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

The purpose of the Vanderbilt Living Space Inspection (LSI) is to make the personal living space of all residents as safe as possible. It includes inspection of:

1. Resident rooms and bathrooms.
2. Canes, walkers and wheelchairs.
3. The resident's feet and footwear.

Once safety problems are identified, tasks for different staff are selected and completed.

The LSI contains five components (Figure 1) which lead staff through a systematic inspection and repair process. Copies of all of the forms in the LSI are provided in Appendix B and may be made into a separate notebook for ease of use.

1. The Living Space Inspection

The Living Space Inspection includes seven sections, each with instructions and questions related to a specific safety issue. (Figure 2)

Under supervision of the Falls Nurse Coordinator, the Falls Nursing Assistant(s) should complete the 2-page inspection. In larger facilities, it is helpful to train additional nursing assistants to divide the workload and increase staff involvement in the program.

Select for a sample of the Living Space Inspection (LSI). The Falls Nursing Assistant should read the directions for each of the seven sections, look for the specific details that are mentioned and answer the questions listed in each section. The nursing assistant should use his or her best judgment based on knowledge of the resident and circumstances. If the answer to a question is "yes" or "does not apply to this resident or room," the nursing assistant should go to the next question. If the answer is "no," the nursing assistant should read the list of suggestions in the matching section of the Nursing Inspection List and Engineer Inspection List and decide which of the tasks will help solve the identified safety problems. Each list is divided into sections that match those on the LSI. There are two symbols used on the LSI to signal involvement of the nursing staff and engineer. The cross means there are tasks in a matching section on the Nursing Inspection List. A wrench means that there are tasks in a matching section on the Engineer Inspection List.

Section 6 of the LSI deals with canes, walkers and wheelchairs in the resident's room, closet and bathroom. If the resident has a cane or walker, the nursing assistant should inspect it carefully. If either needs repair," Repair cane" or "Repair walker:" should be checked on the Engineer Inspection List. If the resident has a wheelchair, "Inspect wheelchair" should be checked. The engineer should inspect all wheelchairs and make any necessary repairs.

2. The Nursing Inspection List and Engineer Inspection List

Select for samples of the Nursing Inspection List and the Engineer Inspection List.

The unit, date and nursing assistant's signature should be written on a Nursing Inspection List and Engineer Inspection List. The room numbers for that unit should be added in the first line. If a room has more than one bed in it, the letter or number of each of the beds in the room should be written across the second line of the form. Each page is designed for the inspection of 14 beds. One bathroom inspection is sufficient when two or more residents share the same one.

The Nursing Inspection List has 20 different tasks that may be checked and the Engineer Inspection List has 17 different tasks. When checking a selected task, it is important to make sure that the check is under the correct room number and bed. Sometimes there may not be a matching section on one of the task lists. For example, in Section 3: Easy Access, the nursing assistant is asked to check whether frequently used items are within the resident's reach. If they are not, nursing staff must make changes but there are no tasks for the engineer to do. On the other hand, all the possible tasks to make the lighting safer in Section 4 are for the engineer to do. Therefore, tasks to increase safety in relation to lighting appear only on the Engineer Inspection List.

If the nursing assistant needs to add any notes to help the engineer or nursing staff complete their tasks, they should be written in the Notes column on the right-hand side of the list. On the back of the Engineer Inspection List there is space to write in safety problems found in common areas such as shower rooms and with common equipment such as gerichairs, shower chairs and lifts.

3. Completing Tasks on the Nursing Inspection List

There are two types of tasks on the Nursing Inspection List:

1. Tasks to be completed by the Falls Nurse Coordinator or the Nursing Assistant.
2. Tasks for other staff to do.

Figure 6. Sample of Nursing Inspection List

[D] Select for Text Description.

The tasks for the nurse or nursing assistant are written as orders on the list. For example, one of the tasks is "Remove unused equipment." Although it may be necessary to talk with other staff to find out when the equipment, such as a cane or walker, was last used and who owns it, this task should be completed by the Falls Nurse Coordinator or Nursing Assistant. Some tasks require the nurse or nursing assistant to instruct unit staff to do something, for example," Instruct staff to keep the overbed table across the bed." This is something that needs to be done not just once, but daily. It is therefore important that the unit staff understand what they are being asked to do and why. The nurse or nursing assistant should explain the tasks and make sure they have been understood. There are also tasks on the Nursing Inspection List for housekeeping staff and the social worker. The Falls Nurse Coordinator should explain to them what is required. Select for a sample of a completed Nursing Inspection List.

4. Completing Tasks on the Engineer Inspection List and Equipment Inspections

Figure 7. Sample of Engineer Inspection List

[D] Select for Text Description.

All of the tasks on the Engineer Inspection List are related to the daily maintenance and repair of the physical plant. Select for a sample of a completed Engineer Inspection List.

There are separate forms for the engineer to use when inspecting and repairing equipment: Engineer Cane Inspection, Engineer Walker Inspection and Engineer Wheelchair Inspection. If the therapy department or a third party is responsible for wheelchair adjustment, the engineer should coordinate with the appropriate persons. By completing the Living Space Inspection, the falls team will ensure that all wheelchairs and their parts have been located in the facility, labeled and repaired. This is an important step in assuring resident safety.

5. Bed Safety

As facilities modify side rail use and replace old bed equipment, it is important to determine if there are potential entrapment zones for the resident's head, neck and chest. Inspection of all beds and side rails should be performed routinely so that parts, mattresses and side rails may be modified or replaced to ensure safety. Refer to the FDA web site for specific guidelines. (http://www.fda.gov/cdrh/beds/)

6. Supervision

When a LSI has been completed, the Falls Nurse Coordinator and Nursing Assistant should meet to review the inspection and the Nursing and Engineer Inspection Lists. At this time the nurse can ensure that appropriate staff are contacted.

The Falls Nurse Coordinator will need to give the Falls Engineer three types of materials

• Falls Engineer Instructions (Appendix D)
• Engineer Inspection Lists (Figure 7)
• Engineer Cane, Walker and Wheelchair Inspections (Appendix B)

The Falls Engineer Instructions contain detailed advice on methods and supplies for all of the engineer tasks related to environmental modifications as well as equipment repair and improvements. The Falls Nurse Coordinator should review all of the completed Engineer Inspection Lists with the engineer and agree on dates for the tasks to be completed. For each resident with a wheelchair and a cane or walker in need of repair, an engineer equipment inspection should be prepared and given to the engineer.

When the program is first implemented, the LSI should be done every 1-2 months until most of the problems are resolved. Based on this progress and the age of the facility, the Falls Nurse Coordinator should decide how often the LSI needs to be done. Whenever a LSI is repeated, the nurse should compare the lists to determine what was found in those rooms previously. Are there problems that were identified last time but have not been corrected? If so, the nurse should discuss the problem with staff to discover barriers and find a solution.

To maintain a wheelchair in good repair, the engineer should repeat the Engineer Wheelchair Inspection at least every six months. The engineer is asked to keep the wheelchair inspection form and reuse it each time he repeats the inspection.