Alarms/Falls/Mobility – Entry 2

Dear Diary:

Well, Hattie is no longer attached to an alarm. After talking with Hattie, the nursing assistants, and nurses working on the night and day shifts, I have a clearer picture of why an alarm was put on her. Apparently, Friday evening, Hattie stumbled when transferring with the night shift nursing assistant; later she fell against the bed again when attempting to transfer herself. Saturday morning she was lethargic, confused and requested to stay in bed. When she got up for lunch the nurse was concerned about her stumbles during the night and her continued confusion, so she put a tab alarm on her. The events of Friday and early Saturday were shared during weekend report, but no one did any further assessment or took the alarm off Hattie. In addition to the tab alarm, the nurse who worked Saturday night also placed an alarm on Hattie’s bed for her “safety.” Before placing these alarms on Hattie, no one took the time to figure out why she was so unsteady.

In piecing together some of the events, I’ve really been surprised about how complicated investigating falls can be. Some of the things I found that contributed to Hattie’s fall include:

  • There is a lot of clutter around Hattie’s bed.
  • The nursing assistant on the night shift didn’t turn on the light either time when helping Hattie out of bed.
  • Hattie doesn’t have any slippers. She was transferring in her bare feet.
  • Hattie was given acetaminophen for hip discomfort at 8 pm.
  • Hattie told staff she wasn’t feeling well Friday evening and most of Saturday. She was lethargic and intermittently confused.
  • Due to her lethargy, and despite encouragement from the nursing assistants, Hattie didn’t eat or drink very much over the weekend.
  • Though Hattie’s been working in therapy on strength and endurance, they have not provided any recommendations for how to assist Hattie with transfers in the neighborhood.

As a result of this investigation, Hattie’s plan of care has been updated to address these contributing factors in an effort to prevent further falls.

Hattie is much better today. She is experiencing some cold symptoms so we’ll have to keep a close watch on her. We were all in agreement that she doesn’t need an alarm. When it was removed from her room, she said, “Thank you. I hate that thing. I’m afraid to move and it makes so much noise.”

We discussed this case at our Interdisciplinary Team fall meeting. At that meeting, we recruited some volunteers to look at our fall investigation process. I wonder how other nursing homes have had success with completing thorough investigations with every fall? We also scheduled a special meeting to discuss how to go about eliminating all alarms in our building. I know that many nursing homes have successfully decreased or eliminated personal alarms. I wonder how they did it?

Signed, Donna

3 Comments

  • I know we also really struggle with accurate and thorough assessment after falls. We have blanks on the incident report, very generic non-detailed descriptions of what happened. I am thinking of adding a checklist with yes/no questions to help investigate the scene to get a better picture of what is happening when a resident falls.

    We do not use alarms in our facility and after being alarm free for a year, it isn’t even a thought for staff to start an alarm any longer. How we started was to pick the “easy” residents, ones who hadn’t fallen recently or who had declined or improved to the point where an alarm didn’t make sense, we went slowly and towards the end we just needed to make a leap of faith and “finish the job” and get rid of those last alarms. There was backsliding, but we were just firm and kept at the goal and made it clear that alarm use was OFF THE TABLE as a fall prevention intervention.

    After the alarms were stopped it is amazing how many staff comment on how quiet and calm it seems.

  • we had eliminated alarms in the building then there was a change in managment and alarms are steadily creeping back into the facility. How do I explain to upper managment that the alarm is not going to prevent a fall it will only alert staff there has been a fall?

  • We also went alarm free. We did a comprehensive falls assessment on every patient that had an alarm. Most patients had a fall recently which showed the alarm was ineffective, so we discontinued all alarms this way.

Share your nursing home perspective on this quality improvement issue.