Proper home care can keep patients from being fall guys

Where does home care fit into the equation?

Every year, thousands of Americans experience a severe fall. The Itasca, IL-based National Safety Council (NSC) estimates that falls caused or led to the death of more than 17,000 Americans in 2000; of those, 9,600 stemmed from falls that occurred in the home. Nearly one-fourth of all people who suffer a hip fracture as the result of a fall die within the year, and another 50% never fully regain their prior level of independence or mobility.

The statistics are even grimmer for elderly Americans: Falls are the No. 1 cause of injury-related death in the United States for men 80 and older and for women 75 and older. Eight out of 10 of those who die from a fall are over the age of 65. Particularly pertinent to home care, 60% of fatal falls for adults 65 years old or older happen at home, according to the Centers for Disease Control and Prevention in Atlanta. (See "Falls and hip fractures among older adults" and "Costs of fall injuries among older adults," in this issue.)

For many elderly Americans, a devastating fall is why they are in the home care system. For others, who perhaps began receiving home care for an unrelated reason, it means a longer program of care that in some cases can extend to the end of their lives. Clearly, home care cannot prevent every fall, yet with careful patient analysis and monitoring, home care nurses and aides, along with family caregivers and friends, can implement a program that will greatly reduce the chance that a patient will suffer a fall in the home.

The causes of falls are as varied as the falls themselves. There can be physical reasons that contribute to falls — factors such as physiological dysfunctions that manifest as gait and balance problems or musculoskeletal disabilities — as well as psychoactive medication use, dementia, and visual impairment. Then, too, there are environmental factors such as slippery surfaces, uneven floors, loose rugs, poor lighting, unstable furniture, and objects left on the floor.

Environmental factors are obviously the easiest to remedy; as such, home care aides and nurses should constantly monitor the patient’s home surroundings for any of these factors and work with family caregivers either to correct these issues or to modify the situation so as to pose the least possible harm to the patient. Sometimes it can be as easy as keeping a clear path to the kitchen, bathroom, bedroom, and living areas and can be remedied by keeping toys, magazines, and other loose items put away or in another room. Floors should be kept clean and dry, and any spills should be cleaned up immediately. As for loose floorboards or uneven floors, aides should talk to the family caregiver about possible ways to ameliorate the problem.

The NSC offers several recommendations for keeping the home environment as patient-friendly as possible. Among them are tucking phone and electrical cords out of walkways (or using a cordless phone to prevent rushing for the phone), installing handrails/grab bars in bathrooms and along stairwells, installing nightlights in bathrooms and kitchens and along the hall or stairs, using non-skid throw rugs over slippery linoleum floors, and avoiding the use of wax products on floors.

Lorraine Waters, BSN, MA, CHCE, director of Southern Home Care in Jeffersonville, IN, says her agency has a handout on safety in the home that addresses things like making sure family members or caregivers remove throw rugs and tuck away extension cords a patient can trip over. "We can do the instructional portion and work with families and patients to make them aware of the risks," she says, "but since we’re not in there 24 hours a day, it’s difficult."

As for the physical side, home care nurses and aides can do a lot to reduce the chance of a patient falling. Patients should be encouraged to get annual eye examinations, as failing eyesight can prevent a person from seeing potential hazards. Regular monitoring and assessment of a patient’s medication also should be done regularly. Many times, certain medications can lead to an unsteady gait or difficulties with balance and mobility.

"Clutter is not the biggest issue we see with falls," says Waters. "We have more problems with polypharmacy, where the patient might have three different practitioners — and prescriptions from all of them — until we come in. No one is monitoring it and evaluating it, and sometimes they aren’t taking it [medication] right, so a lot of education comes into play.

"The second-largest problem we see would probably be the fact that you have a frail, elderly person who refuses to stop moving around on their own or use an assist device, and they end up hurting themselves. It’s sad, but patients usually have three or four falls before something breaks. We see a pattern of falls and try to do intervention at that point, and sometimes we’re fairly successful. It’s a matter of laying it on the line with them and reminding them what will happen if they fall and break a hip."

A recent study, "Medical Profile of a Group of Elderly Fallers," found that the first step in preventing falls is determining who is most susceptible. From there, tracking a patient’s fall and its cause or causes can be crucial to ensuring that a second or third fall doesn’t occur. It would seem that in the home care environment, all patient activity would be monitored, including falls, regardless of whether they were witnessed by a home care employee. Marjorie Jones, director of home care services for St. Francis Medical Center in Grand Island, NE, says that as recently as October 1999, her agency was being told by its Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveyor that it must collect and report data on all falls, whether witnessed or not. Other home care professionals say they have been told not to report unwitnessed falls. What’s the deal?

Says Gregory Solecki, vice president of Henry Ford Home Health Care in Detroit, "Being aware of and documenting an unwitnessed fall was never a Joint Commission standard, but rather an interpretation of the standard to which such activity would apply. In other words, under the standard of patient assessment, asking about and documenting an unwitnessed fall could be interpreted as support of compliance with the standard."

Even so, many of today’s home health care agencies are choosing to err on the side of caution and still keep records documenting a patient’s history of falls, be they witnessed or not. For many, the decision is rooted not only in maintaining an accurate patient history but also in self-protection. Laresa Boyle, RHIA, business office/medical records coordinator for CRH Home Health Agency in Cushing, OK, notes that her agency reports "all falls to protect ourselves. If bruises show up on a patient, the family wants to know what happened. Filing an accident report protects us from being accused of any harm."

"Our policy was to document only witnessed falls," says Ellen Madigan, administrator for Farmington, CT-based Interim HealthCare of Hartford, "but we had our Medicare survey a month ago, and they were not happy. They wanted to see more documentation and follow-up on all falls, including doctor notification, fall prevention, teaching, etc."

Madigan says that as a result of this survey, her agency has reinstituted its policy of using incident reports on all falls so that they may better track them and make sure the proper follow-up is done and documented.

Rebecca Schlegel, RN, manager of regulatory operations for Visiting Nurse Services & Affiliates in Akron, OH, also says her agency still reports "all patient falls, whether or not the clinician was present. We feel that safety education and home safety assessment, equipment usage, recommendations for therapy, etc., may all have an impact on a patient’s risk of falling. Therefore, we feel it is important for us to track falls so that we can review and determine whether we did all we could have to prevent the accident."

Prevention is surely the strongest reason agencies have for documenting a patient’s history of falls. "Whether a fall was witnessed or not, if one occurred, then it has potential impact on the patient’s health and need for services," says David W. Perry, PT, MS, of Perry Therapeutics in Grosse Pointe Woods, MI. "The patient should be reassessed to determine if the fall was an isolated event or has greater significance. The Plan of Care may or may not require modification. It seems we are missing the point if we focus on whether or not JCAHO or state surveyors have this as their focus this year. Their focus is constantly changing. Our focus should be on what is best for the client. And a fall is a potentially adverse event that needs to be assessed and then addressed as appropriate based on that assessment."

Perry is not alone in his view. Carol Johnson, RN, director of clinical services for Community Home Services in Naples, FL, notes that her agency carefully studies fall rates among patients. (For an excerpt from Community Home Services’ patient assessment checklist, click here.) "At each comprehensive assessment, we evaluate the fall situation, and on discharge, we document the number of falls a patient experienced during the care and if any changes were made as a result of it. Unwitnessed falls are our No. 1 variance in the home, with witnessed falls lagging in second place. We analyze every variance to see if we could have prepared our patients better."

One home care professional explains that her agency used to report only witnessed falls in an event report for legal reasons, but that as of late, it has begun looking at tracking reported, unwitnessed falls in an internal report, not only for safety reasons but to trend those occurrences as well. Her agency also might institute a fall assessment process to help identify patients at high risk for falls.

Regardless of your reasons for documenting and assessing patient falls, every step you take to help patients at risk avoid a potentially life-threatening fall brings the NSC one step closer to its goal — preventing almost 50,000 fall-related injuries by 2008 and 75,000 by 2012.

[For more information, contact:

Laresa Boyle, RHIA, Business Office/Medical Records Coordinator, CRH Home Health Agency, Cushing Regional Hospital Home Health, P.O. Box 1409, Cushing, OK 74023. Telephone: (918) 225-2915.

Carol Johnson, RN, Director of Clinical Services, Community Home Services Inc., 851 Fifth Ave. Parkway, Naples, FL 34102. Telephone: (941) 403-6400.

Marjorie Jones, Director of Home Care Services, Saint Francis Medical Center, P.O. Box 9804, Grand Island, NE 68801. Telephone: (308) 398-5470.

Ellen Madigan, Administrator, Interim HealthCare of Hartford, 231 Farmington Ave., Farmington, CT 06032. Telephone: (860) 677-0005.

David W. Perry, PT, MS, Perry Therapeutics, 2065 Van Antwerp Ave., Grosse Pointe Woods, MI 48236-1622. Telephone: (313) 882-9614.

Rebecca A. Schlegel, RN, Manager, Regulatory Operations, Visiting Nurse Service & Affiliates, No. 1 Home Care Place, Akron, OH 44320. Telephone: (330) 848-6239.

Gregory Solecki, Vice President, Henry Ford Home Health Care, 1 Ford Place, 4C, Detroit, MI 48202. Telephone: (313) 874-6500.

Lorraine Waters, BSN, MA, CHCE, Director, Southern Home Care, 1806 E. 10th St., Jeffersonville, IN 47130. Telephone: (812) 283-2602.]