Browsing "Alarms/Falls/Mobility"

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.

Alarms/Falls/Mobility – Entry 1

Dear Diary:

Just when I think we’re making progress, something happens that shows me we’ve got more work to do. I came back to work after the weekend and reviewed the 24 hour reports. I saw that on Friday night Hattie had another fall. Fortunately, she doesn’t have an injury. When I went to the health record to learn more, I saw that the night nurse put a tab alarm on Hattie and it’s been on ever since. Since Hattie broke her hip the last time she had a fall, I suppose the nurse put the alarm on because she is worried about another fall. However, I am not sure if that’s her reasoning because the documentation about what happened isn’t clear. I can’t find a root cause analysis form following the fall, and I don’t see any clear follow-up for Hattie based on this fall. I thought our systems were better than this! I guess I’m going to have to follow up to figure out what happened.

We review all falls at our Wednesday IDT meeting for this neighborhood. It looks like we have a lot of systems issues. How do I begin to sort out what to do next?

Signed, Donna

16 Comments

  • We have been working on decreasing falls for sometime now. We did remove alarms within the facility a year ago and started by not placing alrms on new residents who are at risk for falls. Taking away the alarms on residents who fell when the alarm was on (obviously not effective). Then we moved on to Placing a photo of falling stars and and leaves on teh doors of residents who are at risk (leaf) and those who have fallen (star).
    Now we are looking at staff break times and taking away the chairs at nursing stations so not to tempt staff to sit for a few minutes but to keep “rounding.”

    • How did that go when you took the chairs away from staff at the desk to keep them “rounding”? Has it been a positive or negative experience? I do like looking at staff break times; didn’t think about that. I have been looking at the times resident falls have occurred and comparing that to call lights going off around that time.

      • The overall reaction to removing chairs at the desks was “ok”. The night shift did verbally express their dislike but they are doing fine with it. The break time changes/adjustments went very well. No verbal complaints came forward from anyone as of this time.

  • We also have been working on decreasing falls for some time. We have reduced the number of alarms within our facility but there are those couple of residents that we just haven’t figured out a better solution than to have an alarm on them at this point (any suggestions would be great). 🙂 We also have started putting the number of days without a fall on our daily communication sheet and are giving little incentives (candy) for X number of consecutive days without a fall. Something we just implemented the other day was room to room reporting. Will see how that goes ….

    • We have successfully eliminated alarms at our facility and have been alarm free for over a year now. I remember as we were going through the process we had 2 residents left who still had alarms and we decided to just take a leap of faith. We had the evidence that alarms don’t prevent falls so we just did it. Well…we did not have more falls, in fact falls actually decreased-I think the noise and startle effect really did affect people. You can do it!

  • We also would like to reduce alarms, how to reduce them safely is the question. We have had positive reductions but also have those that would be high risk to remove them. Also, some falls surround refusal to allow staff assistance and adhere to saftey measures, what then?

    • It really is an education issue. We keep, to this day, needing to educate families/ staff that an alarm really could be the problem causing the fall as it can be very startling. We have initiated 1 hour, 1/2 hour or even 15 minute checks on residents.

  • We also are trying to reduce alarm use. I totally agree that the sound of them is very startling. Not to mention if there are several alarms on one unit staff have difficulty determining where the alarm is coming from. We were also (and still are) having problems getting the nurses to paint a complete picture of the circumstances surrounding each fall. If we have all the information we need, we are then able to identify the root cause. Only then are we able to initiate meaningful and effective interventions.

    • We also are having a problem with nurses “painting the whole picture” when a fall occurs. They do not always fill out each and every question on our FSI report which makes it more difficult for our Falls Team to determine which interventions are most appropriate for that resident. We will keep working on that ….

  • We are also trying to reduce alarms. I have 5 people left with alarms and the families are an obstacle. They believe mom or dad is safer with than without an alarm. We have education and have tried but no success with these last 5 families.

  • This feedback is really helpful. I like the idea of more frequent rounds in which the nurses say they are too busy. I reminded them of the time it takes to complete incident reports and resident injury follow up that of course no one wants to see.
    During a behavior concern we had , we assigned different staff to do safety rounds every 15 mn (with 4 staff, they only had to do this 1x/hr) this may work for safety/falls also.
    Thanks again.

  • We recently updated our FSI fall form to better determine the RCA and have started educating other departments about RCA. We have been doing room to room reporting between shifts for both NARs and nurses. It was slow going at first, but I think they have gotten on board and it has become part of their routine.

  • We have added an “Investigative Report” in which any staff member can start or fill out. This goes back to the two hours before an unwitnessed fall. Our UM’s state it has really helped them get a full picture of what may have occured. We have also attached a list of interventions to choose from. This has helped the team to act together at the time to use the most appropriate one.

  • Dear Donna
    When I first removed all the alarms from my floor the staff were in a panic unitl I explained to them the risk of alarms and the fact that alrms do not prevent falls rather create falls. It was an uphill surge to educate staff that our behaviors add to the risk. Yes Donna I educated them to this fact. Behavior as well as falls is a form of communication. Staff are in control of the environment to inlcude nosie. There is always intent surrounding movement. This is where the root cause lies. Rather or not it makes sense to staff it only has to make sense to the residnet and staff need to understand it. Falls have not increased rather decreased with a change in mind set and understanding.

  • If you contact me directly at sguilder@empira.org I will send you a bibliography/resource sheet that contains evidence based information, articles and publications all supporting the removal of alarms in nursing homes.

  • Our facility is working on restraint reduction. At the beginning of our process we started with 4 restraints and are decreased to 1 restraint. In the past, we resorted to tabs or sounding alarms, which we have attempted to avoid. We reviewed those residents who had restraints and determined the cause or need for restraint. We re-evaluated other interventions we can put in place to decrease the amount of time resident has restraint in place or attempt to eliminate restraint in full. We have reviewed medications, referred to therapy, had meeting with IDT team as well as floor or direct care staff. We evaluated the reason restraints were in place, example repeated falls or attempts at unsafe and unassisted transfers and re-evaluated reasons for attempts to self transfer. We look at a holistic approach. Incorporating activities, nursing, dietary, ect. We review falls, nursing interventions, ect every morning by the IDT team for review, re-evaluation and implementation.

Share your nursing home perspective on this quality improvement issue.