Falls in Assisted Living

leslie :-D · Aug 22, 2009

meticulous documentation, esp r/t refusals to transfer.

we have also written a document to effect that pt has been made aware of risk for injury r/t falling, and that all applicable interventions have been implemented, w/o success.

and, if pt becomes injured, s/he will not find facility liable.

pt signs, and paper is placed in front of chart.

granted, it doesn't prevent further falling, but attempts to absolve facility of responsibility.

it's all about the pt's self-determination.

but detailed notes should cover that, as well.

leslie

Long Term Care Columnist / Guide · Aug 22, 2009

Sometimes an ALF resident becomes so inappropriate for this care setting that they MUST leave the facility, whether they want to or not. In this case, the facility has the 30-day involuntary move-out process at their disposal, which is very involved and difficult to execute, but not impossible as long as they have all their ducks in a row.

Before attempting this, however, they have to justify to the State that everything possible has been done to keep high-risk residents safe. That usually means a PT eval, review of medications to see if something they're taking might be contributing to falls (pretty much a given if they're on hospice), full physical exam by the medical director or their PCP, even a psych eval if appropriate. Then they have to try interventions such as alarms, frequent visual checks by staff, low beds, crash pads and so on...........so as you can see, an involuntary move to a higher level of care is quite complicated.

As a hospice nurse, however, you can advocate for your patients if you feel their current environment is unsafe and they need to be transferred to a nursing home or foster care where they can be better supervised. Now, I used to be a DON in assisted living, and I'm a huge proponent of 'aging-in-place'; in fact, I have many times drawn on a number of resources (including hospice) to provide the services that enabled a resident to stay in ALF who otherwise would have had to go to a NH because they required so much care in their final weeks of life.

In most communities, there are at least some resources to help in these cases. Does your hospice employ CNAs who can provide 1:1 care to help reduce the frequency of falls? Or if not, can you involve another home-care agency that does provide 24-hour caregivers? How about utilizing volunteers to sit with these high-risk patients? Are there family or friends who would be willing and able to take shifts staying with them? Even members of service organizations and churches may be available to help.........you just have to do some legwork and find out what's out there.

Just a few ideas..........good luck!

rngolfer53 · Aug 22, 2009

Happens in the home setting as well as ALFs, and because CGs get exhausted, the "staffing" issues aren't all that different.

A while ago, I visited a Pt who, a family member told me, had fallen a couple days before. The Pt was at considerable risk from a fall and was lucky to escape injury because a family member just happened to see the Pt start to go down.

The fall wasn't related to why I was there, but I had a lengthy chat w/the Pt about preventing falls. Things like putting the BSC actually at the bedside (what a concept, eh?) and asking for assist when the need/desire to get up came along.

The response I got was, "I'll know when I get to the point that I need help." This was a person with good intelligence, but who still failed to see the illogic of that statement, or just ignored it.

We can't "reason together" with our Pts in the sense of Don Corleone. As Leslie noted, they do and should have autonomy, and for this Pt, with the end of life in sight, that bit of independence was perhaps more important than what we think of as safety. Who am I to say that's wrong?

You can bet I documented the heck out of my conversation with the Pt, and I made it a point to tell the family about it as well. They weren't surprised that I didn't make much headway.

Any other ideas on what I might have done, both to help the Pt and CMOA (Cover My Own, well, you know)? I don't think the Pt would be comfortable w/someone in the room or checking all the time.

tewdles, RN · Aug 23, 2009

Not much to add here as the pros have it pretty much covered. The bit about documentation is crucial. These patients (when they are cognitively able) are self determining, this means that they actually have the RIGHT TO FALL. Our job is to try to keep them as safe as possible and to make sure that we have documented our efforts. It is a whole different ball game if they are cognitively impaired, maybe even easier.