Statistics make clear that falls are a serious threat to the health of our senior population. One in three people over the age of 65 and one in two over the age of 85 experience at least one fall each year. Within that subset, persons living in the long-term care setting are ten times more likely to fall, and are far more likely to sustain serious injury as a result. In this week’s episode, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Diane Carter, RN, founder of AAPACN @AANAC_LTC to talk about how long-term care facilities can help prevent residents from falling.
Schenk: Hey out there, welcome back. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And we are your hosts for this episode. We have a very informative episode this week. We’re going to be talking about a super-duper problem that occurs in nursing homes across the country, and that is serious injury and sometimes death that occurs after a resident has fallen. Residents are falling from their beds. They’re falling out of their wheelchairs. They’re falling as they’re walking around. I mean it’s a big problem.
Smith: Yeah. I’d say it’s one of the major – along with bedsores and chemical restraints and physical restraints, falling is a major issue.
Schenk: Yeah, but we’re not going to have this conversation alone. In fact, we have a special guest. Her name is Diane Carter. And Diane actually was on our show back in February of 2019 talking about restraints actually.
Schenk: Yeah, very good. For those that haven’t heard that episode or want to know more about Diane Carter, Will, what can you say about her?
Smith: Well she recently left her position as the founder and president and CEO of the American Association on Post-Acute Care Nursing.
Smith: AAPACN. Representing directors of nursing and nurse assessment coordinators in nursing homes. It was there that she managed the organization’s growth to some 17,000 nurse members across the country. She was active in the development of the MDS 3.0 in the early 1990s, which is a phenomenal accomplishment, and all regulation that affects long-term care since. She has served on many technical expert panels relating to long-term care regulation over her career. She served on the Advancing Excellence Campaign steering committee, board of the directors of the Colorado Culture Change Coalition and is a member of the Gero Coalition through the Hartford Institute with New York New York University.
Schenk: And it’s a mouthful and we’re super happy to have her on. Diane, welcome to the show.
Diane: Thanks. Thanks for having me.
Schenk: Great. Glad to have you back on board again, this time talking about falls in nursing homes. And I guess we often hear that when people fall, it’s usually an older person. And it’s my understanding that there are statistics that show that not only do older people fall more often than younger folks but older people that are in nursing homes and skilled nursing facilities fall even more often than the general older population. So I guess the opening salvo, the first question is why is that so? Why are falls happening so often with our older population?
Diane: So to your point that you just made, let me a little bit to that, is the leading cause of nursing home admission is for rehab due to a fall outside of a nursing home. They fall at home, they lose their independence, they need to go to rehab so they land in a nursing home.
The other thing is just for the why of this topic is that millions of people 65 and older fall each year. In fact one out of four older adults fall whether in their home or in the nursing home, and if you fall once, you’re very, very likely to fall twice. They’re serious. They’re costly, and one out of five falls usually cause serious injury like a broken bone or head injury.
And the thing that’s so dangerous about head injuries, just briefly, is they cause – they can result in long term changes in vision, reasoning, emotions, memory and other mental disabilities. And the thing is that’s what leads to an admission to a nursing home long term.
We know that according to several different studies that about 13 percent of nursing home admissions are the result of a fall. You fall in the home, end up in the ER, have hip surgery, you land in the nursing home, and then it sort of tends to progress from there in terms of a decline. So it’s a very serious issue.
Now, why do elders fall? Some very important reasons but the top three reasons are chronic health conditions such as health disease, dementia and low blood pressure, which can cause dizziness, and of course, that’s always usually a factor in someone stumbling or losing their balance. And it’s also just a part of the natural aging process. The thing that I’ve experienced myself is my father is 90 and he goes to exercise three times a week
Diane: Well that kept him upright but you can see now that he is also experiencing the decline in spite of his will to stay healthy and upright. But anyways, so it’s just a part of natural aging, as much as I hate to say that out loud with regards to him.
In Australia, injuries caused by falls are the most common cause of death of people over 75, and I wouldn’t doubt one bit that that wouldn’t be the case in the United States.
Smith: Wow. Yeah, I actually just had lunch with another attorney recently who’s law partner, I want to say he’s probably about 65 – it was in the newspapers here – he got up in the middle of the night and fell and is now paralyzed completely. So yeah, it’s dangerous. It’s insane how things like that can happen.
Diane: It’s very dangerous. And here are the risk factors for falls. Well we already mentioned old age. A history of past falls, of course, sets the stage for further falls. Cognitive impairment, impairments in walking, dressing, toileting – frequent toileting leads to falls, and I’ll talk more about that later. Lower extremity weakness or other disabilities such as peripheral neuropathy or numbness of the feet or lessening of muscle strength – and I’ll mention a couple additional things about that shortly, but that’s very common in older people. Impaired or unstable balance or gait, dizziness, arthritis, stroke or visual acuity, lower body mass, joint pain or weakness and poor vision.
A big issue is side effects of medication. They play an important role in what happens with older people and falls. And of course in your home, oftentimes a physical therapist will come in and look at your shoes, floor rugs, slick floors, there are all kinds of environmental concerns that lead to falls.
There are respiratory difficulty and then your reflexes are just slower. I noticed that with my dad. I noticed that with my dad where he just can’t catch his balance if he starts to fall.
And one thing I had never heard of before was a thing called cataplexy, which has to do with a sudden episode of muscle weakness and falling down without loss of consciousness, and this is related to narcolepsy, which I’m very familiar with. But apparently these episodes are caused by emotions, they believe, so if you’ve had a very upsetting situation, you’re maybe more likely to have difficulties.
So those are the risk factors. It’s a lengthy list but it’s certainly something that affects many elderly people.
Schenk: And that certainly answers the questions of why that population is more likely to fall than other populations, because you’re checking off a list of many things that aren’t applicable to younger folks. So yeah, from a basic standpoint.
Diane: Yeah, right.
Schenk: Is there a time in the average day of a nursing home resident in which given all those risk factors that a fall is more or less likely to occur?
Diane: Well I’ll tell you what. When I was a director of nursing, it was a bazillion years ago, we looked at – we pulled together all the falls within our facility, and I’d seen this throughout the data over the past – well I won’t even tell you how many years, but one of the biggest issues is that I was going to get to is, so what happens in a nursing home in terms of staffing is around when meals are served, so breakfast, lunch and dinner, many of the staff and about half of the residents go to the dining room to eat breakfast, lunch or dinner. So they’re in there helping people with feeding and eating. They’re able to feed themselves. There’s very minimal staffing on the nursing unit, and then of course if people have not been offered an opportunity to toilet before all this staff moves to the dining room, you see all the time people who are on the unit need help, can’t get assistance and they end up falling trying to get to the bathroom by themselves either because they, again, this is also very common, is unfortunately either because they’ve delayed going to the toilet for a very long time and they often slip in their own urine or because they just waited too late and they just can’t get there and they fall with or without that slip risk. But those are critical issues in terms of looking at the risks for falls.
Schenk: That makes sense. I mean that’s an underlying issue in many of our cases. Many of our cases are not even fall-related. It’s the lack of staffing. So kind of like an indirect point that you’ve made is staffing is important, so when there’s meal time, if there is adequate staff, they’re dealing with the meal preparation, the meal delivery versus, “Well did Mrs. Johnson go to the bathroom before this?” “Well we’ll just check when we get through feeding such-and-such a person,” and that’s unfortunately when it happens because you might not have enough hands to take care of everything.
Diane: Yeah, and well I think it was last week, I saw an article in McKnight’s – 43,000 open positions for direct care staff in nursing homes, so don’t get me started on staffing. There just are not enough staff.
Diane: That is what creates these dangerous accidents.
Schenk: Yeah. That’s one of those things where I feel like every few years when we were in elementary, middle school and high school, there would be these reports about the most-needed or the – what do you call it – projections for employment, like you’re most likely to get a job in these industries because the demand is up, but it was always nursing. The whole time it was nursing. If you want to be a nurse, you will get a job.
Diane: Yup. Absolutely.
Schenk: Yeah, so we understand a little bit better the individuals that have more risk for falling. We understand a little bit better when falls are more likely to occur. What about – we know what. What are some ways we can prevent falling, other than having enough staff? But even if you have enough staff, what are some things the nursing home can do to prevent injuries from falls?
Diane: So we mentioned staffing. One of the things that all people need to be aware of, in particular family members, is that medications need to be dosed to approximately a half or a third less because older people’s liver and kidney function is compromised. They have a lower body weight and they suffer from malnutrition. These medications are very strong and they can lead to dizziness and falls. There’s also the issue of any time I see a medication change – am I looking at what those risks are associated with that particular drug?
So there’s a greater risk of fall from the first six weeks after admission. So it’s really important to be alert, to alert staff and to be very cognizant of that additional risk factor. We know that drugs cause toxicity and looking at those therapeutic levels and being certain that they’re correct for older people is important.
Psychotropic drugs, when we’re treating especially behavioral issues with antipsychotics is absolutely inappropriate and these drugs cause many falls in long-term care. Diuretics are another drug – water pills – probably most of the public is familiar with these – frequently cause issue with low blood pressure, because it causes someone to have to go to the bathroom frequently and you see an increase in incidents of low blood pressure, which again, these cardiovascular drugs I think I mentioned, dizziness, weakness, fatigue. Some of these I’ve already mentioned.
Has something changed? Whenever I see a fall or anything happen that looks different than what I’ve seen in the past, I start thinking of drugs. Digitalis is a heartrate drug that’ll end in seizures, diabetic seizures. I mean there are many organizations out there fighting tooth and toenail to get rid of these antipsychotics in nursing homes.
Other risks include unstable gait. You want to look forward to a good restorative program in place or clothing sizes, right? Do their shoes fit? If you lose a lot of weight, your shoes get a lot looser and you may see stumbling. You need gait training either from nurses or PT. Hearing and vision can cause a lot of problems with not understanding your environment.
Infections – I remember when I was a DON how many times did I figure out – I figured out it was an infection because someone fell first. So oftentimes the first sign of an upper respiratory or a urinary tract infection is a fall, oddly. They don’t strike a fever usually if they’re very old. So low blood sugar, we’re seeing many, many more people with diabetes in the nursing home, and that can cause a fall.
Schenk: Just to be clear for the audience, the reason why it’s a first sign of infection for you, or the fall is the first sign of infection is because that all attributes to dizziness.
Diane: It attributes to dizziness, but also because the resident does not spike a fever and you don’t see the usual signs of infection in someone who’s very elderly, the first sign may be that they fell. And then you call and you start asking questions and then you find out that they do have a UTI or a urinary tract infection or an upper respiratory infection. It can be the first sign, a fall, of an infection.
Dehydration, we all know from personal experience, how that can cause – dehydration. Constipation is another problem. And then there’s just a bazillion of things I can talk about but I won’t today.
In terms of doing an environmental assessment around lighting, furniture, floors, accessible call lights – of course accessible call lights being the most important. Can they get help if they need it? And of course, you’ve got to answer the call light.
Schenk: That’s right. And that goes to – if I can interject, that goes directly to the toileting issue most of the time.
Schenk: If they need to go to the bathroom, they’re going to hit the button. And if somebody doesn’t come, they would rather chance walking to the bathroom than going in the bed, and that’s when the fall occurs.
Diane: Right. Right.
Schenk: Diane, you said something very interesting, and I’m not quite sure if we talked about this in your previous episode, but you mentioned something along the lines of whatever the medication is, it needs to be reduced by a certain percentage because they’re too strong. Can you speak to that and generally do the physicians already take it into account?
Diane: Well you hope that the physicians take it into account. Sometimes – I mean doctors are only required to come to the facility twice for 30 days, and every 90 days thereafter. So they’re not going to know how a drug is affecting a resident. But nurses should be alert and cognizant of the fact that someone has gotten a drug and what effect it seems to be having on them. There are certain drugs that you routinely draw tox levels just to see how they’re reacting to the medication, and those are things that are done routinely like Dilantin and Digitalis. So you want to just be aware that any time a drug changes, so if somebody’s functioning fairly well and all of a sudden you see that they’re sleeping in their wheelchair, they’re not eating the types of foods they usually eat, I mean a nurse aide is often the very best person to see, “Oh, she always eats sweets and now she’s not interested in any of her food,” or those kinds of subtle changes, and they can be quite subtle. Yes, those need to be looked at very carefully.
Schenk: And you mentioned bright lights. I believe you mentioned fall pads, those kinds of things. How common are those?
Diane: Well I think it’s a part of oral assessment, and when I think of lighting, a lot of nursing homes, this is for example, okay? For example, a lot of nursing homes, they have these long hallways with a door at the end with a window there. So as a resident heads down that hallway, the closer they get to that really bright light right in their eyes, they’re much more likely to fall. These weird patterns in carpeting and things like that, there are certain colors that shouldn’t be used. There are all sorts of things that need to be assessed and really thought of as you’re looking at care in a facility. So not sure if I answered your question, but there are all kinds of things you need to look at, but that’s just really skimming the surface of all of these issues, lighting in the rooms, I mean just all kinds of things that really, really help with preventing falls that are environmental.
Schenk: So what are some of the signs, physical signs, that someone has fallen?
Diane: Well I mean I would tend to look for, of course, bruising, skin tears, any sort of assessment about how those happened and people should have some understanding of that. We used to say, “Oh, everybody has skin tears. Everybody has…” Well now, we really need to be looking at skin tears. How are they treated? Is the person on Coumadin or an anticoagulant? What’s being done to prevent any kind of skin tears? And so there’s a whole list of assessments that can be done to, I don’t know the right word – you’re a lawyer, but you kind of mitigate against those things happening again. People who have skin tears, they fall, different things, but the vast majority of falls, as I mentioned in the restrain thing, never lead to injury. But we need to be understanding why it occurred anyways. It’s not something like, “Oh, well he falls all the time.” And it used to be much more of a – I would call it an ageist attitude, “Well they’re old, that always happens to old people.”
Smith: “There’s nothing you can do.”
Diane: We don’t want to see that. We want someone to look at what happened, what are the risk factors and how are we going to change the care to make it so the person doesn’t have any sort of events like that again? It may happen anyways, but you want to know that that was looked at.
Schenk: Right. And I think that any time, a red light should go off, is if you do have skin tears accompanied with diminished capacity because that’s definitely a sign there’s been some type of head trauma with the fall. But can you speak a little bit about – you mentioned Coumadin. Why is Coumadin relevant to assessing a fall and is associated with a fall?
Diane: Well it’s an anticoagulant, right, because so many people, as they age, develop atrial fibrillation – it’s a diagnosis. And they’ll put them on Coumadin to address the atrial fibrillation. So here’s the issue. That needs to be measured every week. Those results need to be monitored very, very closely. They need to go to the physician. The physician needs to be looking at what’s going on, and those who are referring them Coumadin are what cause the skin tears, or I don’t know if you’ve ever seen – it’s just a horrible sight – when an elderly person’s on Coumadin and they fall and their whole side of their face is bruised up and their elbows, and of course once the bleeding is started under the surface of the skin, you’re going to see some skin tears because that drug just predisposes you to issues with bleeding under the skin. It’s an anticoagulant and so really, just the smallest bump can cause bruising that doesn’t look too hot.
Now having said there, there are ways to distinguish what’s normal bump bruising, whatever, and maybe somebody hit somebody or something really horrible. I can’t go into that today, but we have means of understanding how those things occur, and it’s not just, “Oh, well they’re old,” which you see all the time.
Schenk: Right. Diane, walk us through how do families get involved with fall prevention in nursing homes with their loved ones? Like what are some steps they can take to make sure their loved one is as safe as possible from injuries from falls?
Diane: Well I’m going to return to my – I’m going to back into my nursing background because this is absolutely so important.
Schenk: By all means, go ahead.
Diane: It’s worth noting that in a study down in hospitals in America, 38 percent to 78 percent of the falls can be anticipated. That means to me that they could have been prevented, and I believe this is true in nursing homes as well, not just hospitals. So the very, very most important step, first thing to do is the minute that your relative is admitted to a nursing home, the family member needs to be there and demand, if it’s not already being done, and I don’t mean a federally mandated tool like the MDS, I mean getting in there and ensuring that an extensive detailed nursing assessment was done to identify all the risk factors I just mentioned, I went through that whole list, and what effect that might have on a resident. And those family member can tell you, if not the resident – I don’t mean to speak for the resident, but the family members need to be there talking about, “He’s been at home, he’s had several falls, this is what we think happened,” so you get a good sense of assessment in terms of this particular individual, what happened to him.
Then you want to look at what are the interventions, the nursing interventions that should have been done to preclude the fall. For instance, the one I think of most commonly is this issue with trying to get to the bathroom and not having access because of staffing. And in that case, if the person has urgency to get to the bathroom or whatever the assessment might be, you certainly are addressing that. And so what you’re going to do is basically do what’s called an extensive bowel and bladder program, which identifies when the resident is most likely to need to use the toilet and then followed through by staff by taking them to the toilet. It’s absolutely critical. You’ll prevent the majority of falls by doing that.
It needs to be, as I mentioned 100 times, many of the federal regulations won’t be necessary if we just individualize assessment for each resident. So you want to go through your list of risk factors and identify what the risk factors are and look at what the nursing interventions should be. And then you develop a care plan. And family members should be involved in that care planning and understanding and watching out too for – I’ve got a care plan for my father or mother, and is the nurse aide or whoever assists with toileting or whatever the issue might be, are they following through? Is it getting done?
And then there needs to be that continuous evaluation. Like I said, you have a set of medications. The fewer medications, the better. I mean the requirement is said in the line but it should be less than that. You are constantly evaluating and going through your process of “Has something changed? We didn’t have any falls for six months. Now we’re having a fall. Was it meds? What was it?” And do we see staff that have been educated and are confident in following through?
And so I like to say, as our title says, what are the five most common ways to prevent falls is – and this is the nursing process: you do an assessment, you do an intervention and a care plan, you continuously evaluate, and of course, you follow through. And the care plan is only going to be as good as the people who are following through on implementation of that care plan. And that family member is just so instrumental to getting that plan down to a very individualized assessment that meets the needs of their resident.
And again, I’ve already mentioned this, but I can’t say enough about staffing. It’s pretty much all I read these days because it’s my cross to bear to keep talking about staffing in nursing homes.
Schenk: Well that seems to be an overarching theme in all these shows is family member participation and staffing, but Diane, you’ve been marvelous once again. This is all great information that our audience can definitely use in the future. How do people get in contact with you if they want to ask a question or if they’re a nurse out there and want to participate? And we were calling it AAPACN – how do you shorten the American Association on Post-Acute Care Nursing?
Diane: I call it AAPACN.
Schenk: AAPACN. I got it. I got it.
Diane: You got it.
Schenk: Very good. How do people get a hold of you?
Diane: Okay, my email address is Diane Carter LTC, as in long-term care, so it’s DianeCarterLTC.RN@gmail.com.
Smith: And we’re going to put that up there.
Schenk: Yeah, it’ll be on the screen for everybody. Well fantastic. Go ahead.
Diane: Let me mention two other things. When you’re looking at admission for a resident in a nursing home, ask about staffing, get all the information that you can. As you’re walking around maybe visiting a facility, watch to see if call lights are answered. Critical pieces.
Schenk: That’s good advice. Yeah.
Smith: All right. Well thank you, Diane. We really appreciate it.
Diane: You’re welcome. It’s been fun.
Schenk: All right, we’ll talk to you next time, Diane. Thank you.
Diane: All right, take care. Bye-bye.
Schenk: Great. AAPACN. AAPACN.
Schenk: She started that organization, I think.
Smith: Yeah, she’s the founder, president and CEO, the American Association on Post-Acute Care Nursing.
Schenk: Yeah. AAPACN. It used to be AAMAC. Now it’s AAPACN.
Smith: She has an amazing background. I mean she worked on the MDS 3.0 in the early ‘90s. For those of us that work on nursing home cases or deal with nursing homes, the MDS is a very well-known assessment and data tool, so that’s amazing that she did that.
Schenk: She’s OG.
Smith: Yeah, OG.
Schenk: OG MDS.
Schenk: Well that’s going to – actually that’s not going to conclude. I have one announcement, a little housekeeping matter. There is a certain individual that’s sitting at this table that is not me that as of Wednesday will be 41 years old.
Schenk: Will Smith turning 41.
Schenk: The big 4-1.
Schenk: So what are your plans?
Smith: Nothing. I never really celebrate my birthday. I mean 30 was kind of cool – “Hey, I’m in my 30s,” and 40 was finally a milestone, “Hey, I’m 40 years old,” but now, who cares?
Schenk: You know what we need to do is like we need to do, forever, from now on, is we’re going to go out, you and I, to a steak place and consume that many, whatever the year is, that many ounces in Tomahawk steak.
Smith: Oh, they’ve got a 41, 40-ounce Tomahawk steak, no problem.
Schenk: Yeah, we need to go to Marcel’s. I haven’t been to Marcel’s yet for their Tomahawk.
Smith: And they have a cote-du-boeuf, which is a French method of…
Schenk: They cook it in beef fat?
Smith: I’m not really sure how they do it to be honest with you. But it looks amazing.
Schenk: But 41. I remember that. I remember turning 41.
Smith: Yeah, six months ago.
Schenk: Yeah, I had a taco party.
Smith: Oh yeah, that’s right.
Schenk: So all right. Well with that, happy birthday to Will, you can consume each and every episode of the Nursing Home Abuse Podcast every Monday morning on our website, which is NursingHomeAbusePodcast.com, or on the YouTube channel, or you can listen wherever you get your podcasts from. And with that, we will see you next time.
Smith: See you next time.