A major goal of health care institutions is to promote a safe environment to enhance patient rehabilitation. A patient fall is regarded as an incident worthy of careful documentation, since it may indicate a failure to achieve this goal. In addition, documentation is necessary to determine any possible liability the facility may have for the occurrence of the fall. Not only do falls inhibit the patient's progress toward rehabilitation, they also are a cause for concern for nursing staff and administration of health care institutions as well as the patient's family.
Falls continue to be a leading cause of accidental death among the elderly. While those aged 65 or over account for only 10% of the population, they represent 25% of the nonintentional fatal injuries. The death rate from falls per 100,000 population for all age groups combined is 57. This increases to 93 in the 65-to-74-year-old age group and to 210 in the 75-to-84-year-old age group. For those 85 and over, the figure per 100,000 jumps to 625.1
Most falls occur at home because 95% of those 65 and over live in the community. The occurrence of a fall, and particularly a series of falls, even if no physical trauma occurs, causes stress for family members as well as the elderly person. The main fear is that the older person will be alone when he/she falls and will be unable to summon help if he/she needs it. Institutionalization is sometimes seen as a remedy for this problem. However, falls are also a hazard in institutions.2"5
Most falls do not result in death, but they are likely to cause some disability or discomfort to the older person. Moreover, even minor falls that do not result in physical injury can undermine the elderly person's sense of self-confidence and accentuate his/her level of immobility. Patients feel fearful of risking a serious injury such as a fracture if they try to be mobile. The psychological damage as well as the physical damage from falls is of concern.
While previous studies have addressed only the incidence and environmental circumstances surrounding fall episodes, more recent literature has pointed to the possibility of a positive relationship between changes in previously stable, diagnosed conditions or the development of new conditions and the onset of a pattern of falls.6-8 Should such a relationship be established, the inclusion of a history of falls would be necessary assessment data when doing health screening for elderly populations. The self-report of a history of falls also would serve as an indicator that further definitive diagnostic evaluation is warranted.
STUDY PURPOSES AND METHODS
This study was initiated to document circumstances surrounding the occurrence of falls ina long-term care facility by analyzing incident reports. It was expected that if specific factors emerged repeatedly as contributing factors to fall occurrences, a more effective safety program should be established to lead to a reduction in the number of patient falls. In addition, the investigators were interested in collecting data about any changes in the physical and/ or mental status of the fall population that might add support to recent literature about falls as an indicator of a change in health status.
SELECTED CHARACTERISTICS OFFALL POPULATION COMPARING SURVIVORS WITH THOSE WHO EXPIRED
The study was conducted during an eight-month period in a 129-bed long-term care facility. The average daily census during the period of study was 122. An epidemiologic framework was used to examine the variables related to fall occurrences. This framework was considered useful in organizing data around host or patient factors, environmental considerations, and agent factors.
Incident reports completed by nursing staff on all falls were examined by the investigators during the study period. The incident reports asked for documentation on the following environmental factors: location of fall, time, day of week, staffing pattern, and obvious environmental contributing circumstances such as wet floors, poor lighting, or faulty equipment. Patient or host factors of age, sex, mental status, ambulatory status, and number and types of diagnoses were noted, as well as agent factors of chemical and /or mechanical restraints. A summary description of the nature of the fall as obtained from the patient or staff member and the presence or absence of objective signs of trauma were recorded. In addition, an examination was done by a geriatric nurse practitioner to determine the extent of injury, to assess any recent changes in the patient's physical and/ or mental level of functioning, and to initiate any necessary treatment.
Two hundred-fourteen falls involving 61 different residents were recorded during the survey period. A range of from 1 9 to 36 falls per month was recorded. The average number of falls per month was 26.8. Fourteen men and 47 women were represented in the study population. Their age range was from 59 to 95 for women and 71 to 88 for men. Their average age was 84 and 80 respectively. The largest number of falls occurred among the 21 persons in the 80-to84-year-old age group. They accounted for 99 or 46.3% of the total number of falls while representing only 34.4% of the study population.
An average of three diagnoses was recorded for each of 61 fall victims with the range being from one to more than seven. The most frequently reported diagnoses were as follows: cardiovascular disorders, 57%; cerebrovascular disorders, 40%; musculoskeletal disease, 40%; neurological disease, 29%; psychiatric problems, 20%; and respiratory illnesses, 19%.
Of the 61 patients in the study, 18 persons fell only once while 19 fell two times. The remaining 24 persons or 40% of the study group fell three or more times with one elderly male falling a total of 20 times. The percentage of falls was evenly distributed between the number of men and women represented in the study. That is, 77% of the falls occurred among the 47 women in the sample while 23% of the falls occurred among the 14 men.
Eighty-four percent of the falls resulted in no observable injury but, of the other 16%, eight falls resulted in abrasions, 14 in contusions or bruises, six in lacerations, and five in fractures. During the study period, four men and 10 women or 24.8% of the study population expired. This represents 41% of all deaths that occurred during the eight-month study period in the entire facility. The average age of those patients who expired was 79 for men and 87 for women. The average number of times falls occurred in the group of patients who expired was 2.8%. Only one person, a 90-year-old woman, died within two days after falling from causes determined to be directly related to a fall in which she sustained a fractured pelvis. Four other persons died within 48 hours after their last fall; however, none of the falls were reported to have caused any objective evidence of injury. Death was attributed to rapidly deteriorating preexisting pathologic conditions.
A comparison of selected characteristics of those in the study population who died and those who survived is shown in the Table. Only 1 1 out of the total study population were taking psychotropic drugs; however, those who expired were almost three times as likely to be taking these drugs as those persons who remained alive at the end of the study period (p< .05). In addition, as indicated in the Table, restraints were more likely to have been ordered for these patients when the fall occurred. No accurate count could be obtained regarding how many patients actually had their restraints applied at the time of the fall. Further analysis of the data revealed the mental status of all five patients who were taking psychotropic drugs prior to expiration was either impaired or confused and disoriented (p<.01).
Environmental information also was recorded. The bedside was found to be the most hazardous location for falls. One hundred thirty-one, or 61% of the falls occurred at the bedside. When other areas in the room were added this accounted for 77.6% of all falls. Other locations for falls were: hallway 11 (5.1%); bathroom 31 (14.5%), and outside 6 (2.8%). As shown in the Table, all but one fall episode occurred within the room for those patients who expired during the study (p<.05). The 47 persons who remained alive through the study period sustained almost onethird of their falls outside their room.
All shifts were included in the study. Eighty-four falls, or 39%, occurred during the day shift while 83 (28.6%) and 47 (22%) occurred on evening and night shifts respectively. Of the 16% who experienced a fallrelated injury, nine or 27.3% occurred during the night shift. Figure 1 shows the percentage of falls and related injuries for the three shifts. Although almost the same number of falls occurred on the day and evening shifts, the percentage of fall-related injuries during the evening shift was almost twice that of the day shift. In addition, while the incidence of falls was lowest during the night shift, the percentage of injuries equaled that of the day shift. This finding points to the need for additional night-time supervision of patients.
PERCENTAGE OF FALLS AND INJURIES OCCURRING ON EACH SHIFT
Falls occurred at all hours of the day and night and were recorded to the nearest hour. Although the distribution of falls was fairly even throughout the 24-hour period, the least falls occurred at 1 2 PM and 3 PM. Ten o'clock in the morning and 8 PM were found to be most frequent fall times. Each of these hours had 22 falls recorded. As shown in Figure 2, the combined times of 9 AM, 10 am, and 1 1 AM and 6 PM, 7 PM, 8 PM accounted for 43% of all falls. These hours are likely to be when most feeding, bathing, toileting, and prebedtime activities occur; however, 10 am and 8 PM also represent break times for the staff, which then leaves fewer staff members present in the patient area for surveillance and patient assistance activities. Fall-related injuries occurred more often after 5 PM and before 7 am. Four out of the five fractures occurred between 9 PM and 2 AM during mid-week. Most often, the reason for the fall was associated with attempting to get up to go to the bathroom.
PEAK FALL TIMES
A physical examination was conducted by a geriatric nurse practitioner on each of the fall victims to determine the extent of fall-related injuries and to investigate the possibility of the fall occurring as a result of a change in health status. While most examinations were negative, two patients benefited directly and dramatically from this procedure. In the first case the examination led to the diagnosis and treatment of macrocytic hyperchromic anemia in a 90year-old female patient. After treatment was instituted this patient's frequent fall pattern was reversed. In one other case a 62-year-old Parkinsonian was referred for a neurological re-evaluation because of increasing frequency of falls. The recommended treatment of Symmetrol 200 mg per day has resulted in a marked stabilization of her gait with decreased rigidity and propulsion. It has produced a decrease of from several falls per month to less than one fall per month.
In comparing this study population with other studies done on fall episodes among long-term care patients, the incidence of falls was higher than that found by Rodstein,7 who recorded 146 falls among 96 patients during a six-month period, or Kalchthaler,4 who reported 190 fall incidents among 189 residents during a three-month time period. This discrepancy may be due to the differences among agency regulations of what constitutes a "fall." In this study, any abrupt involuntary change in body position from vertical to horizontal or to sitting was considered a fall. However, the number of fall-related injuries was considerably lower than that reported by Rodstein or Kalchthaler. A comparison of variables reported in other studies and the present study reveal remarkable similarities in age, sex distribution, number and types of diagnoses, location of fall, and mental status characteristics.2-5'7"9
Characteristics of the fall group who died during the study period differed most from those 47 who were alive at the conclusion of the study in three aspects. They were more likely to be taking psychotropic drugs, have impaired or disoriented cognition, and have restraints ordered to be applied either when up in a chair or as needed for agitation. Without further study it is not possible to determine the implications of these findings. However, extra surveillance is warranted for these patients because of the patients' inability to communicate their needs clearly to the staff. In addition, frequent professional nursing assessment should be done to monitor subtle changes in the patients' conditions.
It is not surprising to find the highest incidence of falls occurring in patients' rooms, since it is probable that they spend the greatest amount of time there. However, it does underscore the need for consistent surveillance of patients' rooms by staff. It also may point to the need to ensure that furnishings do not slide or tip when patients place their weight against them as a form of support.
Peak times for fall episodes corresponded with greatest patient and staff activity time, but also included the morning and evening staff break times. Staggered break times for staff may decrease the incidence of falls during these most hazardous times by increasing availability for surveillance.
Important points to emphasize to staff when discussing patient safety include:
1. Assessment of the patient on admission for a history of falls.
2. Continual surveillance, specifically when patients are most active, during the morning and prior to bedtime.
3. Prompt answering of lights.
4. Extra surveillance of confused patients, especially those who are taking psychotropic drugs.
5. Practice in the proper application of restraints. Restraints should not become a substitute for frequent patient/ staff contact, however.
6. Use of a bedside marker or tag identifying the particular patient as possessing a history of falls. This could serve to alert staff who are unfamiliar with that particular patient's background to increase surveillance.
7. Thorough physical assessment of the patient after a fall to determine if the fall may be related to a change in health status.
Finally, those nursing home patients who are alert should be instructed regarding possible hazards in their environment. This might be included as part of their orientation to the facility. In addition, they should be encouraged to report episodes of diarrhea, increased dizziness, vision changes, or changes in strength to staff, rather than simply attributing these changes to the aging process.
This study represents the first systematic analysis of falls for this long-term care facility. As such, it provided data on various population and environmental characteristics that will be useful in designing a patient safety program and determining its effectiveness. Second, some initial differences were found between those patients who fell and were alive at the conclusion of the study, and those who fell and expired, although population numbers were too small to draw specific conclusions from the data. Third, although a high percentage of the fall population sustained no physical trauma, no data were collected on the psychologic effect the falls had on patients. This important area needs further study.
- 1. Waller J: Injury in the aged: Clinical and epidemiological implications. NY State J Med 1974; 74: 2200-2208.
- 2. Gould G: A survey of incident reports. Journal of Gerontological Nursing 1975; 1:23-26.
- 3. Pablo R: Patient accidents in a long-term care facility. Can J Public Health 1977; 68: 237-247.
- 4. Kalchthaler T, Base ? ? RA, Quintos V: Falls in the institutionalized elderly. J Am Geriatr Soc 1977; 27: 424-428.
- 5. Feist R: A survey of accidental falls in small home for the aged. Journal of Gerontological Nursing 1978; 4: 15-17.
- 6. Cape R: Aging: Its Complex Management. New York, Harper & Row, 1978.
- 7. Rodstein M, Camus A: interrelation of heart disease and accidents. Geriatrics 1973; 28: 87-96.
- 8. Freed DE: An investigation into circumstances surrounding falls of institutionalized aged persons as described by the person and staff present at the time of accident or first at site after accident. Master's thesis. University of Washington. 1974.
- 9. Schested P, Severin-Niekon T: Falls by hospitalized elderly patients: Causes and prevention. Geriatrics 1977; 32: 101-108.
SELECTED CHARACTERISTICS OFFALL POPULATION COMPARING SURVIVORS WITH THOSE WHO EXPIRED