The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

1. Measurement System

An accurate measurement system is an important component of the quality improvement process that allows staff to determine if changes in care lead to improvement.

The Tracking Record for Improving Patient Safety is the key tool used for measurement in the FMP, and replaces old incident reporting tools.

The key indicators for the FMP are outcome measures that include falls, residents who fall, residents with two or more falls and fall related serious injuries (Figure 1). When studied over time, these key indicators are the best markers of improvement.

In addition to these four, there may be other important markers for administration and staff members to consider (Figure 2).

Reduction of survey tags and lawsuits related to falls and injuries is desirable and a comparison of these indicators before and after program implementation will provide important information for facility and corporate leadership. Changes in awareness and organization cannot be measured in numbers, but it is helpful to obtain opinion-based information from staff, and to use their feedback in making program revisions. Perceptions of residents and family members are important indicators of customer satisfaction and should be used to evaluate the program as well. Specific process measures identified through chart audits during the FMP Self-Assessment can be targeted for improvement and monitored over time.

2. Collecting and Using TRIPS DATA

After evaluating and treating the resident immediately, the nurse should investigate the circumstances of the fall and look for all possible causes. The nurse should talk with the nursing assistant(s) who cared for the resident at the time of the fall and encourage full disclosure of the circumstances without placing blame. Even in "found on floor" incidents, staff should brainstorm together to determine likely causes. It is critical that investigation take place immediately so that valuable clues are not lost. "Unknown" should rarely if ever be used on a TRIPS form.

All licensed nursing staff should be trained in the immediate fall response so that even on weekends, a detailed investigation, appropriate documentation and immediate interventions are done.

Using the data recorded on the TRIPS form, it is useful to identify trends related to types of falls. Such details as location, time and activity may reveal that a large percentage of falls occur in one area, at one time of day or during a specific activity.

Implementing the FMP will increase staff awareness and may prompt staff to report falls more accurately when administration uses a clear fall definition and develops a strong culture of safety. For this reason, there actually may be a rise in the number of falls reported during the first months after implementation. Normal variation in falls from month to month can be dramatic and it is better not to rely upon one or two months' data to detect change.

3. Tracking Record for Improving Patient Safety (TRIPS)

A copy of the TRIPS form should be completed by the unit manager or nurse supervisor at the time of each fall. Illustration of the TRIPS form with instructions for the completion of each section follows.

A. Directions for completing the TRIPS form

The first section of the TRIPS form is a basic log that includes a general description of the incident, including severity level, treatment provided, persons notified and documentation methods. The nurse will write in the resident's name, medical record number, date the incident occurred and time of the incident, specifying AM or PM. The day of the week and location of the incident should be checked. When the location is other than the listed options or is unknown, the nurse should check "other" and write in a brief description. Treatment and resident outcome or "severity factor" should be checked. If a form of treatment was provided that is not listed on the form, the nurse should check "other" and describe it.

The next items relate to notification of the physician and family and should include name of the contact and time and date of notification. The last 3 items ask if the appropriate actions were documented on the medical record and plan of care. The nurse should sign the form and write in the date the form was completed.

B. Directions for completing Section B of the TRIPS form

Section B of the TRIPS form contains 18 items and is used to document circumstances of the fall event (items 1-9) and resident outcomes (items 10-17).

Circumstances of the fall

• Item 1 asks if the fall was witnessed or unwitnessed or if the resident was lowered to the floor by staff. If the fall was reported by the resident and was unwitnessed by staff, check "self-reported."
• Item 2 is cause of fall. If the resident slipped, the nurse should specify how this occurred. If there was equipment malfunction, the nurse should specify the equipment item and its condition. If an environmental factor was present, the nurse should specify if clutter, lighting, floor conditions, etc. were present. If the nurse cannot determine the cause after checking with direct care staff and examining clues at the scene, "other" should be checked and "unknown" written in the space provided.
• Item 3 is the activity at the time of the fall. If the resident is in a wheelchair at the time of the fall, staff should be trained to check if the brakes were locked. This should be recorded under "Getting up from chair/wheelchair." If the resident fell while getting in or out of the bed, the nurse should specify if the resident rolled out of the bed onto a mat and if the wheels of the bed were locked or unlocked. If the nurse cannot determine the activity after checking with direct care staff and asking the resident, "other" should be checked and "unknown" written in the space provided.
• Item 4 is staff presence at the time of the fall.
• Item 5 is the type of footwear the resident wore at the time of the fall. The nurse should check whether the footwear had tread or narrow/high heels as well as if the shoes or slippers were a loose fit.
• Item 6 is the assistive device or other aid used during the fall, if any.
• Item 7a-b is type of restraint in use, if any. Both restrictive and less restrictive forms of restraint should be recorded. If the type is not listed, the nurse should check "other" and specify.
• Item 8a-b is side rail use. When two full or four half rails were in use at the time of the fall, the nurse should check "full length side rails." If any other combination of side rails were in use at the time of the fall, the nurse should check "other" and specify the type.
• Item 9a-b is alarm use. First check if an alarm was present. Include alarms attached to a wheelchair and consider all types of pressure or position change alarms as well as room sensors. If an alarm was present, check whether it sounded.

Resident Outcomes

• Item 10 is change in mental status.
• Item 11 is change in level of consciousness.
• Item 12 asks if the blood glucose level was checked and if so, the value. All residents with a history of diabetes should have their blood glucose level checked immediately following a fall.
• Item 13 asks if the resident's pulse was taken after the fall and if so, the value.
• Item 14 asks if the resident's blood pressure was taken after the fall. If so, the systolic and diastolic values should be recorded. For residents with complaints of dizziness or lightheadedness, history of recurrent falls or use of cardiovascular medications, postural vital signs should be taken and recorded beside postural BP. The resident's position during measurement should be checked.
• Item 15 asks if the resident's temperature was taken. If so, the value and whether it was oral, rectal or axillary should be recorded.
• Item 16a asks if the resident had an injury as a result of the fall. If so, the nurse should check the injury site and which side of the resident's body sustained the injury in 17B. In the next four columns, the nurse should check whether the injury was minor, involving a bruise, skin tear or abrasion, or was a major injury that involved laceration with sutures or a subdural hematoma, and if the resident experienced pain. If the resident's injury is not among the listed options, the nurse should put a check in the last column across from the injury site and specify the type of injury.
• Item 17 asks if the resident was in the Falls Management Program at the time of the fall. If not, the nurse should enter the resident into the program and proceed with the full Falls Assessment. If the resident was already in the Falls Management Program, the nurse should send the FAX Alert to the resident's physician with the current fall and the total number of falls sustained in the last 180 days.

The nurse should complete the last item of the TRIPS form if, for any reason, the fall is not described sufficiently in items 1-17 and a narrative note would be helpful.