AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Falls Prevention Self-Assessment Worksheet
Purpose
The Self-Assessment Worksheet is a worksheet designed to help staff review how they currently identify residents who have experienced a change in falls risk, how they determine if new clinical interventions are needed, and how they determine what those interventions are. The self-assessment tool is intended to help identify the current processes and structures the nursing home uses to prevent falls and identify gaps and places for improvement. It is intended to help staff think about ways to transform these processes and how to begin to use the falls risk report in clinical discussions.
The self-assessment tool is an important first step in implementing the reports into current workflow. The team is expected to use the Self-Assessment Worksheet to help understand current fall prevention practices. This is the first step to help them determine how to transform their current practices and to identify ways to incorporate the On-Time Reports into current practice.
It is expected that the Facilitator will work with the Change Team to identify gaps in current falls prevention practices and help them see ways to incorporate the reports to improve these practices and improve clinical interventions. The Self-Assessment Worksheet assists the Change Team to identify how they:
- Determine which residents are at high risk for falls,
- Develop interventions to prevent falls,
- Discuss at-risk residents and formulate changes in care plans, and
- Carry out investigations, including root cause analysis, when an injurious fall occurs.
Description
The assessment has four sections:
- Section 1: Screening for Falls Risk
- Section 2: Falls Prevention Plan
- Section 3: Investigations/Root Cause Analysis of Resident Falls
- Section 4: Communication Practices
Users and Uses
The main users are members of the Falls Prevention Change Team. The worksheet is designed so that the team answers a series of questions that guide them through an assessment of how they currently prevent injurious falls. Once they fill out the self-assessment and discuss it as a team, they will be better able to summarize gaps in current practices and consider ways the reports can help fill in the gaps.
The use of On-Time Falls Prevention not only helps improve risk identification and communication of risk with use of the reports, but also helps enhance the interdisciplinary nature of clinical decision making. An On-Time Facilitator will help guide the Change Team through this process.
Self-Assessment Worksheet for Falls Prevention
This self-assessment tool is aimed at two types of nursing homes:
- Nursing homes that are currently not using an electronic medical record (EMR) for falls prevention but have access to On-Time Falls Prevention from their health information technology (IT) vendor and have decided to use these reports to create electronic risk information to help prevent resident falls. The self-assessment tool is an important first step in implementing the reports into current workflow.
- Nursing homes without access to On-Time Falls Prevention in an EMR to enhance their understanding of current practices and to help them identify opportunities for process improvement.
This self-assessment will help either type of nursing home better understand how effectively they:
- Identify falls risk factors using information from multiple sources.
- Develop interventions specific to the risk factors to mitigate falls risk.
- Communicate the intervention to all staff using multiple processes.
This assessment will cover the following:
- Section 1: Screening for Falls Risk
- Section 2: Falls Prevention Plan
- Section 3: Investigations/Root Cause Analysis of Resident Falls
- Section 4: Communication Practices
Section 1: Screening for Falls Risk
The Falls Prevention Self-Assessment begins with a series of questions that will help the interdisciplinary team identify strengths and areas for potential enhancement related to falls risk assessment and prevention protocols.
- Does your facility have a falls risk assessment policy? Yes |__| No |__| Not Sure |__|
If no, skip to question 3.
- If yes, does the policy include the following:
Yes | No | |
---|---|---|
Examination of clinical risk factors (e.g., high-risk medications, diagnoses, impairments) | |__| | |__| |
Timing or frequency of assessments (e.g., admission, readmission, quarterly) | |__| | |__| |
Use of a falls risk assessment | |__| | |__| |
Interdisciplinary input regarding resident falls risk | |__| | |__| |
Communication of falls risk to clinical and care plan teams | |__| | |__| |
Creation of an individualized, interdisciplinary care plan aimed at preventing falls | |__| | |__| |
Communication of falls risk and prevention strategies to direct care staff (e.g., via CNA care cards) | |__| | |__| |
- Does your facility provide training to nursing staff on how to accurately assess for fall risk?
Yes |__| No |__|
- Is a standardized assessment tool used to assess resident risk for falls? Yes |__| No |__|
If no, skip to Question 5.
Yes | No | |
---|---|---|
The Hendrick II Fall Risk Model | |__| | |__| |
Timed Get Up and Go Test | |__| | |__| |
Berg Functional Balance Scale | |__| | |__| |
Fall Efficacy Scale | |__| | |__| |
4 Stage Balance Test | |__| | |__| |
30 Second Chair Stand | |__| | |__| |
Tinetti Performance Oriented Mobility Assessment (POMA) | |__| | |__| |
Fall Risk Assessment Tool (FRAT) | |__| | |__| |
Activities-specific Balance Confidence (ABC) Scale | |__| | |__| |
Dynamic Gait Index | |__| | |__| |
Six-Minute Walk Test | |__| | |__| |
Morse Fall Scale | |__| | |__| |
St. Thomas Risk Assessment Tool (STRATIFY) | |__| | |__| |
- If not using a standardized tool, does the assessment the facility uses cover the following:
Yes | No | |
---|---|---|
History of falls | |__| | |__| |
Impaired cognition, including fluctuating mental status or change in cognition | |__| | |__| |
Impulsivity | |__| | |__| |
Impaired vision or change in vision | |__| | |__| |
Gait disturbances | |__| | |__| |
Limitations or changes in activities of daily living, including mobility and transfer | |__| | |__| |
Bowel and bladder incontinence | |__| | |__| |
Infection | |__| | |__| |
Underlying medical conditions affecting balance, endurance, strength, judgment, vision | |__| | |__| |
Use of high-risk medications (e.g., antihypertensives, diuretics, hypoglycemic agents, psychotropics, opioids) | |__| | |__| |
Polypharmacy | |__| | |__| |
Use of assistive devices for transfer or ambulation | |__| | |__| |
Attached equipment (e.g., catheters, intravenous lines, oxygen) | |__| | |__| |
Environment (e.g., poor lighting, glare, clutter) | |__| | |__| |
Appliances or devices (e.g., cane, walker, restraints) | |__| | |__| |
Familiarity with the environment (including room change or new admission) | |__| | |__| |
Recent hospitalization or change in condition | |__| | |__| |
- When is the falls risk assessment conducted? (Check all that apply.)
|__| On entry/admission
|__| On reentry/readmission
|__| Monthly
|__| Quarterly
|__| With each MDS assessment
|__| Annually
|__| With a change of condition
|__| Other (specify) ___________________________________________ - a. Who completes the falls risk assessment on admission/readmission? (Check all that apply.)
|__| Admitting Nurse
|__| Charge Nurse
|__| Nurse Manager
|__| Nursing Supervisor
|__| Director of Nursing
|__| Physical Therapist
|__| Other (specify)7b. Is an RN required (per facility policy) to complete the falls risk assessment? Yes |__| No |__|
- If subsequent assessments are completed by someone other than staff noted in question 8, check all that apply to indicate who completes these assessments.
|__| MDS Nurse
|__| Charge Nurse
|__| Nurse Manager
|__| Nursing Supervisor
|__| Director of Nursing
|__| Physical Therapist
|__| Other (specify) ___________________________________________________________
|__| N/A - If residents are deemed to not be at risk for falls, are they reassessed at regular intervals?
Yes |__| No |__|
Section 2: Falls Prevention Plan
In this section, a series of questions will help the interdisciplinary team identify strengths and areas for potential enhancement related to care planning to prevent falls.
- Are care plans developed for all residents determined to be at risk of falling?
Yes |__| No |__|If no, skip to Section 3.
- Are interventions for primary prevention* included in a falls prevention care plan?
Yes |__| No |__|* Primary prevention means taking measures to prevent falls in people who have not fallen (e.g., strength and balance training).
- Are interventions for secondary prevention* included in a falls prevention care plan?
Yes |__| No |__|* Secondary prevention means taking measures to prevent further falls in those who have had a previous fall/falls (with or without injury).
- Do falls prevention care plans include interventions addressing the following falls risk factors?
Yes | No | |
---|---|---|
Cognitive impairment | |__| | |__| |
Impulsivity | |__| | |__| |
Visual impairment/perceptual deficits | |__| | |__| |
Polypharmacy | |__| | |__| |
Use of high-risk medications (e.g., antihypertensives, diuretics, hypoglycemic agents, psychotropics, opioids) | |__| | |__| |
Recent medication change | |__| | |__| |
Orthostatic hypotension | |__| | |__| |
Diabetes mellitus | |__| | |__| |
Gait disorder/balance problem | |__| | |__| |
Bowel and bladder incontinence | |__| | |__| |
Depression | |__| | |__| |
Neuromuscular disorders | |__| | |__| |
Orthopedic/joint disorders | |__| | |__| |
Seizure disorder | |__| | |__| |
Dehydration | |__| | |__| |
Vertigo/dizziness | |__| | |__| |
Infection | |__| | |__| |
History of falls | |__| | |__| |
Attached equipment (e.g., oxygen tubing, catheter) | |__| | |__| |
Appliances or devices (e.g., cane, walker, restraints) | |__| | |__| |
Lack of familiarity with environment | |__| | |__| |
Recent hospitalization or change in condition | |__| | |__| |
Environmental factors (e.g., glare, poor lighting, uneven surfaces, new environment, patterned carpet or floor) | |__| | |__| |
Situational factors (e.g., recent transfer, time of day, responding to toileting urgency, time since last meal) | |__| | |__| |
Section 3: Investigations/Root Cause Analysis of Resident Falls
- Does your facility have a policy to assess residents after falling? Yes |__| No |__|
If no, skip to question 3.
- If yes, does the policy address the following:
Yes | No | |
---|---|---|
Who is responsible for the assessment | |__| | |__| |
Timing of assessment after fall (e.g., immediately, within 2 hours) | |__| | |__| |
Specific components of the physical assessment (e.g., range of motion, neurological evaluation) | |__| | |__| |
Next steps of assessment (e.g., information from assessment used to create/update falls risk care plan) | |__| | |__| |
Interviews of witnesses (resident, family, staff) | |__| | |__| |
- Does your facility provide training to nursing staff on how to accurately assess residents after a fall? Yes |__| No |__|
- Does your postfall assessment process include consideration of the following:
Yes | No | |
---|---|---|
What the resident was doing when he/she fell or when last observed if the fall was unwitnessed | |__| | |__| |
If the activity was unusual for the resident | |__| | |__| |
Interviews with witnesses | |__| | |__| |
Body check for injury and pain | |__| | |__| |
Neurological check for change in mental status | |__| | |__| |
Range of motion evaluation | |__| | |__| |
Vital signs | |__| | |__| |
Surface (floor/ground) that the resident was found on (e.g., wet floor, uneven terrain) | |__| | |__| |
Description of resident gait | |__| | |__| |
Resident footwear | |__| | |__| |
Description of new environmental changes, including new furniture arrangement, new admission, new room | |__| | |__| |
Device or appliance use | |__| | |__| |
Resident ambulation status | |__| | |__| |
Medication regimen | |__| | |__| |
Restraint and alarm status | |__| | |__| |
Toilet use (including last time toileted) | |__| | |__| |
Care plan, including adherence to plan, changes and updates to be made | |__| | |__| |
Suggested interventions for prevention | |__| | |__| |
- Is the postfall assessment completed immediately after the fall? Yes |__| No |__|
If no, then when? _______________________________________________________________
- Who completes the postfall assessment?
|__| Charge Nurse
|__| Nurse Manager
|__| Nursing Supervisor
|__| Director of Nursing
|__| Physical Therapist
|__| Other ___________________________________________________________________ - Do you investigate each fall using a consistent investigative framework, (e.g., root cause analysis)? Yes |__| No |__|
- Do you investigate why the fall occurred? Yes |__| No |__|
- Can you determine if the fall was due to clinical factors (e.g., change in resident risk factors, inadequate care plan)? Yes |__| No |__|
- Are there any particular obstacles or challenges to investigating falls?
______________________________________________________________________________
______________________________________________________________________________
Section 4: Communication Practices
- Review the following list of meetings in which falls risk and prevention is potentially discussed by the interdisciplinary team. For every meeting that occurs at your facility, indicate the type of meeting, the meeting leader, staff invited and in attendance, frequency of the meeting, and whether falls risk and prevention are discussed.
Meeting | Meeting Chair/Leader Name and Discipline | Staff Invited and in Attendance (indicate A – Always, V- Varies, As Needed) | Frequency of Meeting (Weekly, Biweekly, Monthly, Quarterly, Change in Condition, As Needed) | Is Fall Prevention Discussed (Y=Yes, N=No) |
---|---|---|---|---|
Care plan review | ||||
Report or brief with CNAs | ||||
Report or brief with department heads | ||||
Medical staff meeting | ||||
Quality Assurance and Performance Improvement (QAPI) or Performance Improvement Plan meeting | ||||
Falls risk meeting | ||||
MD/Non-physician provider (NPP) rounds | ||||
Report or brief with therapy department | ||||
Report or brief with social services department | ||||
Report or brief with activities/recreation department | ||||
Report or brief with “other” | ||||
Other (please indicate) |
- Training
Indicate the date of the most recent training provided for the following:
Topic | Participants (Check All That Apply) | Date |
---|---|---|
Conducting an accurate falls risk assessment | Nurses _____ Therapy _____ CNAs _____ |
Nurses _____ Therapy _____ CNAs _____ |
Care planning to prevent falls | Nurses _____ Therapy _____ CNAs _____ |
Nurses _____ Therapy _____ CNAs _____ |
Effective restorative/strengthening exercises | Nurses _____ Therapy _____ CNAs _____ |
Nurses _____ Therapy _____ CNAs _____ |
Root cause analysis for falls | Nurses _____ Therapy _____ CNAs _____ |
Nurses _____ Therapy _____ CNAs _____ |
Documentation regarding risks for and prevention of falls | Nurses _____ Therapy _____ CNAs _____ |
Nurses _____ Therapy _____ CNAs _____ |
Documentation - ADLs/mobility, including the importance of noting and reporting changes | Nurses _____ Therapy _____ CNAs _____ |
Nurses _____ Therapy _____ CNAs _____ |
Other (indicate) | Nurses _____ Therapy _____ CNAs _____ |
Nurses _____ Therapy _____ CNAs _____ |
Resources
- Fall Prevention in Long-Term Care: Practical Advice To Improve Care, http://www.medscape.com/viewarticle/579951_2 (requires login).
- Prevention of Falls in the Elderly, http://www.patient.co.uk/doctor/prevention-of-falls-in-the-elderly-pro
- Fall Prevention Task Force, http://www.fallpreventiontaskforce.org
- The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities, https://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/index.html.
- Documentation Checklist: Process Guideline for Evaluation of Falls/Fall Risk, http://www.michigan.gov/documents/mdch/bhs_CPG_Falls_Checklist_206281_7.pdf
- Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model,https://consultgeri.org/try-this/general-assessment/issue-8
- Older Adult Falls Programs, https://www.cdc.gov/homeandrecreationalsafety/falls/programs.html
Menu of Implementation Strategies
The On-Time Falls Prevention Menu of Implementation Strategies for using reports is a list of potential ways facility teams may choose to integrate the falls risk reports into clinical practice. In addition, the menu helps the team consider other possible uses of the reports. The menu allows the facility team to consider which implementation strategies best fit within their workflow and meet the unique needs of their facility, avoiding the “one size fits all” approach to using the reports.
Implementation strategies are developed to include multiple disciplines, not only nursing, to promote the most effective use of reports among disciplines and improve communication across disciplines. Teams are encouraged to identify implementation strategies that may not be included on the list but are suited to integrate seamlessly into workflow at their facility.
The Falls Prevention Menu of Implementation Strategies table below summarizes potential uses for each report, as described in each report section. See Tables 3, 6, 8, and 10.
Falls Prevention Menu of Implementation Strategies
Existing | New | |
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Falls High Risk Report | ||
Care plan meetings | ||
Nursing Assistant Shift Change Report | ||
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Quarterly Summary of Falls Risk Factors by Unit or Facility | ||
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Monthly Contextual Factors by Unit or Facility | ||
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Postfall Assessment Summary by Resident | ||
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Implementation Steps and Timeline
The goal of On-Time is that a facility staff will incorporate the On-Time reports into day-to-day prevention activities and ensure multidisciplinary input into clinical intervention decisions. The Implementation Steps document was created to help nursing homes understand steps involved in implementing On-Time and the likely timeline to make the reports part of daily practice. It is intended to be used by the team champion and the Change Team members to help keep the effort on track and methodical. The timeline is meant as a guide, because quality improvement project timelines often vary, depending on the quality improvement skills and resources available to the participating facilities.
Step 1: Agree To Use On-Time Falls Prevention
Nursing home leadership agrees to incorporate process improvements using On-Time reports into their workflow. Most facilities begin with changes in workflow on one unit and then expand use to all units. Leadership agrees to identify a change team champion and establish a multidisciplinary Change Team to lead the project.
Step 2: Contact Vendor
The Change Team champion or information technology (IT) representative contacts the facility's electronic medical record (EMR) vendor to confirm that On-Time falls prevention reports are in the system and takes appropriate steps at the facility to provide all necessary staff with access to prevention reports.
Step 3: Identify Multidisciplinary Team Members To Serve as the Change Team
The Change Team consists of a Change Team champion, nurse managers from each nursing unit, a therapist (e.g., the rehab director), and nursing assistants. The champion advocates and supports the project and ensures project activities are sustained during turnover of key staff. Nursing leadership may assume this role or delegate the responsibility. Two team leaders co-facilitate project activities; one is a nurse and the second can be from nursing or another discipline.
Team leaders share responsibilities to coordinate and implement activities and coordinate calls with an On-Time Facilitator. The director of nursing determines his or her level of involvement. Ad hoc team members include the staff educator, physicians, nurses, and representatives from other disciplines.
Step 4: Introduce On-Time Fall Prevention
The On-Time Facilitator provides technical assistance via an initial telephone consultation to confirm EMR capabilities and readiness to start On-Time, discusses immediate next steps regarding IT, and guides staff through the introductory materials as needed. The Facilitator answers questions and confirms that the facility team members understand how to access reports and tools and establishes the process for working together.
Step 5: Review Reports
The team reviews reports with the Facilitator to understand content and potential use of reports.
Step 6: Complete Self-Assessment
The team completes the Self-Assessment Worksheet that identifies details about the current processes at the facility to identify residents at risk for falls and to coordinate care planning. The review includes identification of team meetings, huddles, and other communication structures in place, ways risk information is transmitted to clinical staff, and ways care plans are updated and interventions determined. The team is guided by the Facilitator to identify gaps and begin to think about ways On-Time reports can be used to help prevent falls.
Step 7: Pilot a Report With Data
The On-Time Facilitator assists the team in using one of the reports. The team reviews material for the first report and generates the report for one nursing unit. The Facilitator works with the team to understand the first report and answers questions, as needed.
Step 8: Validate Data
This step helps the team gain confidence in the validity of the data in the reports. The team discusses residents populated on the report to ensure that data on the report agree with staff knowledge of residents’ health/risks. Staff may choose to go back to the medical record to confirm that data on the report are consistent.
In completing this task, the team may identify problems in, for example, nursing assistant documentation completeness, and may find it necessary to have the nurse educator retrain nursing assistants, to improve report validity. In addition, the Facilitator can clarify any normal but potentially confusing data situations and how to interpret them. Each report the team uses should go through this process so the team is confident in the information being produced on the reports.
Step 9: Agree To Use Reports/Implementation Strategies
With the Facilitator, the Change Team uses the Fall Prevention Menu of Implementation Strategies. The Facilitator describes the strategies and helps the team determine which reports may help them given the findings from the self-assessment (Step 6). The team can use one report more than one way and in multiple meetings.
Step 10: Create Report/Meeting Strategies
Strategies are based on self-assessment identification of pre-On-Time communication and care plan meetings/huddles and the Fall Prevention Menu of Implementation Strategies. Some new huddles and other meetings may be created and meetings may be altered to accommodate report discussion.
The team reviews the Fall Prevention Menu of Implementation Strategies for each On-Time report and discusses options for using the reports within current communication structures. The team considers meetings, huddles, care plan meetings, or other existing meetings where a report would enhance the current process to identify risk and coordinate care across disciplines.
At this time, the team identifies potentially new processes that may be developed to use the reports. Teams pilot reports and incorporate report discussion into existing meetings or new meetings. Changes in requirements to attend meetings may be needed to increase the number of disciplines and nursing assistants providing input and to change communication networks to improve risk identification.
The Facilitator helps the team initiate the first report meeting strategy. The team makes sure it understands the criteria for identifying residents profiled on the report, knows the definitions of risk factors that are profiled, and receives advice on how to structure existing meetings or create new meetings to best incorporate report discussions. Advice includes who should attend the meeting, what their roles are, who is responsible for the reports, and who will lead the discussion.
Step 11: Pilot All Report/Meeting Strategies on One Unit
The team discusses implementation issues with the Facilitator after piloting of report/meeting strategies. This is an iterative process that should be repeated until the process is smooth and effective.
Step 12: Ensure Implementation Strategies Are Carried Out
Once a new report is incorporated into a meeting, the champion decides on role changes for staff to ensure the report is used at designated meetings with appropriate discipline and nursing assistant input. It is important for the champion to have supervisory responsibility so these changes can be informed and enforced.
Step 13: Develop Plan and Implement New Strategies in All Units
The training and implementation planning process for integrating reports on one unit should take approximately 3 to 4 months once the facility has confirmed the On-Time Fall Prevention reports are available and staff have been granted access to view and print the reports (Steps 3-12). The timeline depends on leadership commitment, stability of staff, staff familiarity with computerized reports, and quality improvement (QI) experience of staff.
Implementing on all units is likely to add another 3 months. The Facilitator will help the team to problem solve implementation issues until all reports and all units are implementing the reports as planned and the team becomes more independent.
Step 14: Monitor Facility Implementation Progress Monthly
After about 6 months, the Facilitator's role is to check in to identify obstacles that could occur and to troubleshoot issues such as turnover of key staff, computer glitches, and implementation issues. The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently (e.g., monthly).
Step 15: Review Fall Incidence
The Facilitator works with the team to generate QI monitoring reports that identify fall rates to provide feedback to the Change Team and support reporting requirements.
Step 16: Sustain the Effort
After approximately 9 months, the nursing home Change Team develops a plan for incorporating implementation strategies for report use into facility policies and procedures. The plan includes incorporating education regarding On-Time into routine educational inservices, including for newly hired staff and training material for temporary employees. A permanent On-Time champion and champions on units should be identified by facility leadership.
Likely champions for each nursing unit are the nurse managers, with backup support by a QI staff member who may be assigned to conduct periodic monitoring of the processes surrounding the use of the On-Time reports in order to ensure that their use is sustained. The director of nursing or a designee should assume the responsibility of ensuring On-Time process improvements are carried out on each nursing unit.
Approximate Timeline
Implementation Steps | Estimated Duration/Time From Implementation |
---|---|
1. Agree to Use On-Time Fall Prevention | |
2. Contact Vendor | Start time is after confirmation of access to reports for frontline staff |
3. Identify Multidisciplinary Team Members To Serve as the Change Team | Within 2 weeks |
4. Introduce On-Time Falls Prevention | 1st month |
5. Review Reports | 1st month |
6. Complete Self-Assessment | 1st month |
7. Pilot a Report With Data | 2nd month |
8. Validate Data | 2nd month |
9. Agree To Use Reports/Implementation Strategies | 2nd month |
10. Create Report/Meeting Strategies | 2nd month |
11. Pilot All Report/Meeting Strategies on One Unit | 2nd month |
12. Ensure Implementation Strategies Are Carried Out | 3rd month to 4th month (some facilities implement in all units simultaneously) |
13. Develop Plan and Implement New Strategies on All Units | 4th month to 6th month |
14. Monitor Facility Implementation Progress Monthly | 6th month to 9th month |
15. Review Fall Incidence | As required |
16. Sustain the Effort | End of 9th month to 12th month |