FALLS IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

Fall(s) or history of falls prior to admission

 

CONTEXT  / /  COMMUNICATION

A work-up may not be indicated if the resident has an end-stage condition and the information gained would not affect the management course or if the resident or health care agent refuses. Management of risk of falling is always appropriate.
Communication with the health care agent by the MD, NP or facility nurse is appropriate, as is treatment of injury to promote healing or manage comfort.

 

ASSOCIATED RISKS

  1. Previous/recent fall and/or fear of falling
  2. Acute or subacute illness
  3. Medical conditions affecting gait or strength: PD, CVA, TIA, MS, ALS, dementia, depression, musculoskeletal conditions with or without deformity, peripheral neuropathy
  4. Medications affecting alertness or vital signs: diuretics, psychotropics, antiepileptics, antiparkinsonians, narcotic analgesics, antihypertensives, antihistamines, antidepressants, antidiabetics, somnolents, aminoglycosies, antiarrhythmics
  5. Polypharmacy
  6. Orthostatic hypotension, cardiac arrhythmias
  7. Syncope, vertigo, history of “dizziness”
  8. Recent immobility with deconditioning
  9. History of fractures
  10. Incontinence of bowel or bladder
  11. Visual and auditory impairment
  12. Hypoglycemia
  13. Use of mechanical restraints
  14. Dehydration
  15. Inability to perform ADLs
  16. Environmental factors: ill-fitting footwear and pants falling over footwear, high bed, soft/low seat, dim lighting or glare, slippery floor, poor or missing eyewear, delay in answering call bell

 

PHYSICAL EXAMINATION

  1. Brief exam with attention to vital signs, specific signs of illness and any injuries (especially head and joint)
  2. Assess new focal neurological deficits especially gait, muscle strength, sensory neuropathy, and cerebellar function and gross vision
  3. Pulse oximetry and accucheck as appropriate
  4. Observe for obvious contributing conditions (physical and environmental)

 

DIAGNOSTIC WORK-UP

  1. As appropriate to diagnose treatable conditions (might include laboratory, UCS, EKG)
  2. Review medications known to increase risk for fall
  3. Cat scan of the head for risk of significant head injury or change in mental status after a fall  where head injury as sustained and no other contributing factors for mental status change
  4. X-ray as indicated to assess for fracture (head x-rays are not indicated)

 

TREATMENT OPTIONS

Treat injury

  1. Hospital transfer for orthopedic injury requiring surgical consult/intervention
  2. ER transfer for laceration not adequately treated with steri-strips – wait 20 minutes to achieve hemostasis before sending to ER for head wound
  3. Schedule ice and analgesics as needed

Treat cause(s)

  1. Order medications appropriate to treat acute illness or exacerbation of chronic condition
  2. Eliminate unnecessary or offending medications where possible
  3. Improve hydration and elimination pattern

Reduce risks

  1. Consider PT evaluation for strengthening or gait training or appropriateness of adaptive equipment
  2. Consider external hip protectors – if available
  3. Eye evaluation if indicated
  4. Discuss environmental changes with nursing
  5. Mechanical restraints as a last resort with well established and documented indications and parameters for use

 

While falls carry the risk of serious consequences for the resident and are considered
quality indicators of care, there must be a balance between preventing a fall  and maintaining independence and freedom of movement.

 

References for Falls

  1. Alexander, NB: Falls and Gait Disturbances in Clinical Geriatrics, Vol. 9, No. 3, March 2001, 56-62.
  2. American Medical Directors Association Clinical Practice Guideline for Falls and Fall Risk, 1998.
  3. Edelberg, HK: Evaluation and Management of Fall Risk in the Older Adult in Annals of Long-Term Care, Vol. 11, No. 10, October 2003, 34-40.
  4. Ettinger, MP: Aging Bone and Osteoporosis in Arch Intern Med, Vol. 163, Oct 13, 2003, 2237-2246.
  5. Bone Mineral Density Measurement and Treatment for Osteoporosis in Older IndividualsWith Fractures in Arch Intern Med, Vol. 163, Oct 13, 2003, 2165-2172.
  6. Honkanen, L: Preventing hip fractures with external hip protectors in Family Practice Recertification, Vol. 25, No. 7, July 2003, 28-31.
  7. Kamel, KK: Hip Fracture Prevention in the Nursing Home in Annals of Long-Term Care, Vol 11, No. 3, March 2003, 25-32.
  8. Reuben, DB, et al: Falls in Geriatrics at Your Fingertips, 2003 Edition, 58-61.

MS/9.99
©EMS
Revised 2.04

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