Skilled Nursing Facility Falls

Jonathan Feinberg, MD – Family Medicine (Geriatrics)

Falls among patients in Skilled Nursing Facilities (SNF) are an all too common occurrence.  Causes can generally be classified into four broad groups:

1. Patient characteristics
2. Medical care planning by physicians
3. Nursing care
4. Environmental factors

Prevention entails:

1. A detailed medical evaluation and plan upon admission including diagnostic tests to identify patients at an increased risk for falls with special attention to medications or combinations of medications
2. Assessment by licensed nursing staff to create an ongoing care plan, follow-up meetings by members of the care giving team, efficient and readable chart systems which facilitate communications between shifts and regular team meetings to generate progress reports and make changes in the plan when indicated
3. Facility maintenance, strict adherence to applicable codes and effective and efficient response to deficiencies when found by state or federal inspectors

Patient Characteristics

By definition, almost all patients who require SNF care have significant restrictions of functional performance related to their activities of daily living. Many of the disease state syndromes that demand removal to a SNF create significant risks of falling. These syndromes include dementia, weakness, stroke, visual disturbance, night-time confusion, orthopedic limitations that produce dysfunctional ambulation and balance problems. Many of these can be aggravated by medications such as those used to treat high blood pressure, which can cause dizziness and momentary decrease in consciousness due to orthostatic hypotension on arising. Other common medications associated with falling are pain medication, many psychotropic drugs used to treat behavioral outbursts due to dementia and diabetic medications, which can cause excessive lowering of blood sugar.

Treating physicians have the responsibility to take these potential risks into account when planning care for their patients upon entering a SNF. Periodic visits to the facility to reassess patients’ progress is essential. Physicians must either be available themselves or provide on-call 24/7 coverage to respond to urgent or emergency situations or concerns of nursing staff.

Nursing Care

The nursing care plan must provide for ongoing assessment to evaluate risk factors and the facility should have clear protocols for reducing fall risk in general and individualized plans for each patient. In the latter category would be included such things as bedrails, lowering the bed so that if a patient does fall out of bed the possible injury will be lessened, properly functioning walkers, geriatric chairs and other restrictive devices where indicated. Incident reports can provide information as to overall frequency and possible remedial needs.

Environmental Factors

Floors must be kept dry and non-slippery. Corridors and rooms must be well-lit during the day. High toilet seats and grab bars in bathrooms and halls are ancillary design characteristics to prevent falls. Ambulatory patients must have appropriate footwear

Medical-Legal Considerations

Falls in SNFs are an important factor in generating plaintiff actions. It is noteworthy that a traumatic event in an individual who is already compromised by significant illness and dysfunction may start a cascade of complications that leads to accelerated decline and often premature demise. This frequent series of sequelae often occurs even if the specific injury caused by the fall is successfully treated. What may seem to be a relatively trivial injury in a well person can be catastrophic to a SNF patient.