Falls are a significant concern in long-term care settings, frequently leading to adverse events. To address this critical issue, the Oregon Patient Safety Commission, in collaboration with community partners, has developed a user-friendly guide. This toolkit is designed to assist long-term care providers in thoroughly investigating falls and implementing effective strategies to prevent their recurrence. Built upon the principles of Root Cause Analysis (RCA) and incorporating evidence-based quality improvement methodologies, this resource aims to enhance patient safety outcomes in long-term care facilities.
Long-Term Care Falls Investigation Guide Toolkit
The Long-Term Care Falls Investigation Guide Toolkit serves as a comprehensive roadmap for navigating the falls investigation process. Adhering to the RCA framework, the guide meticulously outlines the sequence of actions required post-fall, extending through the development of actionable plans and continuous monitoring to ensure the effectiveness of implemented interventions. A crucial component of the investigation lies within the “Analyze” phase. To facilitate a deeper understanding of the contributing factors, the guide directs investigators to three specialized “Drill-Down” guides. These focused guides are designed to assist in pinpointing specific elements that may contribute to falls, categorized into key areas:
- Environment and equipment: Examining the physical surroundings and the role of equipment.
- Medications: Analyzing medication-related factors that could increase fall risk.
- Communication: Investigating communication breakdowns that may contribute to incidents.
Long-Term Care Falls Investigation Guide Toolkit
Falls Investigation Guide for First Responders
Recognizing the need for immediate guidance, the Falls Investigation Guide for First Responders provides a condensed version of the comprehensive toolkit. This guide is tailored to equip first responders with the essential steps for initiating a falls investigation directly at the scene. Its primary intent is to provide a structured approach for the initial phase of investigation, with the understanding that the process will be seamlessly transitioned to another designated individual within the facility, as dictated by organizational structure and policies, for complete investigation and follow-through.
Falls Investigation Guide for First Responders
Sample Falls Investigation Forms
To further support long-term care providers in their investigation efforts, a collection of Sample Falls Investigation Forms is available.
The Falls Investigation Form, developed by the Nursing Home Expert Panel, is meticulously aligned with the investigation process detailed within the Falls Investigation Guides. This form serves a dual purpose: it can be utilized as a benchmark to evaluate existing investigation forms and processes within a facility, or it can be directly integrated and customized to meet specific facility needs. Available in Word format, the form allows for easy modification, enabling facilities to incorporate their unique naming conventions for staff positions while retaining the essential investigation components recommended in the guide. Notably, the form includes side-by-side references to both nursing home and CBC staff titles, offering flexibility for diverse facility settings.
The Nursing Facility Falls Investigation Form is a testament to the practical application of the guides. Rose Villa, a pilot participant from Portland, Oregon, developed this form based on their firsthand experience utilizing the Falls Investigation Guides. This real-world example, provided in Word format courtesy of Rose Villa, encourages other facilities to personalize the form with their facility name and adapt it to their operational context.
Nursing Facility Falls Investigation Form
Similarly, Mount Angel Towers, a CBC pilot participant from Mount Angel, Oregon, created the CBC Falls Investigation Form. This form, also born from practical experience with the Falls Investigation Guides, demonstrates the adaptability of the toolkit. Offered in Word format and provided courtesy of Mount Angel Towers, it serves as another customizable template for facilities to adopt and modify to align with their specific requirements.
