Falls in Nursing Homes
Barry, I was surprised to learn that falls were one of the most common kinds of cases that you handle. I thought that falls were kind of just one of those things that happen as you get older. Why are falls such a major issue in nursing homes?
Barry Doyle: Well, one of the real common reasons that people get admitted to a nursing home to begin with, is because they're experiencing falls at home. They're just not safe to be on their own. And if a nursing home is taking a resident on who's experiencing falls at home, this is something that needs to be care-planned, because this is one of these things that really is a risk to the health and well-being of the nursing home resident.
With a senior citizen population, falls are something that have a serious effect on mortality and morbidity, meaning that falls are more likely to result in death, falls are more likely to result in significant declines in the overall quality of life. So falls are a big, big deal in the nursing home industry and most often, they get treated as such.
Pam: Okay. And so what are the most common scenarios in these kinds of cases?
Barry Doyle: Most of the falls that I see are falls that involve people who have been identified as being fall risks, who have managed to get up, unattended, most typically to go to the bathroom, and on the way there or on the way back, experienced a fall, typically with some fairly significant fractures or other injuries.
Pam: So this is not like your basic slip and fall at a grocery store?
Barry Doyle: No, not at all. When you're talking about a slip and fall involving a grocery store, you're typically talking about someone who slips and falls on a foreign substance, whether it's water or a grape or something like that. And those kind of falls do happen in a nursing home setting, and keeping floors clean is part of a basic care plan in any nursing home setting. But more often, the kinds of falls that we see are what are called physiological falls. In other words, they're falls that are associated somebody's overall state of well-being, typically involves musculoskeletal issues, sometimes involves medication uses. Sometimes it involves what is called orthostatic hypotension, which means a sudden drop in blood pressure.
So these are falls that really are completely unrelated to anything that might be on the floor or the condition of the property itself. It has more to do with the condition of the resident. And if you're working with a lawyer on a nursing home case, involving a fall, who wants to treat this like a slip and fall case, it's not, and it's one of those signs that you're working with somebody who really doesn't know what they're doing.
Pam: So then, what kind of nursing home resident is most at risk for falls?
Barry Doyle: For me there are two really crucial criteria. One of those muscular-skeletal issues. In other words, there's weakness, there's a limp. The basic things that tell you they have some difficulty walking on their own. The second part of this is either intermittent or constant confusion. And the resident can't be relied upon to do the kinds of things that would keep them safe. So when I look at these kinds of cases, intermittent confusion is just as much a risk factor as constant confusion. The reason for it is this. When you have nursing home residents who are in their 70s, 80s or 90s, their level of confusion is going to vary throughout the day, and it's going to make things kind of unpredictable for the staff, as to whether or not somebody's going to be able to follow instructions and take the steps that they need on their own, to really assure their own safety.
So, those two factors together. Muscular-skeletal issues, plus intermittent or constant confusion, to me, are the two biggest risk factors that are involved for trying to determine whether or not somebody's a fall risk. Now there are some other factors as well. Medication usage is one of them. Having vision problems is another. Incontinence is another. Incontinence becomes a big issue, because somebody is going to have the urge to the go to the bathroom, it's going to come on fairly quickly, and even though they may have trouble controlling their bowel or their bladder, they're still people who are grown adults, people who have dignity, and don't want to have an episode of incontinence where they have to be cleaned again, so they may get up unpredictably, suddenly, to go to the bathroom and go without getting the help they need to get there safety, and a fall may occur on the way.
Pam: That's really sad. So, what are the most common steps that need to be taken to prevent falls?
Barry Doyle: Well, one of these is to supervise the residents' activities. It's not always possible to give a one-to-one sitter, in fact, most nursing homes it's really not possible to do that at all. But it certainly is possible to make sure that people are in a common area throughout the day, where there's going to be staff keeping an eye on several residents all at once. When somebody needs help, there's staff on hand who can help them get up and go to the bathroom. Putting somebody on a toileting schedule, so they're brought to the bathroom on a regular basis, and the episodes of incontinence become a little bit less unpredictable. That tends to be something that's really pretty effective.
One of the real common interventions we see is the use of a bed alarm. And there are really two different kinds of alarms that are used. One alarm is a clip that's affixed to the back of somebody's clothes, and when they stand up, it basically pulls a sensor away from a box that sounds an alarm, which is loud, it's piercing, it makes a horrible noise. But just as importantly as notifying the staff that somebody is up, it also serves as a reminder to the resident they're not supposed to be up and unattended on their own. The other kind of bed alarm that you see is one of that's a pressure-sensitive strip that goes under the sheets. And when a resident starts to get up out of bed, the alarm goes off. Same thing, it's a loud, piercing noise that brings the staff and also reminds the resident they are not supposed to be up and unattended.
So all of those steps are things that can be taken together. They're things that need to be done, day-to-day, shift-to-shift, to help reduce the risk of somebody falling.
Pam: So, why not just use a restraint to keep somebody from getting up?
Barry Doyle: Okay, so a restraint is a device which inhibits a resident's ability to move their body freely. And a lot of times people will come into my office and suggest to me that the nursing home should've used a restraint to keep their mother or father from getting out of bed or getting up out of their chair. The problem with the restraints are that many times people will actually injure themselves struggling against the restraint. You'll have a loss of muscle tone, because they spend so much time in bed or in a chair, and that actually increases the fall risk, once they're up and about. And many times you'll see bed sores result, because people spend so much time just kind of pasted into their seat and not able to move at all.
So there are a lot of problems that are associated with the use of restraints. They've very strongly discouraged by the Federal Regulations. It's just not a good solution to a real problem. And if you're dealing with a lawyer who suggests that the real answer to the problem is that they should've used a restraint, it's a sign that you're dealing with somebody who really doesn't know what they're talking about, and you should probably run as fast as you can in the other direction.
Pam: So, Barry, you mentioned that falls are care-planned. Where do you see breakdowns in the care planning process?
Barry Doyle: There are really three, maybe four areas where I see breakdowns in the care planning process most often. The first area would be in the area of assessment. That there's an inadequate assessment done of somebody's fall risk. Most often, the fall risk is understated because the staff doesn't get a good history as to somebody's incidence of prior falls, which is one of these things that tends to feed into fall risk.
The second area that you tend to see breakdowns in the care planning process is with the care plan itself. That steps that really should be taken to mitigate fall risk aren't included as part of the care plan. The third area where you see breakdowns in the care planning process is in the implementation stage. And that's simply just not doing the things that need to be done, day in, day out, to address fall risk. That tends to be allowing people to get up unattended when the care plan calls for an assistive one while ambulating. I've had a surprisingly number of cases where people have been given bed alarms, but the bed alarm has been shut off.
And the last place you tend to see breakdowns in the care planning process is in the evaluation slash revision stage, where you have people who are at increased risk for falling because they're demonstrating increased levels of confusion, more muscular-skeletal weakness, taking new medications that all contribute to fall risk, and no consideration is given to changing the care plan because the resident's condition or situation is changing.
Pam: Thanks Barry. You're watching Fighting For What's Right, with personal injury attorney, Barry Doyle. Please visit our website, at fightingforwhatsright.com.