By definition, a fall is as any event that leads to an unplanned, unexpected contact with a supporting surface. Most studies indicate that falls are a multifactorial event resulting from multiple risk factors, including unsteady gait, cognitive impairments, medication, and others. Understanding this, Federal and state law are clear that nursing homes must take reasonable steps to prevent the risk of fall in each resident. In this week’s episode, and in honor of Fall Prevention Awareness Day, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Dr. Mindy Renfro of Touro University to discuss common interventions for the reduction of nursing home falls.
Schenk: All right, welcome back. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And if you listened to the previous podcast, which also dealt with prevention of falls in nursing homes, you would have learned that Sunday the 22nd, the Sunday before last, was Fall Prevention Awareness Day.
Schenk: And not Autumn Prevention – as in we’re trying prevent autumn from coming, we’re trying to stay summer forever.
Smith: We bring that up because the day after Fall Prevention Awareness is the beginning of fall.
Schenk: Fall/autum. What is your common description of the season? Is it fall or autumn?
Smith: Well I’ve never said au-tumn. If ever, it’s been autumn.
Schenk: What did I say?
Schenk: Autumn. Oh, I really stressed the T? Au-Tuhm?
Smith: I’ve always said fall.
Schenk: Yeah, I always say fall too. I think autumn is more bourgeoise.
Smith: Yeah, it’s bougie. It’s very bougie. Or just old fashioned.
Schenk: Old fashioned.
Smith: Or maybe it’s a northern thing.
Schenk: Or maybe none of those things and we’re the ones…
Smith: Yeah, I have no idea.
Schenk: On the program today to talk about prevention of falls in the long-term care setting is Dr. Mindy Renfro. Will, what can you tell us about Dr. Mindy?
Smith: Dr. Renfro is a geriatric physical therapist and associate professor who teaches in the School of Physical Therapy at Touro University Nevada in research and geriatrics. She was selected by the CDC as a fall prevention expert in 2009 and works closely with the National Council on Aging, American Physical Therapy Association, Geriatric Education Centers and many other organizations. She has studied and published fall risk measures and validation of evidence-based fall prevention programs for sub-populations. She is a long-time advocate and educator of fall prevention and home modification for inter-professional clinicians and aging service providers as well as older adults and their caregivers to ensure safe and successful aging in place. She enjoys being outdoors with her children, grandchildren, and she is the primary long-distance caregiver for her healthy aging parents…
Smith: …who are aged 90 and 93. That is amazing.
Schenk: Hey, congratulations.
Smith: Anyways, Dr. Renfro, welcome to the show.
Schenk: Welcome to the show.
Mindy: Thank you.
Schenk: Fantastic. So the past couple of episodes, we’ve been talking about the prevention of falls in nursing homes because as we stated in the last episode, it comprises a lot of our caseload, injuries from falls, preventable falls. And we talked to the audience about September 22, which was the Sunday before last was Fall Prevention Awareness Day, and in light of that, we wanted to have this episode and the previous episode dedicated to fall prevention, and we thought have guests on that are experts in this field, and your name popped up and that’s why we are so happy that you are able to make it on the show.
And I guess we’ll start it off with in your experience, in your education and your understanding, why do you think that seniors, particularly seniors in long-term care settings, why are they so vulnerable to falls to begin with?
Mindy: Well every single person has their own set of fall risk factors, and the fact that it’s so variable makes it very tough to prevent. So at home, you have the factors of your body, your intrinsic factors, things that are typical for you, your activity level, your strength, your overall fitness, etc., and also your environment, how things are set up at home, how cluttered a house is, how if you have stairs, if the stairs are lit, etc.
But you move into an institution and you add more layers. You add a much bigger environment that is new to you and probably has longer distances. It’s unfamiliar. And then you have staff with their own risk factors. And then you have policies and procedures. So there’s so many layers of fall risk factors that the stakes go up and up and up.
Schenk: That makes perfect sense. And it seems to me that every category of risk that somebody falls into presents its own set of, I guess, interventions that can be set in place to prevent that particular person from falling. And one of those categories that we’ve talked about over and over again on this podcast are seniors in long-term care facilities that have vision impairments, whether the vision impairments are from some type of disease or disorder or maybe from medication. But what are some of the ways that nursing home staff can help prevent falls in that subset population of nursing home residents with vision impairments?
Mindy: Well you know, as a physical therapist and a geriatric physical therapist, I spent about 12 years full time in nursing homes. And one of my greatest frustrations inside so many times, the frustration for other staff members, is loss of eyeglasses. They’re put on the drawer so they don’t fall on the floor and a staff member turns in and doesn’t see glasses, doesn’t put them on, doesn’t look for them, and some facilities mix up what is privacy and what is not.
Mindy: There are many ways to let staff know and visually, if they walk into a room, who needs glasses, who needs hearing aids, who needs an assisted device, without interfering with a person’s privacy, especially if you get their permission to mark it. So there can be visual reminders. There can be how the assisted devices, the glasses, the contact lenses for cataract patients, where they are, if they’re ready to be used, they’re clean, they’re safe, they’re adjusted, they’re correct, and which ones to use? As we get older, we should not be wearing multi-focal lenses. We should have single vision lenses. What that means is you probably have two pairs of glasses. You probably have one for distance and one for reading. And if unwittingly someone puts on the reading glasses to walk somebody, they’re at a great disadvantage, high risk of falling, and vice versa. So it’s very important that the glasses, people know those glasses, they know where they are and they’re in the same place for every patient, and it is marked clearly when they are needed.
In addition to that, because Medicare in its wonderful wisdom does not pay for glasses and does not pay for all vision exams in all areas. We have our patients without going to eye doctors at a point in their life where their eyes are changing the most rapidly. And that’s a huge risk. Very few patients, and I forget this study, but in about 2015, they found only 20 percent of patients in nursing homes had their eyes examined once a year as recommended. So you’ve got to know what your eye health. You have to address it and pay for whatever it is needed and provided. And sometimes it needs to be done by the nursing home. If the family cannot pay for eyeglasses, that can be pursued by the family and the caregiver as needed equipment for safety and mobility.
Smith: You know, something interested that you brought up because we’ve been going through several different podcasts dealing with fall prevention – it’s such a big deal, but I like that you’ve brought this up because this is the first time we’ve mentioned it. Something as simple as people losing their eyeglasses contributes to falls, and you know this from working in nursing homes and I worked in one for a long time, that is something that is very prevalent, which is people losing eyeglasses. It is not first and foremost on the CNA’s minds or the staff’s minds even though it should, and that’s just an interesting phenomenon that really contributes to falls as well.
Schenk: And I’ve got to say that for the first time in my life, I’m starting to understand how important it is how multifocal glasses versus two separate types of glasses – I am starting to now wear – I need bifocals. So when I have my normal glasses on and my wife will try to get very close to my face and whisper something to me, I have to push her back because I can’t see her face. And I never had that happen before where I can’t see her. And she doesn’t understand that – “You’ve got your glasses on!” “Well those glasses are to see you far away.” So what you said is so super important that you have to have the right glasses on or you might as well not even have the glasses on at all.
Mindy: Or they’re a disadvantage.
Schenk: Exactly. You’re hindering them. So we’ve talked a little bit about preventing falls for residents that have visual impairments. There is another, I feel like, major risk factor for falls, are those residents that have a tendency to wander. So can you kind of walk us through what are some of the factors, what are some of the action items in interventions that nursing homes can put in place to prevent falls or to prevent wandering itself, but to prevent falls in those residents who have a tendency to wander?
Mindy: Sure. And that of course varies with time of day and medication, and what you do about it has to vary with time of day and medication. The end point of preventing wandering is a locked unit. And you certainly don’t want to be there if you don’t have to be. So there’s a lot of intervention in between. And it’s interesting that many people from children with autism to older adults with cognitive decline or people having an anxiety or panic attack can be stopped from leaving an area or a room by a simple picture on the wall or door, just a visual cue – stop. Something as simple as a picture of a stop sign on the inside of the door or hanging on the side of the door frame at eye level in a bright color can stop a lot of people.
Mindy: One problem in nursing homes is auditory fall alarms, and if you have a loud noise go off, what do we learn all our lives? If the smoke detector goes off, what do we do? We leave, right? It’s for safety. It’s to get out of there. And then we go into the nursing home. We’re medicated. We’re maybe a bit confused. We’re in a new environment. And when an alarm goes off, what are we going to want to do? Get out of there. So to have an alarm go off to alert staff that you’re standing and you may fall may cause falls.
Smith: And I just don’t think – it seems like when you walk into a nursing home, there are so many alarms going off that people become numb to it, and I just don’t feel like the staff really respond to it.
Mindy: Right, but the other residents do.
Smith: Oh, yeah, the other residents do. You’re right.
Mindy: And that can cause someone to leave their room.
Mindy: Another thing about alarms that work for people who tend to elope but don’t go far because of mobility is we’re putting an alarm on their wrist, not their neck, that when they get up and take a couple steps, it sets off a blinking light in the hallway to the staff that someone’s getting ready to leave. There’s no auditory. It doesn’t flash in anybody’s eyes. It doesn’t wake anybody, but will let people know quickly there’s a problem and it’s here.
Smith: Oh, okay.
Mindy: And it’s a much better response alarm than an auditory alarm that could get three or four people out of their bed and leave.
Smith: Right. Yeah, I have not seen that, but that is a brilliant idea.
Schenk: That’s a great idea. Those alarms are basically just triggers to get up and wander. So Mindy, can you walk us through, maybe it’s not somebody that has a visual impairment. Maybe it’s not somebody that has some type of new medication or medication that affects them in such a way that’s going to increase their likelihood of falls, maybe not people with gait or mobility issues. I feel like a lot of people who fall in nursing homes, it’s because of a transition between a sitting position or a standing position or more often I feel like is getting in and out of bed. Can you talk about some of the ways that we can prevent falls in and around the bed, whether getting in or out of bed or while in the bed falling out of it?
Mindy: Generally it comes down to the old problem of answering the nurse on call light. And that comes down to staffing ratios. And I won’t go into all of the law and legislation that does not exist about staffing ratios except to say that if we had more staff to respond, it’d be a whole lot safer.
Smith: Yeah, amen.
Mindy: As far as the structure of the bed that gets the most attention, I think you’re barking up the wrong tree. Some states have put all the mattresses six inches off the floor and all sorts of things. We have mattresses that have come up on the sides and then you’re trying to get over this lump all the time. I think the physical structural changes to the room really most of the time cause more issues than not because it feels uncomfortable and you’re not used to it.
The best prevention for people not able to get in and out of bed safely is strength – strengthening and balance training, referral to the physical therapist and/or the occupational therapist to work on the lower extremity strength to lift yourself and the balance once you do so you don’t go down. A lot of people if you watch them as they age, ever seen an older family member take three or four times to get off the couch, falling back each time? It’s very common. Those are falls. They don’t go to the floor but they are falls and it should be a trigger to us, “Uh oh, I can no longer stand up. I need to work on both my lower extremity strength and my balance reactions,” and there are all sorts of evidence-based fall prevention programs with or without a PT to deal with that. In the nursing home, it should start with a PT or an OT. So getting rid of the person’s body, the intrinsic factors is the first thing.
The second thing is the environment. We have transfer poles. We can’t use bedrails anymore because they’re dangerous, but we can put up a transfer pole between the ceiling or the floor eight to nine inches away from the side of the bed. So if a person goes to stand up and there’s a big, strong bar there, they’re going to grab it and they’re going to hold onto it and they provide a lot of support while people get their blood pressure back up, while they adjust their vision, while they get a light, while they put on their glasses before trying to move. So that’s a very simple abatement.
The other thing is to prevent the injury if they do fall, and we have all sorts of flooring like SmartCells flooring that decrease fracture rates five, six times.
Smith: And how does it do that? What type of flooring is this?
Mindy: SmartCells flooring was developed in Canada and is used in the UK as well, and it replaces or goes under flooring or on top of, and it has these little cells underneath that you don’t see that if you hit it with a hard object, like your hip, it moves, it deflates, it allows for a change in pressure that doesn’t happen just by walking, but by a high impact.
Mindy: And when that happens, the pressure doesn’t go into the bone. It goes into the floor.
Smith: Ah, I got you.
Mindy: So if you go down, you may scrape yourself up, but you’re probably not going to fracture.
Schenk: Got you.
Smith: SmartCells flooring is not a big expense. A person at high risk of getting up unaccompanied without falling, it would be a very logical change for a nursing home to make. So there are a lot of things and I just really feel that it’s important to make sure nursing homes and families and caregivers know that putting the mattress on the floor and putting a funny scoot mattress and doing all of these things to the bed is missing the point.
Smith: I got you. So what are some things that families can do then, that they should do if they’ve got a loved one who’s a fall risk? And I would assume that everybody should be treated as a fall risk.
Smith: Is that your perspective?
Mindy: Especially at night.
Mindy: My parents are in their 90s and thank goodness they’re still independent but they’re talking about making the move into an ALF, and the first thing that I went from place to place and looked at the fall rates for the facilities.
Smith: Oh wow.
Mindy: So they couldn’t apply to those that had a high fall rate.
Mindy: Then I looked at staffing ratios to make sure that at night, there were still enough people to answer call lights and looked at their staffing ratios and their call-in rates and what the people on site in attendance actually were, not how many people were hired.
Mindy: The other thing to look for to protect is call light response time. And that can be as simple as eavesdropping. We have Alexa now. We have all sorts of ways we can snoop.
Mindy: And knowing how much time elapses between the call light going off and the response coming in is important information. Now Medicare, when they go out and do their annual walkthrough, will tell you what those response times are, but of course when you know Medicare’s in the building, those response times are a whole lot better.
Smith: Right, suddenly you have enough staff. Yeah, exactly.
Mindy: It just doesn’t give you much usable information. So those are the sorts of things I look at first, and then of course the environment. Is there a bathroom in the room and is it readily accessible? Is it safe? Where are the grab bars? Are they moveable? Are they adjustable? Do they fit my family member? And what is their fall prevention policy? What are they doing?
Schenk: Right. So a lot of really great points on preventing falls and reducing – if there was a fall, reducing the injury in the bed. What about where we see a lot of falls and that is in wheelchairs? Can you speak to preventing wheelchair falls?
Mindy: Well there are two types of wheelchairs. There’s the transport chair that’s in there just for someone else to take you places and then there’s the wheelchair that’s fit to you because you’re a permanent wheelchair user. So in most nursing homes, the most common item is the transport chair – someone is moving you from point A to point B and you are passive in the process. It still has to fit you. It should not be huge. It should not be tiny. You should be able to – it should fit you so when it pulls up behind you, the bottom of the seat is at the back of your knee, like any other chair you would want to sit on comfortably. Everything should be working, especially the safety equipment. The brakes have got to work in order to be used, and then they’ve got to be used. The foot pedals must be removable and they have to be moved out of the way when you’re getting in and out and put down in place so that you don’t get your foot. Simple, simple things.
The other most important event is that you have to have a gait belt. All patients should have their own gait belt right by the bed in sight all the time. If you have a CNA carrying one gait belt from place to place, of course it becomes an infection control issue, and if they leave it on someone, they’re not going to have it. But everyone needs to…
Smith: In general, can you explain what a gait belt is and what it’s used for?
Mindy: Oh sure. A gait belt is a strong, lead belt that is attached with a double metal clamp so that it cannot come free, and it’s attached snug but not painfully tight around the waist of the patient, and it’s held by the caregivers with the fingers pointing up to the ceiling to help steady the patient without grabbing an arm or reaching for clothing.
Smith: Okay. Yeah, and that would make sense. If they’re using the same one on everybody, there’s a very good chance that they’re carrying germs or bugs from one person to the next. So every resident, what you’re saying, needs to have their own gait belt, and I do not see that happen. I can tell you right now. At least here in Georgia, I do not see that happen very often.
Schenk: Yeah, and so in the last few minutes here, Mindy, can you kind of speak to just other common strategies for the prevention of falls? I was reading a really excellent article on this subject that was talking about making sure that the residents had proper fitting footwear as a main culprit in falls.
Smith: Oh yeah.
Mindy: Yeah, the socks with the little grippers are a little start but they certainly aren’t enough. We need footwear. Everyone needs to know that if you’re diabetic, Medicare will pay for footwear once a year. Everyone else doesn’t matter but diabetics can at least use that benefit.
Mindy: Shoes should go on and off easily, should secure well. So if they tie, they need to have coil elastic so it’s easy to put on or off, or Velcro. Needs enough room for the toes. Obviously needs a good sole for grip. And it needs to stay on the foot and fit – basic things that we all learned as kids. You can’t have flip flops on. You can’t have things that would fall back. You can’t have nice fluffy things that look cute but you’re going to step on the feet side to side. You need to have pretty much a supportive slipper that’s like a supportive.
Smith: Yeah, right. Absolutely. It makes me think I have a friend who was helping somebody move the other day and they had flip flops on and I said, “Do you not know what you’re doing?” That’s a sure way to…
Schenk: That’s asking for problems.
Schenk: Mindy, you mentioned earlier hip protectors. Can you tell us what a hip protector is?
Mindy: Sure. Hip protectors look like a girdle that’s looser fitting that has slots in the side, and you can put pads in that are created to protect the hip trochanter, the part of the hip that sticks out on the side of your thigh, and/or your sacrum, the part of your lower back between your buttocks. There’s very mixed research on wearing hip protectors that are clothing. The first thing is it changes how well your clothes fit, so you can sure that women aren’t going to wear them. The other thing is it can make going to the bathroom much more difficult to manage putting them up and down, and therefore it can create more incontinence.
Mindy: It is better when possible to put external environmental changes like flooring for hip protection. However, that all said, I will say that in small Caucasian and Asian women with osteoporosis and are at very high risk of fractures, that hip protectors have been shown to decrease fracture rates up to 30 percent.
Smith: Oh wow.
Mindy: So that’s significant.
Schenk: Are you quoting from a particular study?
Mindy: I am, but I would have to look it up to tell you which one it was.
Schenk: That’s okay. That’s interesting that there are subgroups of people that were studied that show the benefits. That’s interesting.
Mindy: Well they tend to be small stature and they also tend to be osteoporotic.
Schenk: I see. Mindy, this episode has flown by. Thank you so, so much for coming on and sharing your expertise, your knowledge. We learn something new every episode and you have brought a lot of great information for our audience.
Mindy: Well thank you very much. I certainly appreciate the opportunity to try to get information out.
Schenk: Dr. Renfro, she’s clearly somebody who knows what she’s talking about.
Smith: Yeah. And it’s interesting, the eyeglasses thing, because just – I don’t think that that’s a huge priority in nursing homes. People lose their eyeglasses. They’re put away. And that can really contribute to your ability to see well which directly relates to your inclination to fall. So it’s interesting.
Schenk: And that is a true story about me not being able to see things up close. It’s starting to get really bad. I’ve had glasses since I was in the second grade, for a long time. I will never forget the day, I might have been 7, and they put the glasses on, and I remember – obviously you don’t know what you don’t know – so I put the glasses on and I’m like, “This is how you all see?” I couldn’t believe it. This is insane. Because you’ve got to understand my vision was so bad – I wasn’t blind or anything like that, but I couldn’t see faces and things like that, and when you put those glasses on, I was like, “Man,” I’m literally thinking to myself, “I’ve been at a huge disadvantage this whole time.”
Smith: Wow. Yeah.
Schenk: I was 7. But anyways, what else? Again, just last weekend, last Sunday was Fall Prevention Awareness Day. So this is going to conclude our series of episodes about fall prevention. I’m not sure – I don’t know what the calendar holds for the next episode. I don’t quite remember what we’re going to cover. Anyways, who knows? I guess that means you’ll have to tune in, audience members.
Smith: Yeah. Is it not NCAPPS?
Schenk: No, that was last… Yes, it will be NCAPPS. See, now Will is thinking four-dimensionally. I was not thinking four-dimensionally. Next episode will be an episode featuring…
Smith: In October.
Schenk: October 14 will be the next episode about NCAPPS. And if you want to know more about NCAPPS or what in fact NCAPPS are, you have to tune in.
Schenk: But that’s going to conclude this episode of the Nursing Home Abuse Podcast. New episodes every other week. You can see it on YouTube, on our website, which is NursingHomeAbusePodcast.com, or wherever you get your podcasts. And with that, we’ll see you next time.
Smith: See you next time.