Falls versus Culture Change

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In trying to be supportive of residents rights and culture change I am having a problem with one of my residents. He is a bilateral amputee who has fallen out of his bed or chair numerous times. He is in a low bed, we have had OT evaluate him and have tried putting his commode lower. WE put a seatbelt on his W/C that he can remove himself. He has 1/2 side rails because he uses them to reposition himself in bed. He has a slide board he utilizes for transfers. Due to a decline his cognitive state has somewhat diminished but is still very able to tell us what he does and does not want. Our doctor ordered bed/chair pressure alarms. WE had tried these in the past but he would remove them. We are trying again but he has asked me to remove them. He states he does not fall but he is. We worked out a compromise that if he can go 30 days without a fall they would be removed and he was agreeable to that. Unfortunately, he continues to fall. Fortunately, despite the many falls he has only ended up with stitches to a nose one time. Does anyone have any suggestions on what I can do with a chronic faller yet keep within him wishes to remain independent?

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Specializes in Geriatrics.

Sad to see this happening. Unfortunately there isn't much you can do. If he is oriented enough to remove alarms and disconnect his seatbelt he will continue to do so. Just try to keep him in sight, if you see him removing alarms, stop him, explain (again) why they are there (for his safety) and if he's seen trying to self transfer, go to help him. The hardest thing for some people is the slow decline to dementia, they want so badly to keep thier independence, but, this puts them at high risk for falls. Due to the dementia, they do not completely understand why they are being restricted and truely do not remember all the falls they have had. Again, very sad situation.

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Specializes in LTC, assisted living, med-surg, psych.

Whatever you do: CARE PLAN IT!!! I can't overemphasize that.....we have to respect our residents' rights above all, and if that means allowing them to fall, that's a risk many people are willing to take in order to maintain their independence to the best of their ability. We can't bubble-wrap 'em, but we can document their refusal to accept fall prevention devices and our efforts to educate and protect them. If it's in the care plan, and the care plan is followed, it'll help protect the facility and the staff if and when the resident falls and suffers a serious injury. Not that you'll feel any better about it........but at least you can prove that you've done everything possible AND respected the resident's rights.

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

My response is also to make certain that the nursing plan of care identifies this problem, the goals, and the interventions used to attempt to achieve the goals.

People have the right to fall...and die...we have a problem with those things in health care.

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Thanks for the input. I know now that I am on the right track. It had been care planned and I had documented my conversations with him. I was alsowondering if anyone also had any ideas on how to keep him from falling! Any new ideas that have worked besides what I mentioned. Thanks again

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Specializes in LTC, Memory loss, PDN.

If I understand this correctly, he keeps falling with the pressure alarms in place - remove them, they're not working. Have you identified what causes the falls, actively transferring self or unintentionally sliding out? Is there more than one cause for the falls? What did OT come up with? How about PT eval to build upper body strength? Long hx of falls or recent onset? I know you cannot answer these questions, because of privacy, but what I'm trying to say is I'd start with a comprehensive hx to include interview of resident, staff, family and possibly others. I think the goal should not be prevention of all falls, but minimizing risk of falls and injury.

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Residents like this are so challenging!

We have used portable infra red motion sensors in this sort of situation. The difficulty is trying to position them where the beam will be broken when the resident is trying to get up and not when they just change position in bed or chair. Staff are forever setting them off inadvertently too. Still, might be worth a try.

What about hip protectors to reduce the chance of fracture when he does fall? You say he's in a low bed, is it all the way to the floor?

I'm assuming you've had his medications reviewed. Is he on warfarin? If he is, it might be worth talking to his doctor about risk/benefit in a case like this.

Agree that your goal should be minimising the risk of injury when he does fall as well as continuing to try to reduce the number of falls. I update an individual trending graph weekly and note on it the dates of your various falls prevention interventions, medication changes, acute illnesses the resident has, discussions with his doctor, physio review, that sort of thing. Sometimes this can show something you might be able to work on, sometimes it just shows you what you already knew only too well, but it helps to prove that you're taking the issue seriously, reviewing it frequently and doing everything you can.

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Specializes in Geriatrics, WCC.

Make sure your NP or MD has written in the progress notes that everything has been tried. You will not be sited if there is no solution. I have a secured unit that these things happen routinely, there comes a time (sadly) that there is nothing left to do.

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Specializes in Gerontology, Med surg, Home Health.

How about a tilted cushion...it's higher in the front so the hips slant backwards and people fall out of their chairs less....or a pommel cushion? Just a thought. I'm with the others. Care plan everything.

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Specializes in LTC Rehab Med/Surg.

Sometimes there is simply no way to prevent people from falling. You do the best you can, but short of 1-1 the falls continue. The right to fall is a concept I just can't get my head around. I understand it. I accept it, because I must. But it just plain seems wrong.

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I may have missed this in anothers suggestion, but can you put a fall mat in place to minimize the injury when he falls?

Also...think about why he is getting up...

Does he need to use the toilet? Put him on a toileting program-like every two hours or less.

Does he want to go out for programing/groups? Make sure aids are taking him out?

Can you plan times up, such as every...2 hours, get him up.

Try a schedule. Try to contract with him, with his input, what his day will be like...every 2 hours toilet, up at certain times for activities, up for meals. Have this contract printed at his bedside to remind him.

I know this type of individualized approach takes time and staff.

I don't think alarms really work...they just alert you as to when the do fall. If it isn't working then get rid of them, documenting why you did so.

I think the schedule could add structure to his day.

Just thoughts from a surveyor stand point.

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Specializes in LTC.

I don't think alarms really work...they just alert you as to when the do fall. If it isn't working then get rid of them, documenting why you did so.

They don't prevent falls but I can count many times when I've heard an alarm go off and got there just in time before the resident was about to get up out of bed or chair.

I disagree with getting rid of the alarms. If you get rid of the alarm and he does fall .. you won't know that he is on the floor until someone finds him.

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