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Liquids on floors represent the biggest risk for falls in health care facilities, but risk managers often overlook the need to assess the fall risk of a particular area with wet surfaces, not dry ones, says an expert.
Henry Shable, senior risk control specialist with ESIS Risk Control Services in Philadelphia, says risk managers aren’t likely to be surprised by the idea that wet floors are slippery, yet people still forget that important fact when they assess the risk of falls with a flooring surface or area.
In many cases, the steps necessary for preventing falls are not complex or unknown, yet they still are not carried out thoroughly and consistently, Shable says. Slip resistance of floors, for example, often does not receive the attention they deserve, he says. Floor-cleaning products may seem safe and slip-resistant after the floor has dried, but that can change as soon as they become wet for any reason.
"You often see that facilities like to keep their floors nice and clean, putting that pretty shine on it. And that’s all well and good in a dry condition," he says. "But it’s when the floor gets wet that you have a problem. A dry floor can be very safe and then you put a little bit of water on it and it becomes very unsafe."
Shable’s company has tested floors in health care facilities and found that they are safe and very slip-resistant when dry, but change to very dangerous as soon as they get wet.
"The lesson is that you can’t just assume that a flooring surface is fine because you tested the slip resistance and it scored well when it was dry," he says. "A good flooring surface will always score worse when it gets wet, but it shouldn’t go from great to terrible. A good surface will still be a good surface when it gets wet, probably just not as good."
To properly test the slip resistance of your flooring, you probably will need to call on facilities management or an outside engineer, who will use a device called a tribometer. Shable advises measuring your floor’s resistance before applying any new or proposed cleaning product, so that you have a baseline for measuring the product’s effect on your own floor.
Product labels not always reliable
If you test a dry surface, it almost always seems safe, Shable warns. He urges caution in interpreting the labels on floor cleaning products that assure you the chemical has been tested for slip resistance on floors and scored well in the safe range. "What they don’t tell you is that they never tested the product wet," he says. "They tested dry in a laboratory condition, but never out in the field after some water got on the floor. The purchasing folks at these facilities need to be careful about what they’re buying."
Liquids on floors can come from a wide range of sources, including snow and rainwater tracked in from outside, incontinent patients, spilled drinks, and medical care activities. "All you need is a little bit on the floor to present a slip, trip, and fall hazard," Shable says.
Other common risks include clutter in pathways, such as resident items in a room or supplies in the hallway. Shable says he shudders when he walks down a hallway and sees equipment lining the walls — a very common scene in health care. "You can walk down a hallway, and both sides are littered with everything from dirty laundry carts to medication carts and lifts," he says. "Folks have to amble around them and avoid them, which is tantamount to an obstacle course for elderly or infirm patients who find it difficult to walk at all."
Operational controls frequently violated
Operational controls, such as identifying circumstances in which a patient must be lifted by two staff instead of one, can reduce the incidence and severity of falls, but those controls are violated too commonly, Shable says. The facility might be short staffed, for instance, making it difficult for an employee to find someone else to help. "Or it might be as simple as saying you’re too busy to go find some assistance," he says. "They try to move the resident outside of the protocols and a fall happens. That’s very common."
When Shable assesses the risk of falls in a health care facility, he investigates whether management has instituted all three types of controls — physical, operational, and management. Physical controls involve keeping the facility clean and free of hazards, and a spill-control program. Operational controls involve defining the manner in which floors are to be cleaned, for instance, and management controls are broader, including such things as establishing an overall program for preventing falls.
Footwear policy important
Shable also recommends implementing a strict work shoe policy in health care facilities. Many employers have only the most vague policies prohibiting open-toed shoes or sandals, while some go a step further and require slip-resistant soles. But even that is not really enough to be effective, he says. "The fact that employees come in wearing tennis shoes does not mean that is a slip-resistant shoe," he says. "You have to go further and define whether you require a tread pattern that’s not worn out, or you can specify a certain type of shoe that is certified as slip-resistant for certain work settings."
Shable notes that some shoe manufacturers even offer guarantees that they will pay the first $5,000 of a claim resulting from a fall. But some employers are reluctant to require such shoe programs because they don’t want to obligate low-income employees to paying for a $25 pair of shoes, and they don’t want to provide the shoes because of high employee turnover. "If you can get a shoe requirement through, it’s a good idea that can have a big impact on reducing employee falls," he says.
But of course, employees are not the only ones at risk of falling. Shable says it is important to include in your fall prevention program a policy that warns patients and family members about the proper type of footwear for the facility. Family members in particular should be cautioned about the hazard of bringing unsafe footwear for the patient, such as soft slippers with a fabric sole. "You have to be willing to say, These shoes you brought in are inappropriate,’" he notes. "It’s easier to say that than to call the family and tell them their loved one has taken a serious fall."
More hazards often overlooked
Shable offers this list of other hazards often overlooked in health care facilities:
• Changes in floor surface. The transition from tile to carpet or marble in the entrance lobby to tile in the hallway, for instance, can be critical spots for falls. Even a change from one carpeting to another can be risky.
• Bold carpet patterns. Elderly patients already have a difficult time with visual acuity; so bold patterns in the carpet can make it difficult for them to discern objects in their path that could pose a tripping hazard.
• Lighting conditions. Many facilities dim the lights in the evening, but that just makes it more difficult to see hazards. Another risk is posed by lighting that abruptly goes from bright to dim, or vice versa. The person’s vision is affected, sometimes significantly, by the sudden change. "That’s why so many people fall in theaters," he says. "You’re temporarily blinded, you take a few steps and down you go."
• Floor cleaning operations. Your efforts to clean the floors properly may actually introduce an unnecessary hazard if done when people are likely to traffic through the area while it is wet. Schedule routine cleaning for off times as much as possible. Even if that means relying more on overnight crews, the additional expense might be worth it.
Investment usually pays off
Paying more attention to these overlooked issues can help you reduce the incidence of falls, if not the severity, Shable says. The average cost of a workplace fall is about $26,000 — including hidden costs such as a manager’s time devoted to investigating the incident — but that figure can rise to the hundreds of thousands of dollars in health care, he notes. "Any reduction in the frequency can result in a very significant reduction in the cost of falls," Shable says. "How much you can expect to reduce the frequency depends on a number of factors, but when I go in to help an employer get a handle on falls, I often tell them that we’ll set a goal of reducing falls by 10% over the next year."
The payback on a fall-reduction program almost always justifies your expenditure, Shable says. If you prevent one $100,000 fall, you’ve probably justified every penny you spent and all the time devoted to the effort, he says. "It’s not uncommon to have management balk when you want to spend $5,000 on a patient lifting device, so don’t be surprised if they don’t want to spend money on an engineer to come in and test your slip resistance," Shable says. "But in both cases, it shouldn’t be hard to show how that money can save you a great deal more in the long run."