriatrics Society offers these fall prevention tips:
- Adaptation or modification of home environment
- Withdrawal or minimization of psychoactive medications
- Withdrawal or minimization of other medications
- Management of postural hypotension
- Management of foot problems and footwear
- Exercise, particularly balance, strength, and gait training
- All older adults who are at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. Flexibility and endurance training should also be offered, but not as sole components of the program.
- Multicomponent intervention should include an education component complementing and addressing issues specific to the intervention being provided, tailored to individual cognitive function and language.
- Exercise may be performed in groups or as individual (home) exercises, as both are effective in preventing falls.
- Exercise programs should take into account the physical capabilities and health profile of the older person, (i.e., be tailored) and be prescribed by qualified health professionals or fitness instructors.
- The exercise program should include regular review, progression and adjustment of the exercise prescription as appropriate.
- An older person should be advised not to wear multifocal lenses while walking, particularly on stairs.
- Vitamin D supplements of at least 800 IU per day should be provided to older persons with proven or suspected vitamin D deficiency.
- Identification of foot problems and appropriate treatment should be included in fall risk assessments.
This is Serious Folks
Three in 10 elderly patients who sought care in an emergency room after a fall were admitted to the hospital for treatment of their injuries, a major share of the $20 billion cost for treating falls in people over age 65 in 2006.
Since 2006, fall-related health costs are believed to have increased substantially because of a larger number of seniors suffering falls, and because of the higher costs of treating the fractures, open wounds, and head traumas they cause.
Falls are the most common cause of non-fatal injuries in the senior population. The industry needs to step up and become active in showing seniors how to prevent falls whether in a facility or at home and elsewhere, perhaps partnering with architects to show caregivers how to protect mom and dad's home.
It is actually good business sense. Keep people healthier and in a better quality of life for more years and should the time come they need the extra help of an assisted or nursing facility they will think of the people who contributed to their extended good health.
Source: CMS’s RAI Version 3.0 Manual