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
The facility Falls Committee and/or Restorative
Nurse identifies residents with recent falls or a high risk for
falls
The Falls Committee and/or Restorative Nurse
identify residents for therapy intervention.
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.
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.
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).
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
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.
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.
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.
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.
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
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.
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.
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.
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
3: Standing and Stepping
Focus: weight shifting side to side, forward and
backwards
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
|