Falls Focus Exercise

Purpose

• Decrease and prevent resident falls and resultant injury

• Delay resident physical declines (resultant of the aging/disease process) that contribute to falls

• Maintain resident gains achieved through therapeutic intervention

• Provide a restorative nursing and activity program that incorporates therapeutic activities and promotes falls prevention

Intervention Steps

1. The facility Falls Committee and/or Restorative Nurse identifies residents with recent falls or a high risk for falls

2. The Falls Committee and/or Restorative Nurse identify residents for therapy intervention.

3. Therapy (OT, PT, and ST) evaluates each resident and determines appropriate Restore/Compensate/Adapt interventions for underlying impairments such as safety, vision, balance, cognition, ambulation, independence, etc.

4. Upon completion of each resident’s therapy program the discharging therapist will identify the 1-2 categories on the attached Falls Prevention Movement Patterns sheet that the resident can most benefit from to maintain gains achieved and prevent recurrence of falls.

5. The discharging therapist will identify through the written Functional Maintenance Plan whether the Restorative 1 or Restorative 2 program is most appropriate (see descriptions below).

6. The Trans-disciplinary Care Plan Team will review each resident’s program at least quarterly through the care plan review to determine effectiveness. The need to revise the program (necessitating re-referral to therapy) or discontinue the Restorative 1 or 2 Program can be determined at this time.

Referral to Therapy Criteria

• Recent decline

• Unsafe performance in daily routine

• Need to determine effective ambulation / transfer pattern

• Need to train caregivers on techniques to promote each resident’s “best ability to function”

• Resident may benefit from ambulation or balance training

• Endurance or strength issues affect gait / safety

• Need to modify environment to enhance safety

• Need for assessment of underlying impairments contributing to falls, such as low vision, cognitive or behavior issues, etc.

• Wheelchair positioning modifications required

• Need to determine appropriate adaptive equipment

Role of the Falls Committee and/or Restorative Nurse

• Monitor and track resident falls, determining patterns and root causes

• Facilitate interdisciplinary intervention, assist to case manage as appropriate

• Facilitate staff education on falls prevention

• Facilitate facility restorative programming

Levels of Intervention Post Therapy Discharge

Restorative definition: Nursing interventions that assist and promote the resident’s ability to adapt and adjust to living as independently and as safely as possible. This item does not include procedures or techniques carried out by or under the direction of qualified therapists. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.

Residents with high fall risk or incidences of falls benefit most from the programs identified below when occurring at least 3 times per week, even if only for very short periods.

Restorative 1: See attached sheet identifying balance work stations which can be done in a small group setting led by Restorative Aides. This group would be for residents with early to mid-stage Dementia that would benefit from a structured Restorative program that involves challenging the patient in the areas identified. This program incorporates the use of an obstacle course with 4 stations that the residents would rotate through to challenge skills. The RNA and any assisting personnel required for safety would run this program 6-7 days a week. (4 patients for 15 minutes participation each) Residents with advanced Dementia may benefit from having the RNA walk them through the obstacle course individually, in a non-distracting / quiet atmosphere.

Examples of Restorative 2 Activities: See attached sheet identifying Nursing / ADL activities, and activity examples which can be implemented as a part of a resident’s daily routine.

Precautions:

• Residents participating in Falls Activities should be wearing a gait belt, being held onto by staff during standing activities.

• Certain activities which may challenge a resident outside their comfort zone may exacerbate agitation or inappropriate behavior. When this occurs, it is best to move slowly, starting within the resident’s comfort zone and then slowly increasing the zone over successive weeks.

• Resident’s who have mid to advanced stage Dementia (Allen levels low 3 to 2, Global Deterioration Scale levels 5-7) benefit most from visual cues, one step commands, and using known activities from their life events.

Tips for Successful Implementation

1. Develop some type of system within the facility to track which residents are on which program – suggest binder at nurses station or dry erase board that is updated.

2. Train caregivers in the 4 movement patterns which promote falls prevention, and how they can be incorporated into daily activities. Make the in-service fun, having the staff demonstrate different approaches that are realistic for the facility.

3. Give Unit Coordinators rewards as an incentive to staff as in #4 below, so that they are coordinating this restorative effort on their unit. The Unit Leader should act as a program champion.

4. Have incentives for staff participation in the program – Have fun with it! Suggest having 2 days per week where one of the 4 movement patterns is highlighted, for a period of one month. On the special day have fun activities such as candy bars, bottled beverages, gift cards, etc to give out if a staff member can describe the pattern, identify at least 4 residents who could benefit from a certain pattern, or identify at least 3 ways to implement the pattern during the resident’s daily routine. If you get a little wild and crazy the staff will buy in to the program.

5. Reward the entire facility staff when certain milestones are met, such as the % of falls reaching the targeted goal or benchmark the facility team has set.

Suggested Timelines for Implementation

2 Weeks: Develop a staff committee which meets to plan the kick off, timelines, incentives, staff training, and structure of the Falls Committee (how to meet, etc.)

3 Weeks: Implement staff training (nursing aides, activity staff, Dementia Unit Staff, etc)

4 Weeks: Hold 2X/ week activities to facilitate staff buy in and memorization of the 4 movement patterns, giving incentives/prizes

Tracking Effectiveness/Results:

See attached form – the Falls Committee and / or Restorative Nurse would meet regularly to assess progress, adjusting the program accordingly.

Staff Training

1. The Falls Committee meets to determine the focus residents for intervention, choose dates for C.N.A. General and Specific Training, and establish incentives and rewards for staff participation.

2. Conduct Mandatory C.N.A. Training;

General

• Discuss the falls problem in the facility, and the impact is has

• Tell the C.N.A.’s you will reward them for participation in this in-service (i.e. candy bars, soda, coupons, gifts, etc)

• Describe the 4 movement patterns that inhibit falls

• Demonstrate / describe what “reaching outside your comfort zone” means, as well as “turn the other cheek”

• Role playing: Have the participants demonstrate giving residents clothing by having them sit on the bed and twist (crossing midline) to reach for their clothing placed next to them on the bed: play balloon volleyball, demonstrating how you can encourage “reaching outside of your comfort zone”

• Emphasize the #1 most important thing to remember: reach outside of your comfort zone

• Have the C.N.A.’s identify the residents who can benefit from these movement patterns

• Give out the candy bars, soda, or other gift for reward, for participation in the in-service.

Following this in-service, place posters around the facility “talking up the program”; stop by and ask a C.N.A. to name a movement pattern, give rewards if they can name one on the spot – give at least 2 good prizes out per week.

Specific (to be conducted 2 weeks later)

• Remind the participants that you will be giving out rewards for participating in this in-service
• Review the 4 movement patterns – quiz participants, encouraging rote memorization of each pattern Have participants demonstrate each pattern.
• Discuss the facility program: which residents are targeted to be using the movement patterns, and which pattern for each resident. Discuss where you can find this information (binder or dry erase board at nurses station) to review. Discuss that Unit Coordinators will be “catching” staff doing the movement pattern with targeted residents throughout the next 3 weeks. Prizes will be given if you are “caught” incorporating these techniques during a resident’s daily routine. At least 2 prizes will be given out per week.
• Give out prizes for participation in the in-service.

3. The core Falls Team Members will mentor the Unit Coordinators at least once during the initial week following the Specific Training In-service. The Falls Team Members will shadow a Unit Coordinator “catching” a C.N.A. doing one of the movement patterns during care of a targeted resident.

4. One month after the Specific Training, the Falls Committee will meet to determine facility follow through, determining the need for further incentives/awards.

Falls Prevention Movement Patterns

1.	Look Up/ Reach Up	Neck and Trunk Extension Leaning Backward Shrugging Shoulders Components Hands over head Look up at the ceiling Stretching neck out to the side Straighten the trunk Lean back towards the back of the chair Shrugging shoulders
2.	Reach High / Low Outside comfort zone	Crossing Midline Trunk Rotation “Turn the Other Cheek” Reaching Forward Toward the Floor Components Reaching hands higher than the shoulder Reaching hands lower than the waist or knees Look / reach towards opposite hip Look / reach behind you, right & left & opposite Reach so far that 1 buttock lifts off the chair Reach towards the floor Can be done sitting or standing
3.	Standing and Stepping Outside comfort zone	Weight Shifting Side to Side Weight Shifting Back and Forth Feet Far Apart Components Stepping from right to left leg, left to right leg Stepping back and forth with one foot in front of the other Wide stance (feet far apart)
4.	Strengthening During Activity	Lean on Arms Extended Standing Time Knee Bends Single Limb Support Components Lean one arm on the table while reaching with the other Push up off the chair with your arms Pull forward with arms Increased standing duration Knee bends to reach low Standing on one foot with balance support

Restorative 1

Balance Obstacle Course Work Stations

See accompanying protocol for a description as to who leads the obstacle course, which residents may benefit, how many residents in one sitting, etc.

1: Look up / Reach up:

Focus: neck and trunk extension

• Both hands together and reach up overhead

• Reach down toward feet/floor

• Reach out to the side (touch your neighbor, including leaning)

2: Reach High / Low

Focus: reach outside of comfort zone, including trunk rotation and crossing the midline

• Touch the dots on the wall (make large and colorful)

3: Standing and Stepping

Focus: weight shifting side to side, forward and backwards

• Stand up and step on footprints placed on the floor

4: Strengthening

Focus: extended standing time, knee bends, single limb support

• Step Stool: one foot up then down – 5 repetitions, switching each foot

• Hold Hand Rail for support, stand on one foot.

Materials needed:

Colored construction paper, paper to laminate foot prints and stars, scissors, duct tape, step stool (suggest large/wide exercise step stool that can be purchased cheaply at Wal-Mart – approximately 3’ X 5’ with rubber non-slip surface 3” height that can be stacked one upon another for increased height challenge.

Location for obstacle course:

An area with a handrail is needed for station #4. Suggest a quiet non-distracting area of the facility, such as a day room or dining room that is not used during certain time periods.

Restorative 2

Using Fall Prevention Movement Patterns
During Daily Activities

Pattern	NURSING / ADL Activities	ACTIVITY Examples
1. Look Up / Reach Up	Brushing / combing hair Put shirt on with hands over head Caregiver places ADL equipment so that resident reaches for it To straighten shirt resident straightens trunk and leans back	Balloon volleyball Parachute ball Scarf movement to music Beach ball toss Watering hanging plants
2. Reach High/Low Outside Of Comfort Zone	Flushing the toilet Putting on shoes and socks Place ADL items for resident to grab within reaching guidelines Store wash basin on closet shelf Get clothes out of closet or drawers Putting belt through pant loops Washing all of upper trunk	Parachute Folding clothes with basket on the floor Balloon Volleyball Floor basketball Ring Toss / Horseshoes Bean Bag Toss Setting the table Simon Says / Hokey Pokey Scavenger Hunt
2. Stand Step Outside Of Comfort Zone	Standing at closet or sink Walk backward a few steps to toilet or chair Weight shift to reach ADL items in bathroom Slide foot into slippers or shoes while standing Making the bed	Marching Band Setting the table Dancing to music Simon Says Mother May I Follow the footprints on the floor Walking on the grass in the courtyard
4. Strength Activity	Dusting table legs Washing the table Making the bed Washing windows Stand at the sink during ADL’s Pick shoes up off the closet floor Sit on different height surfaces (i.e. low couch)	Wheelchair propulsion Gardening Dancing Dusting table legs Cooking class, reaching items from the cupboard Picking up things off the floor during a scavenger hunt Marching Kicking a beach ball