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The Risky Business of Falls and Care Planning’s Role in Prevention

There are plenty of statistics documenting the hazard falls pose for the elderly. The Centers for Disease Control and Prevention (CDC) has a website sharing important facts about falls. CDC notes that:

  • One out of four older adults fall each year in the United States, but less than half of them tell their physician.
  • Falling once doubles the chance of falling again.
  • One out of five falls causes a serious injury, such as fractures or head injuries.
  • By 2030, it is predicted that seven deaths every hour will be related to falls.

Falls in the skilled nursing facility continue to be one of the top survey citations. F689, Free of Accident Hazards, is frequently cited at a high scope and severity based on the level of harm or potential harm to residents. Fall incidents often result in hospitalizations, leave facilities vulnerable to costly enforcement actions, and can lead to litigation. There are two key tasks to complete after falls. First, conduct a thorough root cause analysis that uncovers all the possible reasons the fall occurred and document in the clinical record the analysis and its conclusions. Second, implement interventions specific to the root cause or causes of the fall. This article will explore four ways to update the care plan after a resident falls.

Update care plans with condition changes, even if a SCSA isn’t required

Mr. Smith is a one-person transfer out of bed; once upright, he is able to ambulate with a wheeled walker unattended. Two days ago, Mr. Smith complained of feeling dizzy while walking. He was then diagnosed with atrial fibrillation with rapid ventricular response and was started on metoprolol to control the arrhythmia. He is now back in sinus rhythm.

The above change in condition may not require a Significant Change in Status Assessment (SCSA), but it does require updates to the care plan. Mr. Smith has a new diagnosis, atrial fibrillations, that increases his risk for falls. He is also on a new medication that has side effects that increase the risk for falls (e.g., dizziness, lightheadedness, etc.). The care plan should reflect the resident-specific risks and be timely updated.

Residents with frequent falls

Mrs. Jones fell four times in the last month. Each time, she rolled out of her low bed and onto a safety mat placed next to the bed to protect her from injuries. Despite these interventions, she continues to roll out of bed onto the mat. When staff are asked, they indicate there are no other interventions that can be put in place to keep Mrs. Jones in bed other than devices considered restraints.

The above scenario is a common myth, but it “just is not true,” says Laura Ginett, a partner with the Chicago-based law firm Hall, Prangle, Schoonveld, whose practice includes defending skilled nursing facilities (SNFs) in litigation. Ginett elaborates, “There is always something to do. Move the patient closer to the nurse’s station. Get restorative and physical therapy involved to make recommendations. Get the family involved. Re-educate everyone. Toilet the resident on a schedule. Have pharmacy look at medications that could affect blood pressure or glucose or if they are on too many pills. Plot the time of day and, if there is a trend, increase monitoring at those times.” The care plan should demonstrate the facility staff’s continued efforts to prevent future falls.

Cognition and non-adherence to fall risk interventions

Ms. Felder requires the assistance of one person to ambulate to the bathroom. While at home, she was independent and doesn’t understand why the facility has so many “rules.” She insists she is more than safe enough to walk on her own. In addition, there are days when Ms. Felder refuses her blood pressure medications, stating they make her have to use the bathroom frequently. She is alert and oriented, with a BIMS score of 15 (cognitively intact). Despite reminders to ask for assistance with toileting, Ms. Felder did not ask for help today and fell on the way to the bathroom.

The above situation involves a cognitively intact resident who refuses assistance and medications. One or both of these refusals could cause a fall to occur or trigger other negative outcomes. In cases such as Ms. Felder’s, you will want to have a care plan which addresses the risks of falling and mitigates against noncompliance, for example, by providing education about the consequences of failing to follow instructions.

Dementia residents, family input, and falls

Mr. Daniels has dementia; he is unsteady on his feet and has fallen three times in the last month. His dementia has left him with limited ability to communicate his needs. Staff have tried several different interventions, but Mr. Daniels continues falling. Staff cannot determine why he is falling.

For residents with dementia and communication issues, it can be more difficult to uncover the root cause of falls, but there are several possible interventions that can be tried. First, communicate with family; ask them about the resident’s daily routines, past occupation, and hobbies. Track the time of day of the falls, as there may be a pattern uncovered. Use this and family input to help determine suitable interventions. For example, after talking with family, staff learn that Mr. Daniels once had a grandparent who fell out of a recliner. A week ago, staff moved a new recliner into the room, and that is when Mr. Daniels began falling. Any time someone tried to sit in the recliner, Mr. Daniels also became very anxious. Without family input, staff would not have known about the recliner incident.

Updating fall interventions requires ingenuity and resourcefulness. When conducting a root cause analysis, do not settle on the first cause revealed. Keep digging, use family input, and involve the entire interdisciplinary team when trialing new interventions. Be sure to document all your findings, attempted interventions, and the resident’s response to them thoroughly. The care plan should clearly indicate that it has been updated after every fall, with interventions put in place that address the root cause of that specific fall.


Centers for Disease Control and Prevention. (2017). Important facts about falls. https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

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