Falling – from a bed, in the bathroom, out of a wheelchair – is one of the biggest fears for nursing home residents, their families and staff.

And for good reason. A fall often injures a person and sparks a decline from which recovery is difficult. Just a few years ago, Oklahoma was ranked 48th in the nation for nursing home falls with major injury. Nearly 50 percent of nursing home residents fall within the first 12 months of moving in. If a person has fallen once, he or she is twice as likely to fall again.

While it may not be possible to eliminate all falls, it is feasible – and crucial – to greatly reduce their number. The University of Oklahoma Fran and Earl Ziegler College of Nursing is a leader in that effort, through a falls prevention program in partnership with the Oklahoma State Department of Health.

“A key part of our mission is to provide professional nursing services throughout Oklahoma and beyond and to create a better quality of life for people who live in nursing homes,” says Gary Loving, Ph.D., RN, interim dean of the OU College of Nursing. “Falls are a significant risk for elderly individuals, particularly those with disabilities and chronic illness. Through this program, we can help decrease those risks.”

The program, called “It’s Not OK to Fall,” introduces evidence-based falls prevention strategies to nursing homes across Oklahoma. The program recently ended its three-year research pilot phase, during which nursing homes that incorporated the strategies decreased their rate of falls by up to 50 percent. The program is now moving into its implementation phase.

The funding for “It’s Not OK to Fall” comes through the Civil Money Penalties program. When nursing homes are fined, that money goes to the Centers for Medicare and Medicaid Services, and part of it returns to the Oklahoma State Department of Health, where it can only be used for quality improvement projects that help residents of nursing homes. The Department of Health administers funds for “It’s Not OK to Fall,” which was recently awarded a $1 million grant renewal.

OU College of Nursing staff members Teri Round, M.S., RN, and Diana Sturdevant, Ph.D., RN, led the group that organized “It’s Not OK to Fall.” The program focuses on three primary areas to reduce falls: better sleep, hydration and strengthening for residents. 

Traditionally in nursing homes, employees check residents every two hours during the night, often repositioning them, prompted by the belief that it will prevent skin breakdown. However, that also means people cannot sleep more than two hours at a time. Current research shows that multiple factors are linked to wound prevention, including better nutrition, managing incontinence and enhanced sleep surfaces to reduce pressure. In addition, modern mechanics, such as low air-loss beds, can be useful in reducing pressure.

“The evidence shows that if you let people sleep six or more hours a night, they don’t fall as much,” Round says. “There are other benefits as well. When people sleep better, they tend to eat better during the day because they’re not falling asleep over their meals. And they’re more engaged in their activities, such as physical therapy.”

Staying hydrated is another important element of preventing falls. Nursing home staff encourage their residents to drink adequately during the day, and to make the water more appealing, they fill dispensers with fruit or vegetables to add flavor. Improving hydration often leads to better sleep at night.

Strengthening muscles and improving balance is the third major element of falls prevention. The program introduced a form of tai chi to nursing homes so that residents could participate in a low-impact exercise that has been demonstrated to improve balance. Strengthening also involves teaching “toilet squats,” or raising and lowering oneself over the toilet. This strengthens leg muscles and can reduce residents’ fear of falls.

“When people feel like they might lose their balance and fall, that makes them exercise less, which then makes them more likely to fall,” Round says. “Everything works together negatively.”

However, the strategies must be used in connection with a comprehensive falls assessment of each nursing home. The assessment takes into account the physical layout of the nursing home, from the parking lot to the individual rooms. When a resident does fall, a root cause analysis is performed. This teaches the staff to investigate the specific cause of the fall and develop meaningful interventions, rather than simply keeping track of the number of falls.

By incorporating the program’s strategies, Tuscany Village Nursing Center in Oklahoma City saw a significant decrease in the number of its residents falling. In one month, it decreased the number of falls from 48 to 25. That helped to spur the improvement of its quality measures from a two-star to a five-star facility, as measured by the Center for Medicare and Medicaid Services. Tuscany is home to 120 people.

The facility began by involving everyone in the goal of reducing falls, from the nursing staff to aides to housekeeping and maintenance personnel. Some residents’ rooms needed extra decluttering to remove tripping hazards. Residents who use wheelchairs received a non-skid adhesive on the seat to prevent sliding.

“This project really brought the staff closer together because we worked out situations together,” says Tuscany Village administrator Astrid Chatham. “Non-medical staff may think that they can’t contribute, but they can, much more than they think. In that regard, this program brought our staff together and empowered them to make a difference.”

Tuscany Village also incorporated a strategy of reviewing each resident’s medications and the times they are administered. As a matter of routine, they were giving residents their pills every six hours in a 24-hour period. But after consulting with physicians, they realized some medicines could be given in the morning rather than during the night.

“Once you wake a person up, they’re awake and they start getting up,” says Vickie King, assistant director of nursing at Tuscany. “Once we reworked the medication schedule to allow more of our residents to sleep through the night, we saw a decrease in falls.”

“It’s Not OK to Fall” brings new research evidence into daily nursing home care. It’s easy to simply carry out daily duties the way they’ve always been done, Sturdevant says. The program teaches nursing home staff proven strategies, as well as the importance of viewing each person’s fall risk individually.

“You have to personalize the situation for each resident,” Sturdevant says. “It is a person-centered care model.”

April Wilkerson is a writer for OU Medicine on the OUHSC campus.

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