Fall Risk and Prevention

Empowering DSPs and Caregivers to Prevent and Respond to Falls

🗣️Who Benefits from This Training?

This training is designed for a diverse audience involved in supporting individuals, with specific benefits for each group:

• Direct Support Professionals (DSPs) and Caregivers:

  • You will learn important risk factors associated with falls.

  • You will learn to recognize signs and symptoms of injuries after falls.

  • You will understand the critical importance of reporting falls and related observations.

• Support Coordinators:

  • You will learn important risk factors associated with falls.

  • You will understand the signs and symptoms that DSPs and caregivers will recognize and provide in documentation.

  • You will learn diagnoses that may be associated with fall risk factors, aiding in comprehensive service planning.

Overall Goal: To equip all participants with the knowledge and practical tools necessary to proactively prevent falls and respond effectively and appropriately when they occur.

🗣️ What is a Fall?

Understanding the precise definition of a fall is fundamental to accurate reporting and effective prevention.

• DBHDS Definition: A fall is defined as any situation in which someone descends (or falls) suddenly and involuntarily toward a lower surface or the ground.

  • Source: Virginia Department of Behavioral Health and Developmental Services (DBHDS)

• Potential Complications of a Fall:

  • Broken bones (fractures)

  • Head injuries, including concussions

  • Soft tissue damage (such as sprains, scrapes, and cuts)

  • Functional problems with daily activities, leading to decreased independence

  • Development of a significant fear of falling again, which can lead to reduced activity

  • Broken teeth or other dental injuries

🗣️Important Fall Facts

Falls represent a significant public health concern, with notable impacts across different populations.

• General Population (Age 65 or Older - CDC, 2017):

  • Falls are the leading cause of both injuries and injury-related deaths.

  • Approximately 1 out of every 4 individuals aged 65 or older will experience a fall each year.

  • 1 out of every 5 falls in this age group results in a serious injury.

  • A staggering 95% of all hip fractures in individuals aged 65 or older are directly attributed to falls.

• In People with Intellectual and Developmental Disabilities (ID/DD - Hsieh, Rimmer, Heller, Minor and Grosso, 2014):

  • One in five adults (aged 18-44) with ID/DD reported experiencing a fall in the past year.

  • One in three middle-aged adults (aged 45-64) with ID/DD reported falling in the past year.

  • Nearly 25% of fall-related injuries sustained by individuals with ID/DD required medical attention.

🗣️Factors that Increase Risk for Falls (Part 1: Environmental & Cognitive)

Fall risk factors can be categorized to better understand their impact and to develop targeted prevention strategies.

1. Environmental Factors

These are external elements within an individual's surroundings that can contribute to falls:

• Wet or slippery floor surfaces.

• The presence of loose carpets or unstable rugs.

• Inadequate or poor lighting conditions.

• Wearing poorly fitting footwear that does not provide proper support or traction.

• A lack of stable surfaces to grab onto (e.g., absence of grab bars in bathrooms).

• Chair seat heights that are excessively low, making it difficult to stand up.

• Durable Medical Equipment (DME) that is in a state of disrepair (e.g., wheelchairs, canes, walkers with missing parts or that are not fully functional).

• The presence of clutter on the floor, creating tripping hazards.

2. Cognitive Processing Factors

These relate to an individual's mental abilities and how they process information, impacting their judgment and reaction time:

• An inability to distinguish between safe and dangerous activities (e.g., running on a slick floor surface).

• Slowed decision-making processes, which can delay reactions to hazards.

• A diagnosis of dementia, which often impairs judgment, balance, and spatial awareness.

🗣️Factors that Increase Risk for Falls (Part 2: Neurological)

Neurological conditions can significantly impact an individual's balance, coordination, and muscle control, leading to an increased risk of falls.

3. Neurological Risk Factors

• Seizure diagnosis: This is identified as the most common reason an individual with IDD falls.

• Head trauma.

• Stroke.

• Cerebral palsy.

• Autoimmune diseases affecting the nervous system.

• Infections impacting neurological function.

• Paraneoplastic syndromes.

• Brain tumors.

• Toxic reactions affecting the nervous system.

• Deficiencies in essential vitamins such as Vitamin E, Vitamin B-12, or thiamine.

• Parkinson's disease.

• Multiple Sclerosis.

• Neurological disorders that negatively affect muscle control.

• Neurological disorders that affect proprioception (the sense of body position and movement).

• Ataxia: A neurological symptom that can cause:

  • An unsteady walk and a tendency to stumble.

  • Difficulty with fine motor tasks (e.g., eating, writing, buttoning a shirt).

  • Changes in speech patterns.

  • Involuntary back-and-forth eye movements (nystagmus).

  • Difficulty swallowing.

  • Overall poor coordination.

🗣️Factors that Increase Risk for Falls (Part 3: Physical & Other Health)

A combination of physical attributes and other health conditions can also elevate an individual's risk of falling.

4. Physical Factors

• Having vision or hearing loss, which can impair awareness of surroundings.

• An unsteady gait (manner of walking).

• Poor balance.

• Weak muscles, leading to difficulty with mobility (e.g., inability to walk more than 3 blocks).

• Being age 65 or over (a general risk factor, especially for the general population).

• Having fallen once before (a strong predictor of future falls).

• Being female (studies indicate a higher prevalence of falls in females within the IDD population).

• Skeletal problems.

• A diagnosis of arthritis.

• Polypharmacy: Taking 4 or more medications, which can increase the risk of side effects like dizziness or drowsiness.

• The use of walking aids and other Durable Medical Equipment (DME).

• Experiencing fatigue.

• Urinary incontinence.

5. Other Health Problems/Medical Conditions Which May Elevate Fall Risk

• A diagnosis of diabetes, especially with a history of low blood sugar levels (hypoglycemia).

• A history of Vertigo.

• A diagnosis of Ménière's disease (an inner-ear condition causing extreme dizziness called vertigo, which can last for hours or days).

• A recent illness that has caused generalized weakness.

• Substance use, such as alcohol, which can impair balance and judgment.

• Syncope: The medical term for fainting or passing out, caused by a temporary drop in blood flow to the brain, sudden blood pressure drop, or heart rate drop. Certain medications (e.g., antihypertensives, tranquilizers) and conditions (e.g., cardiomyopathy, arrhythmias) can increase risk.

• Orthostatic Hypotension (OH): A sustained reduction of systolic BP (at least 20 mm Hg) and/or diastolic BP (at least 10 mm Hg) within 3 minutes of standing. OH can lead to dizziness, vertigo, or fainting, significantly increasing fall risk.

 🗣️Behavioral Component to Falls

It's important to differentiate between unintentional falls and intentional actions that may resemble a fall.

• Behavior that Causes a Fall: An individual might exhibit a behavior (e.g., rushing, impulsive movements) that unintentionally leads to a fall. This still requires attention to safety and potential injury.

• "Pretend Fall":

  • This occurs when a person purposefully places themselves on the floor.

  • Important Note: A "pretend fall" is not considered a fall as defined by the DBHDS Computerized Human Rights Information System (CHRIS) reporting system, because it is not sudden and involuntary.

  • Action: If a pretend fall is suspected, it is still crucial to always consider the presence of an injury, even if the fall was intentional. Follow all established protocols for a possible injury. Consultation with a behavioral specialist is strongly recommended to understand the underlying reasons for the behavior and develop appropriate support strategies.

🗣️Signs of Serious Injury After Falling

Prompt recognition of injury signs is critical for immediate and appropriate response.

General Signs of Serious Injury (After Any Fall)

• Inability to move a body part or decreased Range of Motion (ROM).

• Difficulty breathing, labored breathing, or absence of breathing.

• Lack of responsiveness or altered level of consciousness.

• An individual who can usually ambulate cannot bear weight on a limb.

• Visible swelling or redness of any body part after a fall.

• Individual is expressing pain verbally or through non-verbal cues (e.g., grimacing, guarding).

• An extremity (arms, legs, feet, hands) appears deformed.

• Leg length differs significantly.

• Presence of new bruising.

• Guarding behavior (refusing to be touched or moved due to pain).

• Bone protruding through the skin (open fracture).

Indicators of Serious Head Injury (Call 911 Immediately if Apparent)

These signs may indicate a more serious head injury and require emergency medical attention:

• Severe head or facial bleeding.

• Bleeding or fluid leakage from the nose or ears.

• Severe headache.

• Any change in level of consciousness, including confusion, disorientation, or slurred speech.

• Black-and-blue discoloration below the eyes (raccoon eyes) or behind the ears (Battle's sign).

• Cessation of breathing.

• Weakness or an inability to use an arm or leg.

• Unequal pupil size.

• A seizure.

• Vomiting.

🗣️Tips for Preventing Falls (Proactive Measures)

The goal of fall prevention is to minimize the risk of falls and the risk of injurious falls, while actively maintaining individual independence and quality of life.

• Learn All You Can About Falls:

  • Utilize reputable resources such as the CDC's STEADI (Stopping Elderly Accidents, Deaths, & Injuries) program. This initiative provides valuable information for caregivers and providers working with individuals at risk of falling.

• Determine and Assess Individual Risk:

  • Identify if the individual is known to have any of the risk factors previously discussed.

  • Consider utilizing a validated fall risk screening tool (e.g., MORSE, FRAT, or STRATIFY) to formally assess risk level.

  • Engage in open conversation with the individual about their fall history.

  • Discuss possible risk factors and recommendations for addressing them with the individual's Primary Care Provider (PCP).

  • Obtain a comprehensive fall risk assessment from a qualified medical professional such as the individual's PCP, a Podiatrist, a Physical Therapist (PT), an Occupational Therapist (OT), or a Registered Nurse (RN).

• Consider Environmental Assessment:

  • An environmental assessment conducted by a PT or an OT can help identify and reduce fall risks in the individual's surroundings.

  • This assessment should cover all frequently visited locations, including the home, work, day support programs, and group homes.

• Medical Considerations for Bone Health:

  • Ask the individual's Primary Care Physician (PCP) if the individual should be placed on a Vitamin D and/or Calcium supplement. This can help reduce the risk of a fracture if a fall occurs, as some falls can result from spontaneous hip fractures due to thin, porous, or brittle bones.

• Importance of DSP Observations and Reporting:

  • If you witness any tripping, wobbling, stumbling, and/or any behaviors that indicate or imply that the individual is "unsteady on their feet" (even occasionally), it is crucial to inform all members of the individual's support team.

  • Document what you have witnessed, including the date and time, to ensure accuracy and prevent forgetting details.

  • Act as the 'eyes and ears' for the team; clearly describe the incident and your observations, indicating why you believe the individual may have an elevated risk for falls.

🗣️Practical Fall Prevention Strategies

These are actionable steps that can be implemented daily to reduce the likelihood of falls.

• Encourage using handrails when available, especially on stairs or ramps.

• Ensure the individual wears non-skid shoes that fit properly and provide good support.

• Clean up spills immediately to prevent slippery surfaces.

• Ensure there are no loose cords in walkways that could cause tripping.

• Encourage yearly vision checks to address any changes in eyesight that could affect balance and perception.

• Remove small rugs or secure them firmly to the floor to prevent slipping.

• Be aware of pets that may unexpectedly get underfoot, especially small animals.

• Keep walkways clear of clutter to ensure unobstructed paths.

• Encourage and ensure the correct use of Durable Medical Equipment (DME) such as canes, walkers, or wheelchairs, as prescribed.

• Monitor medication side effects that may cause dizziness, drowsiness, or affect balance.

• Install grab bars in bathrooms near toilets and in showers/tubs for added support.

• Use non-slippery surfaces in showers/tubs (e.g., non-slip mats or textured surfaces).

🗣️When a Fall Occurs: Immediate Response

Even with the best prevention efforts, falls can still happen. Knowing how to respond immediately is critical.

• Despite best efforts, falls can still occur! They can cause injuries such as broken bones, head injuries (like concussions), soft tissue damage, fear of falling again, and broken teeth.

• Always Consider Injury: Even if you cannot visually identify any injuries, always assume there could be an internal or unseen injury.

• Call 911, if appropriate:

  • If any signs of serious injury (especially head injury indicators listed previously) are apparent.

  • If the fall occurs from a significant height (e.g., porch, ramp).

  • If the fall occurs from a vehicle lift or patient lift.

  • If the individual uses DME equipment (cane, wheelchair, gait trainer, lift, stander, bed, powerchair) and the fall involves this equipment.

  • If the fall occurs while exiting a vehicle or if the individual is thrown from a vehicle during an accident.

  • If the fall occurs on stairs.

  • If the fall occurs after a recent hospitalization.

  • If the fall occurs after a significant change in the individual's health status.

• Follow-up with Primary Care Provider (PCP):

  • Even if the individual does not appear to have any immediate injuries, follow up with their PCP as soon as possible after any fall. This is to determine if diagnostic testing or another medical intervention is needed.

  • The PCP may recommend evaluation by a neurologist, Physical Therapist (PT), Occupational Therapist (OT), Ear Nose and Throat (ENT) specialist, or another medical specialist to determine if diagnostic tests, therapy, medication changes, and/or direct care changes need to be initiated.

• DBHDS Health and Safety Alert "First Aid for Falls": Refer to this specific resource for additional information on how to respond to a fall that may have resulted in a serious injury.

🗣️After a Fall: Ongoing Actions

Immediate response is followed by a series of crucial ongoing actions to prevent future falls and ensure comprehensive care.

• Inform the Team: Do not delay! Inform all members of the individual's care team as soon as possible after a fall. The individual may require additional supports to limit and/or reduce their risk for a serious injury due to a future fall.

• Develop a Plan: Collaborate with the care team to develop a comprehensive plan that addresses the identified risks and aims to reduce the possibility of a future fall.

• Individualized Service Plan (ISP) Meeting:

  • Conduct an ISP meeting after a fall to identify any appropriate referrals or interventions that should be incorporated into the individual's plan.

  • Update the individual's ISP annually, whenever there is a change in the individual's health status, and/or specifically if they have experienced a fall.

• Durable Medical Equipment (DME) Inspection:

  • Regularly inspect the individual's DME (e.g., wheelchair, walker, rollator, stander, shower chair).

  • Recommended: Monthly DME safety checks. However, if an individual frequently knocks or bangs their DME (accidentally or due to behaviors), more frequent safety checks may be necessary.

  • Key areas to inspect for repair needs:

    • Broken parts

    • Loose bolts, screws, brackets, clasps, etc.

    • Seat belt or harness tears

    • Missing armrests

    • Ripped vinyl seat backs or bottoms (which can tear and cause a fall to the floor)

    • Loose or damaged wheelchair seat cushions (which can cause the individual to slip to the floor)

    • Loose wheelchair brakes that do not keep the tires from moving

    • Footrests that do not work properly and/or are missing

    • Parts that are loose and/or wobbly

    • Missing clothing guards (if an individual wears long or loose-fitting garments, they can get caught in wheel spokes, potentially pulling the individual to the floor)

  • Reporting DME Needs: If any DME repair needs are identified, email the OIH/MRE Team at mreteam@dbhds.virginia.gov to request instructions on how to schedule an appointment for a DME safety assessment. The MRE Team can often repair DME on the same day or provide resources for vendors.

🗣️DSPs Connect the Dots: Daily Observations

Direct Support Professionals (DSPs) are crucial in fall prevention and response due to their daily interactions and observations.

• You are the boots on the ground! Your daily observations are invaluable.

• Based on your daily observations, you may recognize a change in an individual's status that warrants prompt evaluation.

• If you notice any of the risk factors for falls (e.g., changes in gait, increased unsteadiness, new medications, signs of pain, or behavioral changes), it is imperative to report and document quickly.

• Example Scenario and Daily Note:

  • Situation: An individual fell down three steps face forward and landed, hitting his head on the floor. He has a swollen area above the right eye. He is breathing but his eyes are closed, and he is not moving.

  • Example of a Daily Note (following agency documentation standards): "4/10/20 While out with community engagement at a small shop, individual fell down three steps. He hit his head and did not respond to his name for a few seconds. Just above his right eye started to swell. 911 was immediately called. Staff stayed with the individual and monitored his breathing. By the time EMS arrived he was responding to voice commands and trying to get up. Staff asked him to remain lying on the floor until he was evaluated. He was taken to the ER due to hitting his head. DSP notified Day Support Manager."

  • Takeaway: This example demonstrates how a DSP recognized an emergency, took immediate action, and documented the event thoroughly. This is a critical skill for all DSPs.

🚀Case Study & Application (EXAMPLE)

This case study provides an opportunity to apply the knowledge gained from this training.

• Case Study: Gabby

  • Gabby has experienced numerous falls over the years and has suffered many broken bones as a result.

  • She struggles to maintain her balance when getting up to stand and has an unusual gait, appearing to walk sideways.

  • Gabby possesses excellent perception skills but communicates by making sounds and hand gestures.

  • She is most successful ambulating when she has staff with her who are familiar with her cues and how to assist her with walking.

  • Incident: Today, several staff are out sick at Day Support. Gabby is scheduled for Group Day hours as well as Community Engagement hours. She is assigned to go out with a seasoned staff person, but this staff is unfamiliar with Gabby's specific ambulation supports. The staff takes Gabby's travel chair, as they are going to Gabby's favorite activity of helping at the food bank.

  • Upon arrival at the food bank, the staff parks the van and attempts to assist Gabby out of the vehicle. Gabby keeps her left arm folded up on her chest and uses her right hand to manage her cane. Gabby tries to communicate by sounds and gestures that they left her cane back at the center. The staff is unsure of Gabby's message and continues to assist her out of the vehicle. Gabby gets scared and starts falling forward. The staff supports Gabby's weight, but she does sustain a bruise on her side from hitting the van door. Gabby indicates she is okay, but later that night she ends up at the ER.

• Apply What You've Learned:

  • Based on the information provided in this training and Gabby's case study, list three interventions that, if implemented, would likely have prevented this fall from occurring.

    1. Ensure staff are familiar with the individual's specific support needs and communication methods. In Gabby's case, the staff was unfamiliar with her ambulation supports and her cues for communicating about her cane. Proper training and understanding of the individual's ISP are crucial.

    2. Verify all necessary Durable Medical Equipment (DME) is present and functional before outings. Gabby's cane was forgotten, which was essential for her ambulation success. A pre-outing checklist or routine could prevent this.

    3. Prioritize the individual's safety and comfort, and do not proceed if communication is unclear or support needs are not met. The staff continued to assist Gabby despite her attempts to communicate distress and the absence of her cane, leading to the fall.