September 18 -22, 2023, marks Falls Prevention Awareness Week in the United States. Despite widespread fall prevention programs, fall incidence rates are on the rise in the United States, with an average 1.5% annual growth rate from 2016 to 2019. Although information specific to assisted living (AL) is difficult to track given the varying degrees of reporting and oversight, an overview of claims data provides a snapshot of the current state of fall-related claims in AL. According to the 2022 CNA Aging Services Claim Report:

• Both the number of fall-related closed claims and their average cost in AL has increased since 2018.
• Fall-related allegations account for more than half (54.8%) of all claims in the AL setting.
• Top contributors to fall-related allegations include:
  • Improper care, such as dropping a resident during transfer, conducting a one-person transfer when two people were required, or failure to identify a resident as at risk for falls (51.0%)
  • Failure to monitor (44.0%)
  • Unsafe environment (4.7%)
• The average cost of fall-related claims remains the highest in AL ($239,074) compared to other aging services settings.
• Death was the most common outcome of fall-related claims in AL and skilled nursing settings (59.4%), followed by fracture (30.7%) and head injury (3.9%).

Comprehensive fall prevention programs remain the quintessential strategy for reducing fall risks. And while most care settings are federally required to develop and implement fall prevention programs, AL facilities are not subject to federal oversight. Instead, AL facilities must look to state and accreditation requirements and professional standards or best practices to inform their programs. Joint Commission, for example, began offering accreditation for AL communities in 2021 and has included reducing the risk of falls in the AL setting in its 2023 National Patient Safety Goals. 

As a residential care setting that primarily serves older adults who are particularly vulnerable to increased risk of falls and fall-related injuries, fall prevention programs must be wide in scope and deeply engrained within the facility’s overall approach to resident safety. ECRI recommends the following:

1. Create and maintain an interdisciplinary falls management team to design, implement, monitor, and routinely revise a falls management program using appropriate systems for assessing fall and injury risk, establishing a falls baseline, monitoring the facility's falls data, and conducting reactive analyses of falls.
2. Develop, implement, and routinely update all falls management policies and protocols, including risk assessment and reassessment tools (e.g., Morse scale or Hendrich II scale). Ensure that assessment tools include an assessment of both the person's risk of falling and the risk of serious injury.
3. Require initial and ongoing falls management education programs for professional staff, clinical personnel, volunteers, and nonclinical facility employees (e.g., security, housekeeping, food services). Education should address conducting a thorough risk assessment of residents, conducting a risk assessment of their environment, implementing proper interventions, responding appropriately to falls, and correctly filing event reports.
4. Assess or reassess residents on admission, when their physical condition changes, when they are transferred to another level of care, and when a fall or near miss occurs. Reassessment should occur at least quarterly and include review of medication regimens.
5. Ensure that the resident’s risk of falling, and of sustaining a fall-related injury, is effectively communicated to the resident and family and to all clinical and nonclinical staff. Employ a mechanism to identify residents who are at increased risk for falls (e.g., whiteboards in nursing stations, resident door signs, etc.).
6. Educate residents and families on the risk of falling, but also on the benefits of increased mobility and autonomy. Provide informational materials to residents and families. Ensure that families do not have unrealistic expectations.
7. Conduct environment-of-care rounds regularly to reduce or eliminate extrinsic risks (e.g., equipment in poor repair, clutter, inadequate lighting). Provide a mechanism for residents, visitors, and staff to report extrinsic risk factors whenever identified.
8. Provide standardized equipment designed to help prevent falls, such as grab bars, elevated toilet seats, and bath mats, in all rooms.
9. Implement effective interventions to manage residents who are at risk of falling. Set goals against which the proposed interventions can be measured (e.g., reduction of falls per 1,000 resident-days or reduction of falls with injury per 1,000 resident-days).
10. Communicate to staff members clear and consistent policies for documenting and reporting falls and conduct reactive analyses of falls incidents to identify strategies to continually improve the falls management program.

Later this fall, ECRI will open registration for our 2024 Falls Prevention Safety Collaborative. Stay tuned for more details on the collaborative coming soon.