By Elizabeth George

Thirty seconds is a long time when you’re on the high side of high-intensity interval training.

Thirty seconds is a very long time when you’re enduring pain.

And, 30 seconds can feel like an eternity when your baby is screaming on a crowded airplane. 

But it’s not a long time for a caregiver to enter a room in which a memory care resident is relaxed in a recliner, gather her clothing from her drawers, and lay them on her bed before rousing her from a light sleep and prompting her to stand. Immediately after, this particular resident slid to the ground.

What caused this fall?

Laura Hastings, Director of Care Services for SafelyYou (a Senior Living Foresight partner) reviewed the video showing the fall incident and shared her analysis.

“The caregiver in this situation did a lot of things right. She was organized and well prepared to get the resident ready for the evening. What she missed was the opportunity to sit eye-to-eye with the resident and communicate to her what was happening and what she needed from the resident. When the resident began to stand at the care-staff’s urging, she wasn’t supported strongly enough for the transfer. The transfer process was too rushed to be done safely.” 

SafelyYou refers to this type of incident as a “witnessed fall”. That’s when a resident has an unintentional fall in the presence of care staff. Based on observations of thousands of falls in memory care, SafelyYou estimates that 10% of falls are witnessed by another person. In addition, 60% of those with a witnessed fall will have at least one unwitnessed fall.

Analyzing and identifying categories of fall events has enabled SafelyYou to help its client communities develop personalized recommendations that are reducing falls with memory care residents and decreasing related ER visits. SafelyYou is sharing data and insights with the industry about types of falls, their causes, and what can be done to reduce them.

A look at a subset of this data reveals the top cause of witnessed falls. The main cause?  Resident transfers.

Specifically, of those witnessed falls related to transfers:

• 82%: staff underestimated the support they needed
• 36%: mobility aid was used incorrectly
• 34%: related to challenging behaviors
• 19%: staff were cueing residents before staff were ready

Recently, SafelyYou took a deeper dive into their data looking for insights into additional barriers that contribute to witnessed falls. Here are the top five, along with a few of the constructive actions that their client communities are taking to address them:

1. Time restraints: Care staff, particularly in communities with low staff-to-resident ratios, may feel pressure to get things done quickly to meet resident needs causing them to rush through transfers.
   
   Action: Try to rebalance staff workloads as needed and where possible, so staff have adequate time to facilitate safe resident transfers. Do your best to stay attuned to staff needs, keep an eye on when the team might be feeling overworked and encourage them to speak up when they feel overwhelmed.
   
2. Staff turnover: Staff members working so intimately with residents get to know them and learn helpful information about their health conditions, like which side of their body is strongest or weakest. When these caregivers leave their jobs, these seemingly small but consequential details often get lost.
   
   Action: Capture as much information as possible on a resident’s care plan. Be proactive about facilitating communication between departing care staff and those assuming responsibility while those leaving are still with your organization. Details matter.
   
3. Staff reluctance to impose on co-workers: If the care plan specifies a one-person transfer, staff may be reluctant to ask a co-worker for help which may put them at risk for injury. As Laura Hastings says, “care staff may feel they need to get the task done on their own and know their co-workers are just as busy as they are”.
   
   Action: Reinforce the message that safety comes first and encourage staff members to ask for and accept support from co-workers when needed for transfers. Create a culture of teamwork and recognize positive behaviors when you see them.
   
4. Change in resident status: Health status of residents, particularly those in memory care units, can change instantly. Says Laura, “Anyone attending to memory care residents has to be really present with them to detect the subtle changes that can render care plans obsolete in a short space of time.”
   
   Action: Capture and communicate changes in transfer status and resident-specific guidance with all care staff as quickly as they are identified. Update care plans regularly.
5. Census change: Senior living demographics can change quickly, not only for staff but also for residents who are not yet known to care staff looking after them. One person’s risks are not the same as another’s.
   
   Action: Building a relationship with a new resident can take time. Learn as much as you can upfront about your resident and reinforce during training that good communication with residents ahead of and during a transfer is just as important as good technique, especially when a relationship is new.

Even with the best of preparation and skill, falls will happen. Encourage your team to take a proactive approach to post-fall learning so they can better protect the resident from future risk. Spending a few minutes thinking about root cause can mean the world of difference.

Have you had success with reducing witnessed falls in your community? We’d love to hear your tips in the comments section.

Thirty seconds can seem like an eternity in certain circumstances. But sometimes it’s worth taking a little bit more time to make sure that your residents and staff are supported and safe. 

To read how SafelyYou helped reduce falls by 31%, download their whitepaper.