QUALITY IN LONG TERM CARE AND

ASSISTED LIVING

Jane Belt, MS, RN, RAC-MT

Plante Moran, PLLC [email protected] plantemoran.com

plantemoran.com

614‐222‐9020

Objectives 1. Delineate pertinent F-tags related to falls, accidents, restraints, dignity, choice, homelike environment and sound 2. Describe the impact of the use of alarms 3. Review root cause analysis in fall reduction 4. Identify strategies and interventions to reduce the use of alarms plantemoran.com

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Some Facts  Annually, 30-40% of elderly living in the community fall  50% of nursing home residents fall at a cost on average of $9,100 to $13,500  In the US, falls are the leading cause of accidental death and the 7th leading cause of death in people ≥65  75% of deaths caused by falls occur in the 13% of the population who are ≥65  In 2000, direct medical costs for fall injuries totaled $20 billion  By 2020, the costs are projected to reach $44 billion Merck Manual Professional Edition. Geriatrics. Falls in the Elderly. November 2013 plantemoran.com

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Deficiencies Top 5 Citations in the United States, March 2015 1

F441

37.7% Investigates, controls/prevents infections

2

F371

35.2% Store, prepare, distribute, and serve food

3

F323

29.6% Accident hazards

4

F309

24.6% Each resident must receive care for highest well-being.

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F329

22.2% Unnecessary drug: In excessive dose. Top 5 Citations in INDIANA, March 2015

1

F441

40.3% Investigates, controls/prevents infections

2

F371

39.2% Store, prepare, distribute, and serve food

3

F282

4

F323

37.1% Services must be provided by qualified persons. 35.8% Accident hazards

5 F329 31.4% Unnecessary drug: In excessive dose LTC Stats: Nursing Facility Standard Health Survey Report Research Department – plantemoran.com American Health Care association. March 2015

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Reducing Falls: Consider…. The Rules

 OBRA - attain/maintain highest level of function  F272 – functional assessment drives care planning  F222 - right to be free from physical or chemical restraints imposed for purposes of discipline or convenience

Convenience = any action taken by facility to control or manage a resident’s behavior with lesser amount of effort by facility / not in resident’s best interest. Consequences of devices listed as: decline in physical functioning, become a hazard, residents lose dignity and show symptoms of withdrawal, depression plantemoran.com

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Reducing Falls The Rules

 F240 – quality of life – create and sustain environment that humanizes and individualizes each resident  F241 – care promotes and enhances dignity  F242 – self-determination. Can make choices in their life  F252 –Safe, clean, homelike environment

A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. plantemoran.com

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F252: (Rev. 48, Issued: 06‐12‐09,  Effective: 06‐12‐09) Some good practices that serve to decrease the institutional character of the environment include the elimination of:  Overhead paging and piped-in music throughout the building;  Meal service in the dining room using trays (some residents may wish to eat certain meals in their rooms on trays);  Institutional signage labeling work rooms/closets in areas visible to residents and the public;  Medication carts (some innovative facilities store medications in locked areas in resident rooms);  Mass purchased furniture, drapes and bedspreads that all look alike throughout the building (some innovators invite the placement of some residents’ furniture in common areas); plantemoran.com

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F252: (Rev. 48, Issued: 06‐12‐09,  Effective: 06‐12‐09)  The widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, “From Institutionalized to Individualized Care,” Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network. plantemoran.com

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Reducing Falls  F258 – Sound levels. Do not interfere with resident’s hearing; enhance privacy when The Rules desired, and encourage interaction when desired. Of concern to comfortable sound levels is the resident’s control over unwanted noise.  F323 – Accidents. Environment free from hazards and provides supervision and assistive devices to prevent avoidable accidents by identifying and evaluating hazards and risks; implementing interventions and monitoring for effectiveness and modifying interventions as needed plantemoran.com

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Contradictions in Our Delivery of Care: OBRA = keep folks at highest level of function  Quality of Care = no decline in function  Quality of Life = choices, rights, adjust to residents’ needs

And…. or is it But…

OBRA = keep folks at highest level of function  Improvement Initiatives = eliminate / reduce restraints  Safe environment – “no falls” Nursing homes did a terrific job of restraint reduction. Indiana QM for Physical Restraint Usage down to 0.8% plantemoran.com CONGRATULATIONS!!!

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Enter the Substitution restraint restraint

alarm No publicly reported data on usage

Do you know your facility’s usage rate? plantemoran.com

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Looking at Alarm Use

Building alarms not the issue

 Realized restraint use resulted in negative physical and psychological outcomes, so alerting devices that emit an audible warning signal when a resident moves in a way perceived to put them at risk popped up. Most commonly:  Cord attached to clothing with a clip and ending with a magnet that activates when person exceeds length of cord  Pressure sensitive pads for chairs, wheelchairs, beds – activate with decreased pressure  Pressure sensitive mats for the floor – activate when pressure increased  Light beams on the bed or door that activate when beam crossed plantemoran.com

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Alarms – Why?  Make others feel safer  Best used as a call light  If resident trying to remove – it is NOT the best option  If overused, staff ignore due to alarm fatigue  Surveyors seem to like  Families believe the alarm prevents falls plantemoran.com

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Fall Prevention  We really cannot prevent ALL falls  But restraints and alarms cannot either

 There is absolutely no evidence base for the use of alarms as devices to prevent falls and injuries  “As with restraints and siderails, we have false beliefs about their effectiveness” (Pioneer Network)  If a resident with an alarm falls…the alarm did NOT work!! plantemoran.com

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Alarms are Counterintuitive  Alarms tell us to TAKE ACTION Run

Get out

 In the nursing home, alarms tell residents to SIT DOWN and not move

Sit down plantemoran.com

What do you need?

Reactionary versus anticipatory or proactive

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Alarms – What Do We Have?

Noisy Restraint  Just like physical restraints, negative consequences:  Sleep deprivation  Alarm sounds with movement  Disturbs resident  Disturbs roommate  Disturbs sleep cycle

How do you feel when your sleep is disturbed?

 Lack of deep sleep which then compounds agitation, contributes to loss of appetite and decreased balance and endurance plantemoran.com

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Alarms – What Do We Have?

Noisy Restraint  Just like physical restraints, negative consequences:  Behaviors  Cognitively impaired  Disturbed by noise  Do not know what is happening  Creates noise, fear, confusion

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Let’s Talk about Noise   Empira, a Minnesota consortium of 16 SNFs at the time received a 3-year grant program to study fall reduction and published results (10/2008)  Early on all facilities identified that most falls occur during the noisiest times of the day – shift change, meals, alarms sounding  Noise was identified as the major environmental factor contributing to falls  Staff conversation, alarms, and TVs identified as some of the elements Found that if noise was stopped the facility plantemoran.com

could reduce falls

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Noise and Dementia  Noise dramatically impacts their quality of life  Dementia worsens the effects of sensory changes as it affects perception to external stimuli, such as noise and light  As hearing is linked to balance – increases risk of falls through either loss of balance or increase in disorientation as a result of people trying to orient themselves in an over stimulating and noisy environment

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Other Noises in the NH  Think about the other devices besides personal alarms that make the NH environment noisy:  Staff pagers  Telephones  Doorbells  Alarms on medical equipment Try to minimize these types of intrusive noises especially when combined with background noise and at night time plantemoran.com

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Noise Levels in Decibels

140 130

Jet plane taking off Fireworks exploding

120 110

100 90

Lawnmower & motorcycle starting Personal alarms, land line phone ringing

80 70

Normal conversation

60 50 40 30 20 10

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Whisper 21

Alarms – More Negatives  Just like physical restraints, negative consequences:  Loss of mobility, increased weakness and when have a fall – more likely to get hurt  Skin breakdown – immobility or fear of shifting position  Alarms encourage residents NOT to move  Repeatedly told to “sit down”  Don’t want to make noise so don’t make those small shifts in weight to avoid the alarm sounding plantemoran.com

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Alarms – More Negatives  Just like physical restraints, negative consequences:  Incontinence  Not responding to resident’s potential toileting needs  Dignity and Privacy  Visual  Auditory

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Alarms = Noisy Restraint  What do residents say and do  Dislike them – detach or hide  Feel alarms are intrusive – loss of dignity  Embarrassing  Loss of freedom – loss of privacy  Wishes and preferences not honored  Start to use as a call bell

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So… Alarm = Noisy Restraint  How do staff respond to the alarm    

Direct the resident to sit down Walk in the room and turn the alarm off Experience alarm fatigue due to desensitization Go to “wrong” alarm – one that is not sounding

 Other issues  Device malfunctions (cord breaks or detaches, battery dies, fails to activate, staff forget to turn back on  Give staff false sense of security  Absorb great deal of time for staff as they respond to alarms  Cause reactionary actions rather than anticipatory

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Just as We Assumed Restraints  Were Safe  What research showed us:  Routinely using restraints did not lower the risk of falls or fall injuries.  They should not be used as a fall prevention strategy  Restraints can actually increase the risk of fallrelated injuries and deaths

The same is coming into evidence with alarms plantemoran.com

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OK – What Can We Do?  Pioneer Network program called: Promoting Mobility, Reducing Falls and Alarms  Promoting mobility means building and maintaining core strength, endurance and balance, and providing supports to enable residents to move around safely with as much independence as possible  Alarms in contrast – inhibit mobility and promote immobility, stiffness, decreased muscle tone and falls plantemoran.com

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Promoting Mobility  Alarms became our default practice in response to a fall and we overlook the process of root cause analysis and designing interventions that actually address the root cause of the fall  At home we use timers (alarms) to tell us when wash is done, cookies baked, smoke in the house, time to get up – we wait until the alarm sounds – we don’t check. Opposite is needed to promote safe mobility – staff proactively anticipates residents’ patterns, needs, and indications of help and promote mobility while preventing falls plantemoran.com

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Promoting Mobility  Using muscles builds muscles  Unused muscles become deconditioned  Dr. Tinetti – “A good way to prevent falls is to build muscle strength and bone density by engaging in weight bearing exercise. Walking and transitioning from sitting to standing build our strength.”

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Promoting Mobility  Address risks  Know how each resident functions in the environment and identify internal and external risks. Consistently assigned NAs’ insights and observations related to fall risk are important contributions

 Individualize care  Know resident’s customary routines to anticipate and be proactive in meeting their needs. Use adaptive devices and mobility aids to maximize safe mobility. Individualize interventions based on individualized risks, strengths, and circumstances plantemoran.com

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Promoting Mobility  Build mobility into daily routines  Standing for a few extra seconds  Walking an extra few steps  Encourage walking each day, with or without a walker or assistance.  Decrease use of wheelchairs – add sitting spaces to rest along the way  Add assist bars as needed  Lower closet bar and shelves plantemoran.com

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Promoting Mobility  Build mobility into daily routines (cont.)  Help residents who cannot walk to move and exercise even while seated  Get everyone involved – keeping residents mobile is a team sport  Try to make things fun with music and props such as “chair dancing”  Work with therapy to carry out prescribed exercises  Ask what you can do to support progress plantemoran.com

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Promoting Mobility  Build mobility into daily routines (cont.)  Encourage residents to stand during commercials on TV  Take standing breaks during Bingo and other sitting-type activities  Get the music going!! Get staff in the room to dance with the residents – dance with folks in wheelchairs, too  Get residents out of wheelchairs and transfer to dining room chairs at meal times  Take residents for walks – inside and outside  Encourage families to take walks with resident plantemoran.com

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Promoting Mobility  Build mobility into daily routines (cont.)  Encourage team participation from all shifts and all staff  Ask activities’ staff for ideas of things to do to keep residents active  Work with families to best meet their relative’s needs  Share your successes, large and small  Be a cheerleader for safe movement  Help your nursing home be a leader in keeping residents mobile plantemoran.com

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“I did then what I knew then, when I knew better, I did better.” ~ Maya Angelou

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How Can We do Better in Fall  Reduction? Two Approaches Proactive (fall prevention) • Speculate on risk factors of falls • Actions based on conjecture • Actions based on predictions • Continued monitoring plantemoran.com

Reactive (post falls action) • Investigate as falls occur • Collect factual evidence from the fall event • Analyze, study the causes, trends, patterns • Root causes

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Fall Prevention Program NOW  Your absolute best tool is  Starts with educating staff on RCA  Q. Why did the alarm go off?  A. Resident was moving

Hold on

 RCA: What does the resident need that set the alarm off?  RCA: What was the resident doing just before the alarm went off? plantemoran.com

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Purpose of  Root Cause Analysis  Root Cause Analysis (RCA) helps you identify the primary cause(s) of a problem, so that you can

1. determine what happened, 2. determine why it happened, and 3. figure out what to do to reduce the likelihood of it happening again.

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Philosophy of RCA  Focuses on systems and processes — NOT on individuals!  The true problem must be understood before action is taken, i.e., causal/contributing factors or root cause(s)  Problems are best solved by eliminating and correcting the root causes as opposed to addressing the obvious symptoms with scatter-gun approaches plantemoran.com

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RCA 5‐Step Process Gather Initial Information and Define the Problem Fill in the Gaps

Analyze/Identify the Root Cause(s)

Develop Action Plan(s)

Recommend and Implement Solutions(s)

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CRASH AND BOOM!! 

#1 = Obviously – provide care and comfort to the resident #2 = Are you OK? What were you trying to do? Starting to gather your information plantemoran.com

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RCA Step 1 – Gather  Information, Data and Clues   Have to be a detective – look, listen, smell, touch  Look at the position of resident – on side (which side), on back, on stomach. Where are arms and legs?  Observe the surroundings carefully – noise level, clutter, lighting  Type of flooring – wet, dry, glare  Assistive device in use; equipment  Eyeglasses, phone, remote, call light plantemoran.com

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Major Investigation Areas of for  RCA

External

Internal

Systemic

Causes

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External Factors – Account  for at Least 30% of NH Falls           

Noise – the #1 external cause of falls!! Lighting: dark, too dim, glare, shadows Floor surfaces: uneven, wet, slippery, patterned floor Stairs: inadequate handrails, edges not clearly defined Furniture: too low, too soft, tips easily, on wheels Bathroom: slippery tub or shower, lack of grab rails for toilet or tub, grab bars blend into wall color Shoes/slippers: too loose, badly worn heels, soles too slick Personal items/assistive devices out of reach Equipment: worn out or broken, improper usage, clutter Mats Tubing

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Internal Factors For Falls Mood status and cognitive changes + frequent napping, increased falls, increased agitation

= sleep deprivation #1

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Internal Factors For  Falls (cont.)  Reduced lower extremity dysfunction and/or strength  Arthritis  Hemiplegia  Peripheral neuropathy  Parkinson’s disease  Poor balance  Deconditioning  Posture and gait changes related to aging  Decreased vision – natural aging and numerous pathologies  Ground surfaces  Low-lying objects  Less acuity – decreased peripheral vision, depth perception  Decreased ability to note contrasts (colors) plantemoran.com

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Internal Factors For  Falls (cont.)  Altered cognition  Depression  Dementia – inattention, can be easily distracted  Urinary dysfunction  Nocturia  Fear of incontinence  Polypharmacy  Prescribed/over-the-counter/self-prescribed; antipsychotics, alcohol, sedatives/hypnotics, tricyclic antidepressants, antihypertensive agents, analgesics, and diuretics  Four or more drugs simultaneously  Inappropriate dosages plantemoran.com

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Internal Factors For Falls (cont.)  Recurrent falls  Number of intrinsic factors – orthostatic B/P  Syncope – impaired cerebral perfusion  Denial of illness, weakness, and dependence  Pain  Podiatric conditions such as ingrown toenails, corns, bunions  Adjusting to new environment: recent move, recent admission, transfer  Multiple diagnoses: conditions affecting stability, mobility, and cognitive function plantemoran.com

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Systemic Factors – Operations  Time of day  Day of week  Change of shift  Fall location  Staff present  What was staff doing (cleaning, repairing, stocking)  Any other functions going on at the time  Consistent assignment followed?? plantemoran.com

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RCA Step 2 – Identify the Gaps  Discuss other sources that might have additional information regarding the problem:  Interviews/re-interviews (staff, resident, family)  Documentation  Observations  Re-enact if possible

 Consult your interdisciplinary team plantemoran.com

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Get the Team Together and  Start Asking Questions?  Who last saw resident?

What was the resident doing? plantemoran.com

How was the resident then? 52

RCA Step 3 – Analyze and  Identify the Root Cause  According to Webster’s  Problem = a difficult or perplexing question or issue; a question posed for consideration, discussion or solution  Cause = a reason for an action or condition; something that brings about an effect or result plantemoran.com

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The Root of the Problem  Best to start with basic human needs  Pain – same position too long?  Need to use the bathroom?  Hungry or thirsty?  Cold or warm?  Tired or need to lie down?  Lonely, bored, desire comfort?  What about their interests, hobbies, routines?  What upsets them or calms them down? plantemoran.com

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Consider More Roots! External Factors Internal FALLS Systemic Factors Factors Falls caused by interaction of external, internal and systemic factors plantemoran.com

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Step 3 – RCA: The Root  of the Problem  Why did the alarm go off?? Why? What? Where? When? What was going on when they fell?  What does the resident need  What was the resident doing just before the alarm went off?  If the resident fell with an alarm on – did the staff put it back on? WHY  Did staff consider that alarm might have contributed to fall?  Was the alarm used as a substitute? Busy staff? Poor supervision or monitoring? Lack of or incorrect assessment of resident’s needs?

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Step 3 – RCA (continued)  What conditions allowed the problem to occur?  What other factors impact the problem?  What are the underlying reasons each causal factor exists?  Can you impact the contributing factor? Why?

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Why?

Why?

Why?

Why?

Root Cause

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Step 3 – RCA: Why 5 Whys?  The 5-Whys is a question-asking method used to uncover the underlying causes of an event.  Ask "Why?" questions until all logical causes (and/or root causes) can be identified.  Can highlight the relationship between several potential root causes of a problem  Uncovering root cause leads to an Action Plan that is more likely to prevent the event from happening again. plantemoran.com

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Step 4 – RCA: Develop the Plan Time to Rethink Alarms  No documented, statistical evidence that alarms reduce falls  We know there are negative effects of alarms both for the resident and the staff  Person-centered care is driving new focus – significant change in clinical practices  Start with education – for the resident, family and staff (see brochure) plantemoran.com

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Rethink  An external device is NOT going to change a resident’s mind as to why they want to move  Consider a more individualized fall risk assessment  Identify individual risk areas  Assess physical environment, too  Don’t be an advocate for restraints and alarms  Encourage reducing and discontinuing restraints and alarms plantemoran.com

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How to Reduce Alarms Three methods seem to be most commonly used: 1. By resident status 2. By unit, shift and specific times 3. Cold turkey

Several protocols to remove alarms, ask clinical team about their preference

 Remember – the easiest way not to use an alarm or restraint is never to put one on!  Rethink – from here on out – set a policy that no restraints or alarms are to be placed on any new admission or any resident currently not using one, will not be allowed to have one plantemoran.com

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Take a Look – Resident Status/Triage 1. Begin rounding on residents who have fallen 2. No restraints or alarms on any new admission 3. Do not put a restraint or an alarm on any resident who does not currently have one on 4. If resident has not fallen in ____ (30) days 5. If resident has a history of removing restraint or alarm 6. If alarm appears to scare, agitate, or confuse residents 7. If resident has fallen with an alarm on, do not put it back on plantemoran.com

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By Unit, Shift, Specific Times 1. Begin rounding on residents who have fallen 2. Start on day shift on 1 nursing/household unit 3. Then go to 2 nursing/household units on day shift 4. Then go to 2 shifts on 1 nursing/household unit 5. Then go to 2 shifts on 2 nursing/ household units, and continue until completed all units in the facility

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By Unit, Shift, Specific Times 1. Week 1: Day shift alarms silenced 2. Week 2: Day shift and evening alarms silenced 3. Week 3: Alarms silenced on all 3 shifts 4. Week 4: Alarms silenced on all 3 shifts / residents monitored  Plan evaluated:  Daily  Weekly and  After months 1 and 2 of implementation plantemoran.com

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Cold Turkey 1. All alarms will be removed by ________ (date) Probably not the best idea until staff realizes that rounding is their best strategy Falls will most likely increase right at first After 3-4 months will see the decrease in falls as staff now good at anticipating the needs of the residents rather than reacting to an alarm plantemoran.com

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No Alarms – What do We Do Now? Advocacy for the efforts starts at the top Action begins – for all staff, all departments, all shifts Inclusion of the physician Daily meetings, education, brainstorming and implementation of interventions  Communication across shifts/among departments  Regular review of contributing factors of falls (e.g., medications, diet, activity, footwear)  Regular communication with residents and families and full inclusion of their input into decision-making    

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Rethink  Consistent staffing – THIS IS AN ABSOLUTE MUST!!!!  What can we do for distraction, encouragement – what engaging, entertaining activities can we provide to reduce boredom and/or agitation  Consider a blanket warmer – terrific to soothe and relax restless folks  Weighted blankets, weighted baby doll, a purring kitten  Activity boxes – could be on lap, nightstand, on table  Reading materials, jewelry boxes, tackle boxes, headsets with soothing music plantemoran.com

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Rethink        

Strategic timing of meaningful activities Exercise – core strength Balance training for static and dynamic balance General strengthening for lower extremities and antigravity muscles Vestibular rehab Gait training with appropriate assistive device Functional and safe sit-to-stand transfers Adaptive equipment – sized appropriately

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Rethink  Positioning and transferring – allow to stand briefly  Toileting plans  Review of medications/effects/pain  Timing of meals and snacks  Efficient follow-up of any clinical changes  Placement of personal items  Bed height - sit on edge of bed – ankles, knees, and hips at a 90 degree angle  Reduction of noise – alarms, TVs, paging, staff talking plantemoran.com

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Rethink  Colored call light cords  Colored toilet seats  Contrasts – grab bars, hand rails, floor, walls, shoes, personal items  Choice of materials (and color) for bedspreads  Anti-rollback brakes for wheelchair  Self-locking brakes for wheelchairs  Frequency of preventive maintenance for resident equipment plantemoran.com

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Rethink  Even with dementia – use resident strengths  Many can reminisce as long-term memory stays intact (may need props)  Can read words even after ability to recognize pictures is lost  Sing/hum familiar tunes  Sense of curiosity remains  Investigate “Music and Memory” certification program  Reading groups – large-print children’s books, Bible, poetry, songs and hymns, jokes  Seated Tai Chai plantemoran.com

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Rethink  Heat shrink Tubing and/or grip material  Nursing assistants stationed in halls  Removing chairs from nursing stations  Check high-risk residents at least hourly  All departments take time each day to engage with residents  Frequency of preventive maintenance for resident equipment  Automatic timer/dimmer  Night lights plantemoran.com

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Hourly Rounding “4 Ps” by Sue Ann Guildermann   POSITION:

 Does the resident look comfortable?  Does the resident look bored, restless and/or agitated?  Ask the resident, “Would you like to move or be repositioned?”  Ask the resident, “Are you where you want to be?” Report to nurse

 PERSONAL / (POTTY) NEEDS:

 Ask the resident, “Do you need to use the bathroom?”  Ask if they’d like help to the toilet or commode. Report to nurse

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Hourly Rounding “4 Ps” by Sue Ann Guildermann  PAIN:

 Does the resident appear in to be uncomfortable or in pain?  Ask the resident, “Are you uncomfortable, ache or are in pain?”  Ask them what you can do to make them comfortable.  Report to the nurse.

 PLACEMENT:

 Is the bed at the correct height?  Is the phone, call light, remote, walker, trash can, water, urinal, tissues - all near the resident?  Place them all within easy reach.

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Rethink  As a culture need to realize the fact that in NHs we are working with the frailest of the frail much of the time. Some are going to fall, get injured and even die as part of normal life and risk taking. No way to prevent all falls  We don’t want to contribute to their risk of injury from falls by immobilizing them and causing decline. Best we can do – work to strengthen balance and endurance.  Know as a person. Better we know them – better we can respond to needs and help him/her sleep, drink, and move as safely, freely and comfortably as possible with our help plantemoran.com

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Strategies that reduce mobility through the use of restraints and alarms have been shown to be more harmful than beneficial and should be avoided at all costs

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Our New Approach Old: Mary, sit down

New: Mary, I see you standing – what do you need? plantemoran.com

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Questions?? THANKS FOR ATTENDING Contact Information:

Jane Belt Plante Moran Clinical Group [email protected] 614-222-9020

ENJOY THE CONVENTION plantemoran.com

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Resources  State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. (Rev. 127, 11-26-14) (Rev. 130, 12-12-14) http://cms.hhs.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

 Chedekel, Lisa, “Nursing home in State Going “Alarm-Free” Liking the Results,” published in TheDay.com, March 25, 2013  “Rethinking the Use of Personal Change Alarms,” Quality Partners of Rhode Island, state Quality Improvement Organizations, under contract with CMS, 2007  Kneisler, Sarah. Presentation “The Interdisciplinary Team” plantemoran.com

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Resources  Advancing Excellence : www.nhqualitycampaign.org  Medicare Quality Improvement Community www.medqic.org  Laurel Health Care Company, “Rethinking the Use of Personal Alarms in LTC”, OHCA session #T09, May 2014  Rader, Joanne; Frank, Barbara; Brady, Cathie, “Rethinking the Use of Position Change Alarms”. January 4, 2007  Kaldy, Joanne. “The Buzz: Facilities Are Going Alarm-Free”. Caring for the Ages, August 7, 2008  Stratis Health | 952–854-3306 | www.stratishealth.org. “Effective Fall Prevention Strategies Without Physical Restraints or Personal Alarms”; presented by Sue Ann Guildermann, April 24, 2012  Dressler, Diane; Maryland Department of Health presentation. “Eliminating Restraint Use in Maryland – 2014 Reinventing Quality”. plantemoran.com

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Resources  RAI MDS Manual: http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

 Shell, Linda M. RN, BSN, MA. Preventing Falls: It’s Easy to Miss What You’re Not Looking For…  Tideikaar, Rein. Falling in Older Age: Second Edition. New York, Springer Publishing Co., 1997  Tideikaar, Rein. Falls in Older Persons: Prevention and Management in Hospitals and Nursing Homes. Boulder: TACTILITICS Inc., 1993  Tideikaar, Rein. “Home Safe Home”. Geriatric Nursing. Vol. 10, No. 6, 280-284. New York: American Journal of Nursing Company, 1989. . Rotterman, Program Director for the Institute for Person-Centered Care. “Personal Alarms: Another Form of Restraint and Oppression Among the Frail and Elderly? You Decide” July 30, 2013 plantemoran.com

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Resources   Weighted 19” Baby Doll: http://www.toysrus.com/product/index.jsp? productId=12076777&CAWELAID=1097046507

 Fluffy purring cat doll: http://www.amazon.com/FurReal-FriendsLulu-Cuddlin-Kitty/dp/B001TMA03U  Better Balance E-Course. http://www.thebalancemanual.com/?gclid=CODO5dSylsECFe0Mgod7VcAWw.  Elder Gym. http://www.eldergym.com/exercises-for-the-elderly.html  Activities to Share. http://elderhelpers.org/blog/category/activitiesto-share/  Root Cause Analysis. QIO: Qsource – http://www.Qsource.org plantemoran.com

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Resources  The Merck Manual – Professional Edition http://www.merckmanuals.com/professional/geriatrics/falls_in_the_elderly/falls_in_the_ elderly.html

 Anetrini, Lisa RN, LNHA, MS; Piccirilli, Trista, RN, LNHA, CDP; Lindsay, Meredith, MSW. “It’s Alarming, Isn’t It? The Alarm (and Restraint) Free Environment”  Pioneer Network – Promoting Mobility, Reducing Falls and Alarms. www.pioneernetwork.net/Providers/StarterToolkit/Step2/Mobility

 CDC – Falls and Older Adults, Falls Prevention Project: Stay Safe. Stay Active. www.cdc.gov/HomeandRecreationalSafety/Falls/compendium/4.4.1_appendixD1.html #stage2 plantemoran.com

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