Each year 50%–70% of nursing home residents fall, and many such incidents go unreported. Up to 20% of falls result in a serious injury. In that setting, falls present a prime opportunity for Quality Assurance and Performance Improvement (QAPI) efforts. In senior living  — given that falls represent 70% of that sector’s liability claims — the QAPI model may provide significant opportunity for all senior-care providers to reduce risk.

QAPI is a process for maintaining and improving quality and safety, and addressing other issues related to resident care and comfort. It is a data-driven, proactive, systematic, goal-driven approach. Three keys to QAPI success include leadership, accountability, and presence. Speaking at a webinar on QAPI Approach to Addressing and Preventing Falls, Thomas Annarella, LNHA, Administrator at Valley Hi Nursing and Rehabilitation in Woodstock, Illinois, said, “QAPI helps facilities get and stay on top of quality scores,” as well as be proactive on common concerns and issues that often lead to grievances and even litigation. Consider the following example.

The Quality Quest: The Story of a Faller

Everyone knows “fallers.” They’re residents who are lovely and pleasant, but they’re not compliant with safety measures. For instance, they don’t use their walker, they wear loose-fitting slippers, and/or they don’t use the call light for help to go to the bathroom or get out of bed. As a result, they are at a high risk for falls.

Annarella offered the case of one such resident, “Ida,” a 75-year-old with a history of falling admitted to the facility for rehab after a fall. She had a walker but often ambulated without it. Her actions led to four falls since entering the facility nearly a month prior. While three of the falls didn’t result in any real injury, the fourth required a trip to the hospital for sutures to her forehead. While Ida’s family was more frustrated than upset about her repeated falls, one member was threatening to call the Department of Public Health.

There was an important opportunity for QAPI to help Ida and prevent falls among other residents as well.

All In: Part Detective, Part Reporter

QAPI starts with some hard questions. It is important to start the investigation — beginning with the queries — early, before people forget and facts and timelines get confused. Questions that will help you get to the root cause of the fall, how it happened, and how it might be prevented include:

• What happened just before the fall?
• What has happened in the last few days?
• Did the family just visit?
• Was the environment loud and chaotic?
•  Where were the staff?
•  Was there an unmet need?

In the case of Ida, said Annarella, the investigation determined that her falls all occurred at approximately the same time in the afternoon when staff was doing its shift report. It also was noted that Ida complained of pain frequently after lunch and was restless in the afternoon. Ida seemed to do best, the investigation suggested, in the morning when she was receiving rehab and attending activities.

A review of Ida’s medication record showed she had a scheduled pain med in the morning and PRN medication for pain in the afternoon, which she only got on some days. The investigation determined that Ida didn’t get her afternoon med when a particular nurse was working.

Ultimately, the investigation concluded that Ida’s morning pain meds wore off by lunchtime. At the same time, her memory was declining and she often forgot to use her walker. When staff were proactive with Ida’s pain meds, she was comfortable and sat in the lounge watching TV.

The QAPI Team

Like everything in post-acute and long-term care, QAPI is a team sport. It doesn’t end with the observational investigation and questioning. The QAPI team uses the plethora of information at their disposal, including quality indicator reports, Electronic Medical Record (EMR) trending and risk reports, and safety committee trending data. Annarella stressed, “A facility with a true quality focus is a master of their data and metrics.”

A key part of QAPI is looking at trends: when falls occur, how many falls occur in each unit and under the care of each team, the location of falls, the type of falls, compliance with safety measures, etc.

It is also essential to look at environmental issues such as lighting and flooring, acuity changes, changes in familiar routines, and the use of alarms. Annarella stressed that while it is important to collect detailed data, “You must be able to read and understand it.” By analyzing the data, the care team can identify opportunities for change or new resources, tools, or training.

In the case of Ida, the team devised some fall-prevention strategies that included staff education on proper pain assessment and management, as well as scheduling activities to engage residents during peak fall risk times.

How to Know if QAPI Is Working

QAPI isn’t a “one and done” process, Annarella emphasized. “Don’t pull the plug too early,” he said. Monitor the process and adjust as needed. Work with staff to make sure changes and innovations are sustained and that people don’t slide back into old habits. He also emphasized the need for transparency. “Don’t manipulate the data to support your hypothesis. It is okay to be ‘wrong’ in QAPI if you are pushing toward a solution.”

Watch the full webinar here.

Download the free tip sheet: Tips for Successful QAPI Approach to Addressing and Preventing Falls