Official definitions from regulatory bodies
Defining a fall is not left to a facility's discretion; federal and state guidelines dictate the criteria for reporting. The Centers for Medicare & Medicaid Services (CMS) and other health authorities provide specific definitions to standardize care and ensure patient safety protocols are followed.
The Centers for Medicare & Medicaid Services (CMS) definition
According to CMS guidance, a fall is defined as an unintentional change in position resulting in a resident coming to rest on the ground, floor, or another lower surface. This definition includes several key components that are critical for long-term care facilities to understand:
- Unintentional Descent: The movement must be an uncontrolled, unplanned descent. It is not the result of overwhelming external force, such as another resident pushing them.
- Location of Rest: The descent concludes with the resident coming to rest on the floor, the ground, or a lower surface like a bed, chair, or bedside mat.
- Witnessed vs. Unwitnessed: The definition applies to both witnessed falls (seen by staff or others) and unwitnessed falls (when a resident is simply found on the floor). In the case of an unwitnessed event, a fall is presumed to have occurred unless evidence suggests otherwise.
- Intervention Does Not Preclude Classification: If a resident loses balance and would have fallen without staff intervention, this is still classified as a fall. These are often referred to as "intercepted falls" and still require investigation and documentation.
- Absence of Injury is Irrelevant: Whether or not the resident sustains an injury is not a factor in the initial classification of the event as a fall. A fall without injury is still a fall and must be reported.
Additional criteria and factors
Beyond the core definition, long-term care facilities must consider other nuances when classifying a fall. The Agency for Healthcare Research and Quality (AHRQ) highlights the importance of reporting all types of falls for a complete safety picture. Key circumstances to report include:
- Found on floor (unwitnessed): A resident is found on the floor, and the staff must investigate how they got there.
- Fall to floor (witnessed): A staff member or visitor sees the resident fall.
- Near fall (intercepted): A resident is stabilized or lowered to the floor by staff, preventing an unassisted fall.
- Fell from a low bed: If a resident rolls off a low bed or mattress onto a mat or the floor, it still counts as a fall.
Why a broad definition of a fall is important
Capturing every fall and near-miss is vital for quality improvement and resident safety. The broad definition of a fall serves several critical purposes in a long-term care environment:
- Accurate Incident Tracking: Standardizing the definition allows facilities to accurately track the incidence and circumstances of falls, providing data to identify trends and potential systemic issues.
- Root Cause Analysis: By documenting every fall, regardless of injury, staff can conduct a root cause analysis to understand why the fall occurred and implement targeted prevention strategies.
- Risk Factor Identification: Comprehensive data helps staff and administrators identify specific risk factors, such as environmental hazards, medication side effects, or resident-specific health conditions.
- Personalized Care Planning: Based on a resident's history of falls and near-falls, care teams can create individualized fall prevention plans that address specific risk factors like gait instability, cognitive impairment, or specific medications.
- Regulatory Compliance: Facilities are required to follow federal and state guidelines for reporting falls. Accurate classification and documentation ensure compliance and avoid potential penalties or legal issues.
Types of falls in long-term care
Falls can be categorized in different ways to help with analysis and intervention planning. The following table compares some common classifications used in long-term care settings.
| Classification | Definition | Key Characteristics | Implication for Care Plan |
|---|---|---|---|
| Unassisted Fall | The resident falls without anyone being present to intervene or assist them. | Higher risk for significant injury due to lack of intervention. Often unwitnessed. | Focus on environmental modifications, mobility aids, and scheduled checks to prevent future falls. |
| Assisted/Intercepted Fall | The resident begins to fall, but a staff member or another person helps ease their descent or breaks the fall. | Indicates that staff were present and able to intervene. Less likely to result in major injury compared to unassisted falls. | While still a fall, it highlights the importance of adequate supervision and responsiveness. Interventions may focus on gait training or improved staffing. |
| Witnessed Fall | The fall is observed by staff, another resident, or a visitor. | Provides immediate information about the circumstances of the fall, aiding in investigation. | The immediate response can be more informed. The incident report can include direct observations of what led to the fall. |
| Unwitnessed Fall | A resident is found on the floor, and no one saw the event occur. | Requires a comprehensive post-fall investigation to determine the potential cause and circumstances. | The investigation must consider all possibilities, including underlying medical issues, environmental factors, and medication side effects. |
Preventing falls in long-term care
Preventing falls is a multifaceted process that involves the entire interdisciplinary team, including nursing staff, physical therapists, and physicians. A thorough fall prevention program identifies and addresses both intrinsic (resident-related) and extrinsic (environmental) risk factors.
Intrinsic risk factors
These are factors related to the resident's health and physical condition, many of which can be addressed through proper care and management:
- Impaired Gait and Balance: Weak lower-extremity muscles and unsteady gait are common causes of falls in long-term care. Physical therapy can improve mobility and strength.
- Polypharmacy: Residents taking multiple medications, especially psychotropic drugs, are at increased risk due to side effects like dizziness, drowsiness, or changes in balance. Regular medication reviews are essential.
- Cognitive Impairment: Residents with dementia or cognitive deficits may be more prone to falls due to disorientation, impulsive behavior, and confusion. Activities that engage residents and reduce agitation can help.
- History of Falls: A previous fall is a significant predictor of a future fall, indicating a need for a targeted, individualized care plan.
- Vision and Hearing Problems: Impaired vision or hearing can affect balance and increase the risk of tripping over obstacles. Regular vision and hearing checks are necessary.
Extrinsic risk factors
These are external factors in the environment that can contribute to falls and are often more easily modified:
- Environmental Hazards: A cluttered living space, uneven flooring, wet surfaces, or unstable furniture can all lead to falls. Regular safety rounds are essential to identify and fix these issues.
- Lighting: Poorly lit hallways, resident rooms, and bathrooms can obscure hazards and increase the risk of a fall, especially at night.
- Equipment: Improperly fitting assistive devices (like walkers or wheelchairs) or equipment malfunctions (such as faulty bed brakes) can increase the risk of a fall. Regular maintenance and staff training on equipment use are vital.
Conclusion
Understanding what is considered a fall in long-term care is foundational to resident safety. A fall is defined not only as an uncontrolled descent to the floor but also as an intercepted event or an unwitnessed incident where a resident is found on the floor. This broad definition is intentionally designed to capture all incidents that may signal a risk to resident health. By rigorously documenting and investigating every fall, long-term care facilities can develop robust, evidence-based prevention programs. Addressing both intrinsic and extrinsic risk factors, from medication side effects and gait instability to environmental hazards, enables facilities to create safer living environments and improve resident quality of life. This proactive approach ensures regulatory compliance and fosters a culture of safety for vulnerable residents.
