Fall Risk, Recognition and Response

Fall Risk, Recognition and Response

HCIS Senior Care Blog

Fall Risk, Recognition and Response

Author – Cyndi Siders, RN, MSN, CPHRM, DFASHRM, CPPS, Executive Consultant

 “My Mom is in Good Hands Now…”

Mrs. Helga Olson and her son John request an appointment for a tour of your Assisted Living facility/Skilled Nursing Facility .  Helga arrives holding on to her son’s arm. She appears to have some pain while walking.  Helga has a large bruise on her right cheek and right arm.  She tells you proudly that she has just celebrated her 83 birthday.  She also tells you that she has lived in her current home for 46 years.  Her husband died three years ago and she has been living alone since his death.

You ask Helga if she would like to use a wheelchair for the tour.  She gladly agrees and tells you she slipped outside after the last snow fall and she is feeling a bit sore.  You casually ask Helga if she has fallen before and she states only a time or two in the last year.

As you are taking the tour, Helga recognizes a few people she knows from community activities. Helga tells you at the end of the tour that she would like more information about the next steps for moving into the facility.  Her son John smiles and says, “I am so relieved that you won’t be falling anymore.  They will take good care of you.”


The Facts…

  • One in four people 65 years of age and older fall each year.
  • Less than half of the Medicare beneficiaries who fell in the previous year talked to their healthcare provider about it.
  • Every 20 minutes an older adult dies from a fall.
  • 1 out of 5 falls causes a serious injury such as a head trauma or fracture.
  • Almost 2.8 million older adults are treated in emergency departments for nonfatal fall injuries each year.1


The Facts…

  • It is not uncommon for family members to believe that an admission to a senior care facility will protect their family member from falling again.
  • Many seniors and family members are unaware of the risk factors for falling and that the aging process may increase their risk for falls.
  • “Most falls are caused by the interaction of multiple risk factors.” The greater the number of resident risk factors, the greater their chance of falling. Some risk factors are modifiable.2

Clinical team members in senior care are in a unique position to support early recognition of senior fall risk factors.  To minimize the risk of falls, care providers should FIRST assess the risk of modifiable risk factors.3

■ Lower body weakness ■ Poor vision
■ Use of psychoactive medications ■ Difficulties with gait and balance
■ Postural dizziness ■ Problems with feet and/or shoes

Source (Adapted From): Centers for Disease Control and Prevention National Center for Injury Prevention and Control. STEADI – Stopping Elderly Accidents, Deaths and Injuries. Important Facts About Falls.  https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.  [March 18, 2018]


Clinically Pertinent Assessment…

Clinically pertinent assessment of resident risk factors involves assessment and interventions that support identified intrinsic and extrinsic risk factors.4

Intrinsic Factors Extrinsic Factors
Advanced age Poorly fitting foot wear
Previous falls Outside walkway with ice and snow
Gait & balance problems Not having eyeglasses, hearing aids
Muscle weakness Dim lighting or glare
Poor vision Obstacles & tripping hazards
Postural hypotension Slippery or uneven surfaces
Chronic conditions including arthritis, diabetes, stroke, Parkinson’s, incontinence, dementia Psychoactive medications
Fear of falling Improper use of assistive device

Source (Adapted From): Centers for Disease Control and Prevention National Center for Injury Prevention and Control. STEADI – Stopping Elderly Accidents, Deaths and Injuries. Risk Factors for Falls. https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf [March 18, 2018]

Boston Globe (January 19, 2016) Death at Wilmington nursing home raises new questions:

“Mary Meuse was all set to visit her family on Christmas. Two days later, the 83-year-old resident of Woodbriar Health Center in Wilmington was dead.  A certified nursing assistant using a mechanical lift to move Meuse from her bed to a wheelchair Christmas morning violated a cardinal safety rule, according to a former Woodbriar staffer and a report the nursing home filed with Massachusetts regulators.

Most mechanical lifts require at least two people for safe operation, according to the Food and Drug Administration. But the 21-year-old nursing aide, with no assistance, improperly placed Meuse in the lift, according to the report, and Meuse slipped out, crashed to the ground, and broke both legs. Meuse, who was on blood-thinning medication for heart problems, was not sent to a hospital until the next day. By then, she was bleeding internally. She died in the hospital Dec. 27.”5

Family seeks answers after man dies in nursing home he helped found

Walter Haddad was a well-known member of the community. He helped start the nursing and rehab center that eventually became his home.

One night, “he got up to use the bathroom, fell, and hit his head on the nightstand. But the staff, according to his family, did not call for medical help. Instead, they put Haddad, 87, back in bed. Thirty-six hours later, he was dead.”6

The Boston Globe cited state and national quality data regarding the facility’s performance as part of the article.

Kreisman Law Offices. (September 19, 2016). $586,600 Arbitrator Award in Assisted Living Facility Injury and Death Case:

“Violet Moseson, a 97-year-old resident of an assisted living facility, was mandated to be checked on every morning. The facility was to perform safety checks each morning for this resident and others. At the time of this occurrence, the electronic system through which the facility was supposed to communicate with Moseson was not turned on in her apartment when she moved in.

A week later, Moseson fell in her apartment at night. It was alleged that she spent the next 2-3 days trying to get help. There was a trail of blood and excrement in her apartment when a family member found her lying on the floor. Because of the severity of the fall, Moseson suffered spinal fractures, contusions as well as progressive dementia. Moseson died several months later…”7

Recommendations for Healthcare Providers…

  • Visit the Centers for Disease Control and Prevention, STEADI Stopping Elderly Accidents, Deaths and Injuries website for tools and resources for residents, families and healthcare providers. Some of the available tools include:
Algorithm for Fall Risk Assessments and Interventions Stay Independent Brochure
Safe Medication Review Framework Risk Factors for Falling
30-second Chair Stand Test 4-Stage Balance Test
Timed Up and Go (TUG) Test Measuring Orthostatic Blood Pressure

Source: Centers for Disease Control and Prevention National Center for Injury Prevention and Control. STEADI – Stopping Elderly Accidents, Deaths and Injuries. STEADI Materials for Health Care Providers. https://www.cdc.gov/steadi/materials.html (March 18, 2018).

  • Be informed about technology advancements including, but not limited to, motion sensor technology, wireless communications and smart appliances to support senior independence and safety.8,9
  • Ensure a formal process to manage expectations on admission (e.g., admission welcome letter) and during care planning meetings. Include language supporting proactive assessments and interventions for resident safety and partnering relationships. Introduce the concept of Shared Risk Agreements when resident and family choices are not in alignment with recommended care. An example of sample language, includes but is not limited to (consult legal counsel for facility specific language):

As people age, bones and muscles become weaker, skin integrity and circulation changes, vision declines, and balance becomes a problem.  This normal process of aging can increase the likelihood for a fall and fracture and other injuries.  (Facility Name) frequently assesses safety risks, including fall risk and implements interventions and precautions that are intended minimize the likelihood of an incident, but unfortunately, they still can occur.  Working together, we can minimize the risk of falls and accidents.

Please ask for help when you need it.  Our nursing assistants are assigned to care for several residents.  As a result, you may have to wait for short periods of time for assistance.  It is our goal to answer your call light as quickly as possible.  Staff also has been trained to anticipate resident needs whenever feasible.10

Recommendations for Care Team Members…

  • Perform a formal falls risk assessment including intrinsic and extrinsic factors on resident admission, re-admission from hospital or other inpatient stay, after an emergency room visit, quarterly, with significant changes in condition and medications, and immediately following a fall.
  • Ensure interventions/precautions support the level of identified risk and are accurately documented on the plan of care.
  • Consider new admissions, with risk factors, as high-risk for falls for a designated period of time (e.g., 72 hours or until acclimated to their surroundings).
  • Communicate daily safety awareness of resident clinical, equipment, and environment risks. Include the resident and family as part of regular safety conversations.
  • Ensure complete documentation of resident falls including assessments, monitoring, interventions, changes to the care plan, communication and documentation. Continue post-fall monitoring and documentation for 72 hours or until resolution of any injuries.
  • Establish a structured communication process for transfers and handoffs that includes fall risk and fall risk interventions (e.g., Morning Stand-Up Meetings)
  • Focus hourly rounding on meeting immediate care needs – Purposeful Rounding includes, but is not limited to:

o   Positioning

o   Pain Management

o   Personal Needs – (toileting, hydration, nutrition)

o   Placement of personal items within reach

o   Personal connection (e.g., I’ll be back to help you get to dinner in 30 minutes)11

Recommendations for Quality Assurance/Performance Improvement Committees…

  • Evaluate the accuracy of fall risk assessments (critical thinking based on resident clinical presentation) and selection of precautions/interventions to minimize resident risk, through the quality assurance and performance improvement process.
  • The Agency for Healthcare Research and Quality recommends the following outcomes measures for senior care facilities: number of falls each month, number of residents who fall each month, number of residents with two or more falls each month and number of falls with serious injury each month.11,12
  • Consider a “5 Why” approach when investigating/analyzing the contributing factors of resident falls. Example: Why did the resident fall out of the chair? – He was reaching for something; Why was he reaching for something? – He thought there was a bug on the floor.  Why did he think there was a bug on the floor? – He has been seeing bugs since starting a new medication.  Why was he started on a new medication? – He developed a urinary tract infection.  Why did he develop a urinary tract infection? – He has been drinking less. Why has he been drinking less?   Please note there may be a number of contributing factors for one patient fall including patient condition.


  1. Centers for Disease Control and Prevention National Center for Injury Prevention and Control. STEADI – Stopping Elderly Accidents, Deaths and Injuries. Falls are a Major Threat for Your Patients. https://www.cdc.gov/steadi/pdf/steadi_falls_major_threat_1in4-a.pdf (March 17, 2018).
  2. Centers for Disease Control and Prevention National Center for Injury Prevention and Control. STEADI – Stopping Elderly Accidents, Deaths and Injuries. Risk Factors for Falls. https://www.cdc.gov/steadi/pdf/risk_factors_for_falls-a.pdf (March 17, 2018).
  3. Ibid.
  4. Ibid.
  5. Lazar, K. Boston Globe (January 19, 2016). Death at Wilmington nursing home raises new questions. https://www.bostonglobe.com/metro/2016/01/18/death-resident-after-nursing-home-accident-raises-new-concerns-about-company/opPd0TMprgB21WN8Wmd6ZI/story.html. [March 17, 2018]
  6. Michael Levenson. Boston Globe. Family seeks answers after man dies in nursing home he helped found. https://www.bostonglobe.com/staff/levenson
  7. Kreisman, R. Kreisman Law Offices. (September 19, 2016). $586,600 Arbitrator Award in Assisted Living Facility Injury and Death Case. http://www.robertkreisman.com/nursing-home-lawyer/category/nursing-home-fall-cases/. [March 18, 2018]
  8. Aging Care.com Technology for Elderly Enhances Health, Safety. https://www.agingcare.com/Articles/techology-for-elderly-living-at-home-147427.htm [March 18, 2018]
  9. Sollito, M. Elder Law Associates. Technology for Elderly Enhances Health, Safety. http://elderlawassociates.com/news-eview.cfm?newsID=597&categoryid=110&pagenum=1 [March 18, 2018]
  10. GuideOne Admission Letter. http://www.goriskresources.com/NursingFacilities/Resources/index.htm. (October 13, 2016)
  11. Agency for Healthcare Research and Quality. Preventing Falls in Hospitals. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
  12. Agency for Healthcare Research and Quality. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention. https://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxman4.html
  13. Agency for Healthcare Research and Quality. The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities. https://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxman4.html






This blog, which does not reflect any official policy or opinion for Vaaler Insurance, Inc. or Siders Healthcare Consulting, LLC, is provided for informational purposes only. It is not intended to provide legal or medical advice, nor is it intended to be an exhaustive list of all risks that need to be addressed for a healthcare organization. While every effort is made to provide accurate information, changes may occur and inaccuracies happen despite best efforts. This information is not a substitute for individual consultations with professionals in these areas and should not be relied on as such. Please work with your legal counsel and business advisor(s) for a plan that is specific to your organization. © 2018 Vaaler Insurance, Inc.

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