The Evercare quality improvement initiative aimed to reduce falls in a nursing facility from a significantly high rate (91st percentile) to below the industry standard by 10% annually, employing a multi-faceted approach over four years. The program's success resulted in a fall rate reduction from 13.34 to 4.16, improved compliance with regulations, and decreased fall-related injuries while enhancing staff accountability and intervention strategies. Continuous monitoring and staff education have remained vital, highlighting that a collective effort and understanding of intervention importance are essential for sustainable outcomes.

1. Evercare Quality Improvement Awards Falls Reduction Program Susan E. Harris, CRA, ADC, LNHA Assistant Executive Director Daughters of Israel West Orange, New Jersey

2. Faculty Disclosures: Ms. Harris has disclosed that she has no relevant financial relationship(s).

3. Learning Objectives By the end of the session, participants will be able to: Objective 1 Understand the importance of multi-pronged interventions Objective 2 Understand the relationship between falls patterning and the decrease of falls Objective 3 Understand how program model can be replicated Objective 4 Understand how the falls reduction model can be utilized to affect change in other areas

4. Facility Demographics Daughters of Israel West Orange, New Jersey Total # of Beds = 303 6 separate nursing units Inclusive of Alzheimer’s and End Stage Units Type of Ownership = Non-Profit

5. QI Project Falls Reduction Program Description of Problem- Falls were significantly higher than others in country, region, state Additional compounding problems Falls Quality Indicator at 91 st Percentile Fall Rate = 13.34; Industry standard = *4.16 Based on historical performance trends Objective – Develop a Performance Improvement team to reduce resident falls by 10% annually *Per study published by L. Rubenstein, et al, in materials distributed by CMS at a QI training seminar, Baltimore, MD, May 2000

6. Project Timeline Project began – May 1999 Falls committee met twice weekly, then weekly Reported to CQI weekly Currently audits reported at CQI Planning & Implementation Core of program developed over 4 years Various components added after that time When did project end? The reduction of falls is an ongoing process Monitoring, evaluation and CQI reporting continues today

7. QI Planning & Implementation Leadership Falls Sub-committee of members included staff close to the problem Team Work Team analyzed falls and determined what could be done to reduce them Data collection tools developed Communication Project introduced through care plan team meetings; in-service education Results communicated to staff through Team meetings In-service education Posted QI studies

8. Falls Sub-Committee DON Charge nurse Floor nurse Nursing assistants In-service coordinator MDS coordinator Activities staff Alzheimer’s Unit Director Physical therapist Social worker Dietician Medical Director Administrator Quality Assurance Director

9. Falls Reduction Program Issues Encountered Tried falling leaf program briefly but too much was involved Tried developing a definition of what is a fall which didn’t make any difference in what we were looking to accomplish

10. Tools Used to Affect Change Computerized falls tracking system to identify Unit Time of fall Ambulatory status Use of side rails Use of restraining device Any injury incurred Staff involved Shift Expanded to look at other relationships with falls

11. Tools Used to Affect Change Data on the patterning of falls Developed a weighted falls risk assessment – at specific score CP required Policies and Procedures for Falls Reduction Program Changed incident report to better collect needed data Back page included list of investigation points to cover Today divided into 3 columns to improve data collections and understanding Falls Care Plan Book – interventions listed by reason for fall Created Falls Tracking System Staff Education Falls Investigators QI audits of falls care plans and changes made to them per fall Incentive programs for units with the lowest number of falls monthly

12. Facility Expenses The cost to us to reduce falls is minimal $1500 covered educational seminars, travel to seminars Planning and implementation for all staff involved approximately 654 hours per year

13. Resident Outcomes Prior to Program Falls QI 91 st to 95 th percentile Fall Rate = 13.34 Average of 1119 falls annually Today – 2008 Falls QI 37 th percentile Fall Rate = 4.16 Average of 398 falls annually

14. Regulatory Outcomes No deficiencies for falls Surveyors not looking as hard in this area Falls QI is low Compliance with regulatory codes has increased

15. Improved Quality of Service Outcomes In the first 4 years of this program dropped our fall rate by 59.2% Staff follow-up for care plans and intervention changes went from 0% accuracy to 95% accuracy Exceeded 10% goal Restraint use has not increased Fall related fractures has decreased Met national benchmark

16. Enhanced Staff Performance Outcomes Improvement on: Investigation of falls Understanding patterning/causal factors Trained to pay attention to observable facts surrounding a fall Immediate response to care plan for updates Understanding when to change or add interventions Understand importance of immediate intervention Care Plans no longer state “will not fall” , “Will not have any injury” Retain personhood Activities are crucial Good communication with families in regard to a fall

17. Improved Organization, Management Structure and Systems Outcomes Entire process changed centralized at CQI to decentralized on units Fall Management is a priority for everyone Chair and bed alarms are overused or misused – changes in intervention use Weekend supervisor now begins investigation at the time the fall occurred All shifts trained on falls prevention Nursing assistants held accountable for falls interventions All CP and CNA CP updated at every fall Interventions in place earlier at admission, readmission, unit or room change Response at one fall or to high risk assessment score No longer document care plan remains same – change what isn’t working Starts prior to admission Tracking system used for falls carried over to skin tears and bruises Investigation process now used to investigate abuse allegations

18. Financial Outcomes Average hospital charge for fall related injury $11,800.70 (Nurse Practitioner, March 2002) Decreased rate of emergency admissions to hospital Most recent Evercare rate = 77 admissions per 1000 member years; one of lowest in country QI New Fractures declined from 67 th percentile in 2002 to 38 th percentile in 2007 Results in less need for post fracture care

19. Closing Thoughts Replication of Model – inexpensive to set up; easy to implement; mostly requires staff buy in and understanding that it is a priority for all Lessons Learned – It is not any one intervention that made a difference but instead the use of a multi-pronged attack of the problem and using multiple interventions at one time. Insights – Not all falls can be prevented must also look at what can be done to minimize severity of injury Questions?