P006: Office of Facilities Management (FY18 Parent)

P006: Percent of long-term care residents experiencing one or more falls with major injury

Definition

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Story Behind the Curve

Falls are common in long term care facilities and are a major safety concern for long-term care facilities.
While not all falls and injuries can be prevented, it is critical to have a systematic process of assessment, intervention, and monitoring to minimize fall risk.
Falls data are aggregated across the two New Mexico Department of Health long-term care facilities: New Mexico Behavioral Health Institute and Fort Bayard Medical Center. The Fiscal Year 2018 data is as follows:
- Quarter 1 Percentage of residents sustaining a Fall with Major Injury: 1.75%.
- Quarter 2 Percentage of residents sustaining a Fall with Major Injury: 2.55%.
- Quarter 3 Percentage of residents sustaining a Fall with Major Injury: 3.77%.
Every new resident is assessed for fall risk. This assessment is then included in each individual residents' care plan, contributing to the success of this measure. However, it is a significant challenge to balance each resident's need for independence with the inherent risk for falls. While the overall outcome for 3 quarters (Year to date) is within the goal of 3, there is an increase in the quarterly outcomes each quarter with quarter 3 exceeding the goal.
Individual facilities, and treatment teams within the facilities, evaluate every fall to help determine the root cause of the fall and then incorporate interventions such as closer observation, assistance with transfers, etc. into the treatment plan. A request for further analysis and action plans will be made to the Long Term Care facility Falls Prevention Teams.

Partners

HealthInsight New Mexico, the Centers for Medicare and Medicaid Services contracted Quality Improvement Organization for New Mexico
The Joint Commission on Accreditation of Healthcare Organizations
New Mexico Department Of Health, Division of Health Improvement
Governing Body for facility oversight
Centers for Medicare and Medicaid Services provided CASPER Reports
LTC Facility Falls Prevention Teams

What Works

Education of employees, residents, and family members has demonstrated some success in being able to protect residents.
Close observation continues to be our best method of preventing falls in nursing home settings.
Therapy services that focus on strengthening individuals, and assist in preventing falls by improving balance and mobility.
Individualized resident treatment planning following any fall assists in prevention efforts.

Strategy

Ensure that Skilled Nursing Facilities have active Falls Prevention Committees. Both facilities continue to hold these meetings on a regular basis.
Monitor that Falls Prevention Committees are analyzing causes of falls and are taking appropriate actions to prevent future falls. This is the major focus of these teams and these efforts continue.
Track quarterly outcomes of each facility as well as aggregate data to determine improvement or lack of improvement.

Action Plan

Quarter 1: Ensure active Falls Prevention Committees will hold at least 1 meeting per quarter. Ongoing.
Quarter 2: Falls Prevention Committees will document actions being recommended and implemented to reduce the number of falls (documented in minutes). Ongoing.
Quarter 3: Treatment teams of facility units will voice interventions being implemented locally to help reduce the number of falls. Over the first 3 quarters of Fiscal Year 18, there is an increasing trend in the percentage. A request for further analysis and action plans will be made to the Long Term Care facility Falls Prevention Teams. Ongoing.
Quarter 4: Encourage employees to participate in falls prevention activities and bring new suggestions and ideas to the committee.

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