How Compliance Committees Can Spot Hidden Fall Risks In Nursing Homes

We build on fall prevention and root cause analysis by asking compliance committees to take a deeper look at resident falls through targeted audits. We share two practical tools to guide record reviews, surface contributing factors, and strengthen a culture of safety and readiness across the whole facility.
• Building on prior fall prevention conversation and resident experience
• Using compliance and QAPI as an extra set of eyes
• Auditing records for missed root cause signals
• Focusing reviews on high fall risk residents
• Investigating residents with frequent falls for patterns
• Using the AHRQ On-Time Falls Prevention worksheet
• Checking whether staff training is enough to mitigate falls
• Using the Alliant Health Solutions fall prevention toolkit
• Looking beyond the fall to behavioral health and other changes
• Treating fall prevention as an interdisciplinary team responsibility
• Reinforcing survey readiness through consistent practices and engagement
I want you to take a look at those blogs

Transcript

Welcome And Prior Episode Context

SPEAKER_00 0:00

Welcome to Vital Compliance Insights. This episode, I'm going to build upon the prior episode where I interviewed Janine Earwood, physical therapist, healthcare analyst. We talked about fall prevention among residents in nursing homes. She did a great job at talking about the experience that residents may have where they fall. She talked about the importance of root cause analysis. Okay. But today I want to build on the component of audits. I want to ask the compliance committees out there to dig in a little deeper as to what's going on related to resident falls. I know DON's, nurses, nursing assistants are very busy on the floor providing care. So we're going to need another set of eyes to come in here, and that's the compliance committee, the quality assurance folks, to come in and say, wait a minute, we're going to just take some resident records. We're going to take a look at those to see what are we missing? Are we missing anything in our endeavor to identify root cause analysis that where it contributes to a residence falls? Now, we certainly don't want residents falling and experiencing major injuries, but we want to look at those residents that are, first of all, high risk for falls. Okay, we know who they are. After we've conducted our comprehensive assessment, we can identify who they are. Okay, so we have a population identified. Second thing is we know we can identify residents that have frequent falls. Okay. So why is this particular resident falling so frequently? And when, why? There's so many key components to analyzing this. So if so if we know these things are true, then what we want to do is ask the compliance committee to come in and do some audits. Now, what I will do is on the Verity Consulting website, I will add a couple of documents for your review and reference. I think they're very helpful and they really can at least stimulate some thinking about angles that you may not have considered in a facility when you're looking at residents who are experiencing falls. So the first one is from the Agency for Healthcare Research and Quality. It is a document titled On-Time Falls Prevention. And it's a self-assessment worksheet, and it goes through quite a bit. I can't remember how many pages, 16 pages total. And what I like about it is it really takes you down the path of looking at the risk assessment. What's the plan that we put into place? It talks about root cause analysis to help start to dig in a little further. And so, with that, you're gonna want to take a look at that. And oh, the other part that I want to mention is the training. It stimulates some thinking about have we done enough training about m measures to mitigate falls for our residents? Okay, so take a look at that. I'll put it on the website. And the other document that I want to make reference to, it is uh now the other document that I like that I'm making reference here to is it's a fall prevention toolkit. And and I know there's a lot of those out there in the world. One I particularly like, um it was produced by the Alliant Health Solutions. It was a quality innovation network organization that did some work for the CMS in 2023. So they developed this quality improvement initiative worksheet. And I like it because it's set up in a very simple format to help walk a person through a team through to conduct some fall, the incidents of fall, occurrences in a facility, what's going on with a particular resident. And it takes you through all these steps to try to analyze a little further on what's going on with the resident. And I like it because it doesn't just look at why did the resident fall, but are there any other kinds of contributing factors like behavioral health, maybe some other things that need to be looked at hand in hand along with the fall itself. What else is happening? It might not just be the fall, it might be some other changes that are occurring with the resident as well. So I'm gonna put that on the Verity team website under the blogs for you as well. Okay. The point here I'm getting at is it really does bring into focus the fact that we have high-risk areas in our nursing facilities, residents who fall. I've talked in previous episodes about antipsychotic medication use. So this is a good, these are some tools, I should say, just to help stimulate some thinking about what you can do to analyze the compliance committee can do to further analyze levels of risk in the facility and put together some approaches to audit to make sure we're not missing things. Because sometimes when you start digging through these, you really find out there there could be some unexpected surprises during the course of the review. So, with that goal being to keep residents safe at all times, as to the extent that we can possibly do so. So I want you to take a look at those blogs. I'll put them on the Verity team website, those two documents there. And I just want to wrap up and underscore the importance that this is an interdisciplinary team issue. And we need folks that are engaged and willing to really ask some hard and key questions so that we can all move in the right direction of providing the highest quality of care. And I really want to add that, you know, it's kind of like in my past life, we always talked about survey readiness or whatever, you know, to be ready, to have a sense of we're prepared to look at our environment of care and make sure our practices are in place, that everybody knows what they're supposed to do at all times. And for the all levels of administration, the compliance folks, the uh vendors, the therapy vendors, if you have a vendor, or maybe it's an in-house therapy, that everybody's engaged with the same goal in mind is to make sure we have a culture of readiness and safety, and we're all all hands on deck to make sure we're we're all doing everything we can to keep our residents as safe as possible. So I'm gonna wrap this up. Thank you for listening today to this episode, and stay tuned for more episodes.