Background

Community Nursing Home Pickering is a 233 bed long-term care home located in Pickering, ON, (Central East LHIN) and was in the first cohort of homes to join Residents First. The home's high rate of falls, particularly for a subset of residents who average more than two falls per month, drove the need for quality improvement (QI) in the area of falls prevention. One unit in the home, Maple, was identified as having the most frequent fallers.

Project Aims

Community Nursing Home Pickering's aim was to reduce the number of falls on the Maple unit by 50% from 12 falls per month to 6 falls per month by December 2010.

Quality Improvement (QI) Program

Project scope: 37 bed unit (Maple)

QI Team: Administrator, Director of Care, Clinical Nurse Specialist, Registered Nurse (1), Registered Practical Nurse (1), Personal Support Worker (3)

QI Program Actions:

• Incident report review to determine cause of falls.
• Defect checklist to identify frequency of causes (falling out of bed).
• Root cause analysis with day, evening, and night shift staff.
• Fishbone diagram to categorize the causes of falls and identify change ideas.
• Development of a poster to increase staff, visitors and family awareness and excitement of the home's goal to reduce falls.
• Implement and test change ideas using Plan Do Study Act (PDSA) protocols
• • Individualized care plans for frequent fallers
  • Visual cues for bed alarms
  • Change in staff work routines
  • Action plans for residents who self transfer and those who experience confusion and discomfort due to pain. 

Results

Community Nursing Home Pickering was successful in reducing the number of falls on the Maple unit by over 50% from 12 falls to 2 falls per month. Introduction of the frequent fallers individualized care plan and the revised break time schedules were instrumental in reducing the number of falls on the Maple unit. A "team" approach, front line staff engagement, and good communication to all staff and family about the fall reduction program were also important contributions to the home's success. Please see run chart below for further details.

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