• Falls are common in long-term care facilities and are a major safety concern for long-term care facilities.
• While not all falls and injuries can be prevented, it is critical to have a systematic process of assessment, intervention, and monitoring to minimize fall risk.
• Falls data is obtained from the Certification and Survey Provider Enhanced Reports (CASPER) for the New Mexico Behavioral Health Institute and Fort Bayard Medical Center long-term care facilities. The FY18 results were:
  • Quarter 1: 1.8%
  • Quarter 2: 2.6%
  • Quarter 3: 3.7%
  • Quarter 4: 4.0%
  • FY18: 3.9%

        The target of 3.0% was not met.

• Every new long-term care resident is assessed for fall risk. This assessment is then included in each individual resident's care plan, contributing to the success of this measure. However, it is a significant challenge to balance each resident's need for independence with the inherent risk for falls.
• Individual facilities, and treatment teams within the facilities, evaluate every fall to help determine the root cause of the fall and then incorporate interventions such as closer observation, assistance with transfers, etc. into the treatment plan. A request for further analysis and action plans will be made to the Long-Term Care (LTC) Facility Falls Prevention Committees.

• HealthInsight New Mexico, the Centers for Medicare and Medicaid Services contracted Quality Improvement Organization for New Mexico
• The Joint Commission on Accreditation of Healthcare Organizations
• NMDOH Division of Health Improvement
• Governing Body for facility oversight
• Centers for Medicare and Medicaid Services provided CASPER Reports
• LTC Facility Falls Prevention Committees

• Education of employees, residents, and family members has demonstrated some success in being able to protect residents.
• Close observation continues to be our best method of preventing falls in nursing home settings.
• Therapy services that focus on strengthening individuals, and assist in preventing falls by improving balance and mobility.
• Individualized resident treatment planning following any fall assists in prevention efforts.

• Ensure that Skilled Nursing Facilities have active Falls Prevention Committees. Both facilities continue to hold these meetings on a regular basis.
• Monitor that Falls Prevention Committees are analyzing causes of falls and are taking appropriate actions to prevent future falls. This is the major focus of these teams and these efforts continue.
• Track quarterly outcomes of each facility as well as aggregate data to determine improvement or lack of improvement.

• Q1: Ensure active Falls Prevention Committees hold at least one meeting per quarter. Completed.
• Q2: Falls Prevention Committees will document actions being recommended and implemented to reduce the number of falls (documented in minutes). Completed.
• Q3: Treatment teams of facility units will voice interventions being implemented locally to help reduce the number of falls. Over the 4 quarters of Fiscal Year 18, there is an increasing trend in the percentage.  A request for further analysis and action plans will be made to the LTC Facility Falls Prevention Committees. Completed.
• Q4: Encourage employees to participate in falls prevention activities and bring new suggestions and ideas to the committee. Completed.

• In FY18, the percent of long-term care residents experiencing one or more falls with injury was 3.9%.  This annual result did not meet the target of 3.0%.
• Intervention measures are ongoing to prevent falls with major injuries.  Facilities continue to promote education of root causes of falls, utilize therapy services, and maintain active Falls Prevention Committees.