Reader question

Falling Leaf programs tell who is most at risk to fall

Question: Our hospital recently acquired a long-term care facility that I’m now responsible for, and the first thing I noticed was the disturbingly high rate of falls among the elderly patients. I’ve heard of a Falling Leaf program that might help, but no one at the facility is familiar with it. Can you help?

Answer: Falling Leaf is a program that identifies the patients at highest risk for falls and then aggressively works to monitor them and find the root cause of their falls. The program can dramatically reduce the number and severity of falls in any health care setting, says Carolyn Spradlin, RN, BSN, CPHQ, CPUR, program manager for nursing homes with MissouriPRO, a quality improvement organization that contracts with the Centers for Medicare & Medicaid Services to assist health care providers with improving care and patient safety.

Spradlin developed the Falling Leaf program four years ago when she was administrator of a long-term care facility, as an adaptation of another strategy known as the Falling Star program. Falling Star involves assessing patients or residents for their risk of falls and then identifying those at high risk with a visible symbol, usually a falling star graphic placed on the patient’s door. The idea is that the staff will then know to watch that patient more carefully and intervene more quickly if they observe unsafe behavior.

That strategy has been successful for many health care providers, but Spradlin recommends the Falling Leaf program as an improvement. With Falling Leaf, the key difference is that there is more emphasis on identifying the patients at extreme risk, not just those at risk of falling, and the program encourages staff to find the root cause of the patient’s falls. Falling Star and Falling Leaf can both be used in the same facility, she says, with Falling Star as the overall program and Falling Leaf concentrating on the subset of patients at the highest risk.

Using Falling Star alone can reduce falls, she says, but it can have the unexpected drawback of obscuring those most at risk.

"The problem is that when you assess someone for a risk of falls, and no matter what assessment you decided to use, you’re going to end with a large number of people at risk," she says. "Then if you make symbols for everyone at risk, the staff can get accustomed to seeing falling stars everywhere. That means no one really gets special attention. There are too many of them."

To select those who should included in the Falling Leaf program, Spradlin says you can use any number of assessment tools to find patients at risk for falling. Whatever you use, those scoring at the top of the scale are the ones to designate as Falling Leaves. But Spradlin also says there are certain red flags that should automatically classify the patient as a Falling Leaf: Previous falls at your own facility, and anyone newly admitted to the facility. All long-term care patients should be placed in the Falling Leaf program for 72 hours on admission because the staff doesn’t know the patient and the patient is unfamiliar with the surroundings. (Falling Leaf works in any health care setting, Spradlin says, but it might not be necessary to include all newly admitted patients in all settings. Make that decision based on your patient mix.)

Once placed in the Falling Leaf program, each patient is monitored monthly by the patient safety committee or fall prevention team and removed when appropriate improvements have been made. The fall prevention team also affixes a falling leaf symbol to the patient’s door, notifying everyone that the patient is at extreme risk of falling.

Spradlin recommends using small magnetic Falling Leaf signs, similar to refrigerator magnets that can be put on the metal doorframe at the entrance to the patient’s room. These signs can be removed easily, which makes it more likely they will be moved when the patient is moved from one room to another.

The strategy involves more than simply identifying the patient as high risk. Falling Leaf also requires that the staff observe the patient more frequently, for instance, and develop a more intricate care plan and change it often if necessary.

"But the biggest issue is determining why there is a fall problem," Spradlin says. "The caregivers need to determine why the person keeps putting themselves in this unsafe condition. Are they trying to go to the bathroom? Are they hungry? Are they lonely and looking for someone to talk to?"

Pain is another common factor, and Spradlin says better pain control usually results in fewer falls. Finding the root cause of the falls can be challenging sometimes, but she says staff must be determined. The Falling Leaf program also involves all staff in the facility who might encounter patients, not just nurses and other caregivers. If a maintenance person or housekeeper passes a room with a Falling Leaf, that person is encouraged to look inside and note whether the patient is doing anything risky. If so, the staff member is supposed to inquire about the patient’s needs and encourage him or her to wait for nursing assistance. Spradlin also recommends that you keep a simple log at the nursing station where all staff can note their observations about Falling Leaf patients.

"The focus is on the true needs of the person and what might be leading to the falls, rather than just saying they’re doing an unsafe behavior. There’s a tendency to pick up the person, reset the alarm, and hope you catch them the next time," she says. "We need to create a whole culture among staff so that we find out why they’re falling instead of just stopping the fall."