Falls in the Nursing Home

Falls are a leading cause of injury and death in the nursing home setting. Complications from falls can be serious and include broken bones, bruises, limited movement, and brain injuries. If an elder has a history of falling, there is a good chance he or she will fall again. An elder who fears further falls and injury will limit mobility, leading to loss of muscle tone and balance, which makes the risk of falling even greater yet.

What are some risk factors that make elderly patients at risk for falls?

  • Polypharmacy (multiple medications)
  • A previous fall
  • Irregular heart rhythm
  • History of a stroke
  • Parkinson’s disease
  • Dementia (ex. Alzheimer’s disease)
  • Acute illness (such as a urinary tract infection or pneumonia)
  • Depression
  • Bone and muscle deformities
  • Difficulty walking
  • History of broken bones
  • Bowel or bladder incontinence
  • Dizziness, especially when moving from a sitting to standing position
  • Use of restraints
  • Low blood sugar
  • Dehydration
  • Seeing or hearing impairments

What are some medications that may increase the risk for falls?

Medications used to treat depression, seizures, Parkinson’s disease, anxiety (ex. Ativan and Xanax), psychosis, and pain may increase the risk for falls. The use of diuretics (water pills) can increase the risk for falls due to the side effects of dizziness and dehydration.

What are some things I can look for when visiting a nursing home that may increase the risk for falls?

  • Dim lighting
  • Poor or weak seating surfaces
  • Glare on walls and floors
  • Use of full-length side rails on beds
  • Uneven flooring
  • Loose carpet or throw rugs
  • Walkers and wheelchairs that are in poor repair
  • Wet or slippery floors
  • Elders wearing inappropriate footwear, such as open backed slippers or shoes that do not fit appropriately
  • Lack of safety railings in bedrooms and hallways
  • Malfunctioning emergency call systems
  • Lack of grab bars in bathrooms
  • Bed side rails and other restraints were once thought to protect residents from falls, but newer research shows that they may actually contribute to falls because elders may crawl over side rails, producing greater injury than if the side rails were not in place. Residents have also been fatally injured with the use of physical restraints, and their use decreases movement enough that pressure sores and decreased mobility may become an issue. The best “restraint” is monitoring by staff. Sensor cushions or nurse alerts that sound when a person rises from a bed or chair are helpful to alert staff of the need to assist a resident.

What are some things I should look for that would show me the nursing home is working to prevent falls?

  • Edges of stairs painted in bright colors to help with depth-perception problems
  • Well-maintained hand rails installed at a proper height
  • Highlighted light switches
  • Grab bars on toilets and tubs
  • Elevated toilet seats
  • Furniture positioned in non-obstructing patterns
  • Visibility of staff, reflecting adequacy of staff
  • Chairs with side arms

If your loved one falls in the nursing home, what are some things you should look for as possible causes besides those already mentioned?

  • Make sure the bed position is at the lowest level. Staff members tend to raise beds to make them or give resident care, but may forget to put them down. This could lead to a fall because a resident may have trouble getting into a raised bed, or if in bed, may try to stand when his or her feet do not touch the floor.
  • Is your loved one hearing and seeing adequately? If not, ask for an eye or hearing examination. Also, check to see if glasses are clean and if hearing aids are working (make sure the batteries are not dead).
  • Ask for physical therapy to evaluate for the need of muscle-strengthening exercises or the need for assistive devices (or modification of those currently being used).
  • If your loved one is ambulatory and incontinent of urine, find out how often he or she is being toileted.
  • Exercise the use of the call light. Turn it on and find out how long it takes to be answered. Unanswered call lights are a common cause of falls.

Resources
AGS CPG for all patients (long term care and outpatient/community).
American Medical Directors Association.
AMDA CPG for Falls and Fall Risk specific to nursing home residents.
Dimant J, Kaplan N, Finkelstein R., Gearhart, SA Proceedings of NYOAS Best Practices Conference on Promotion of Mobility Independence in Long-Term Care Facilities, New York State Department of Health and Hunter/Mount Sinai Geriatric Education Center. Crown Nursing Home Associates, 1990.
Rubenstein LZ, Power C. Falls and mobility problems: Potential quality indicators and literature review (the ACOVE Project). Santa Monica, CA: RAND Corporation, 1999