In-Hospital Falls

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According to the Centers for Disease Control and Prevention (CDC), each year one in every three “older adults” (65 years and older) falls. Centers for Disease Control and Prevention, Falls Among Older Adults: An Overview, available at http://1.usa.gov/19A97Zb. According to the CDC's report, in 2010, approximately 21,000 older adults died from unintentional fall injuries. The most common fall-related injuries were fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.

Among older adults who sustain a hip fracture, studies show that nearly 50% never regain their previous level of functioning, while 30% die within six months. John Jorgensen, MPA, RN, Reducing Patient Falls: A Call to Action, Best Practices for Falls Reduction: A Practical Guide, Mar. 2011, p. 2.

In addition to the recovery and mortality problems falls create for older adults, these events carry significant costs. When adjusted for 2010 inflation, “falls among 'older adults' cost the U.S. health care system $30 billion in direct medical costs.” Centers for Disease Control and Prevention, Costs of Falls Among Older Adults, available at http://1.usa.gov/19huwbH.

Since in-patient falls are avoidable, in 2008, the Centers for Medicare and Medicaid Services (CMS) joined with the CDC to enact a new payment provision whereby Medicare and Medicaid would no longer reimburse hospitals when one of eight so-called “never events” during a hospital stay led to injury. Falls were included on that list of events that should never happen after a hospital admission. Consequently, hospitals would no longer receive payment by Medicare and Medicaid for treatment related to injuries caused by in-hospital falls. Jorgensen, supra at 2. CMS and others assert that that the initiative is a “strong incentive for healthcare providers to implement practices that reduce the number of preventable patient falls.” Jorgensen, supra at 2.

Efforts to increase health care quality and decrease costs are causing hospitals throughout the country to take steps to reduce the amount of inpatient falls by adopting fall-reduction programs. One of the first places hospitals turn to for guidance on establishing these programs is the Joint Commission on Accreditation of Healthcare Organizations. Accordingly, attorneys representing individuals who suffered injuries resulting from an in-hospital fall should also look to the Joint Commission in order to determine whether a hospital's fall-reduction program, protocols, or policies deviated from acceptable standards of care.'

The Joint Commission

The Joint Commission on Accreditation of Health Care Organizations is an independent, not-for-profit organization whose mission is to “continuously improve health care for the public ' by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” The Joint Commission, About the Joint Commission, http://bit.ly/1aaLEi9. To gain accreditation, hospitals must allow on-site surveys to determine whether the hospital is in compliance with the Commission's current National Patient Safety Goals and Provisions of Car Standards.

According to the Commission, the purpose of the National Patient Safety Goals is to improve patient safety and focus on problems in health care safety and how to solve them. The Joint Commission, 2013 Hospital National Patient Safety Goals, http://bit.ly/17WV9Ei. Because these goals and standards are revised annually, it is important for hospitals that are seeking accreditation to ensure that their safety programs are up-to-date with any new requirements or compliance procedures.

National Patient Safety Goal 9

In 2005, the Joint Commission introduced a National Patient Safety Goal to help to reduce the risk of patient harm resulting from a fall. Jorgensen, supra, at 2. Dubbed National Patient Safety Goal 9, or NPSG 09.02.01, the goal consisted of two requirements: Requirement 9A and Requirement 9B. Joint Commission Resources: Special Report! 2005 Joint Commission National Patient Safety Goals: Practical Strategies and Helpful Solutions for Meeting These Goals, http://bit.ly/15VzcHh. At the time the goal was introduced, hospitals seeking accreditation were only expected to comply with Requirement 9A, which stated that hospitals must “assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to address any identified risks.”

Requirement 9B, which was only applicable to long-term care facilities at the time, required: 1) the implementation of a fall reduction program, “including a transfer protocol”; and 2) that the “the effectiveness of the program” be periodically evaluated. Special Report! 2005 Joint Commission National Patient Safety Goals: Practical Strategies and Helpful Solutions for Meeting These Goals, http://bit.ly/1e915M7.

In addition to complying with Requirement 9A, in 2005, hospitals were also expected to regularly assess each patient's risk for falling by reviewing “risk factors such as previous history of falls, cognitive impairment, impaired balance or mobility, musculoskeletal problems, chronic diseases, nutritional problems, and use of multiple medications.” Id. At the time, the Commission also offered the following compliance “suggestions” as part of their risk reduction strategies:

• Install bed alarms or redesign bed alarm checks and tests;
• Install self-latching locks on utility rooms;
• Restrict window openings;
• Install alarms on exits;
• Add fall prevention to education of patients, residents, or individuals served and their families, improve and standardize nurse calls systems;
• Use low beds for those at risk for falls;
• Revise staffing procedures;
• Counsel individual caregivers; and
• Create a fall-preventing committee to assess new individuals or patients for fall potential, to regular review falls, evaluate interventions, and look for trends and patterns, and to communicate their findings to other staff.”

Id.

Revisions and Additions

In 2006, the Commission revised National Patient Safety Goal 9 and expanded Requirement 9B so that it applied to hospitals. Joint Commission Resources: Joint Commission Perspectives on Patient Safety, Special Report! Helping Solutions for Meeting the 2006 National Patient Safety Goals, Vol. 5, Issue 8, August 2005, available at' http://bit.ly/19AaE1s. The Commission advised that a hospital's fall reduction program “should include an assessment process, risk reduction strategies, transfer protocols, in-services, involvement of patients/families in education, and evaluation of environment of care issues.” It also offered the following tips on compliance solutions:'

• “Identify the drug/drug classes that are most frequently associated with an increased risk for failing;
• Use a transfer protocol to guide the staff in how a patient or resident can be transferred safely from a wheelchair, chart, stretcher or bed;
• Evaluate how long it takes for the staff to address patient calls (and shorten that time, if necessary) and ensure that food, liquid, and toileting needs are met;
• Promote a normal sleep pattern for patients;
• Use a reliable and valid instrument to predict and identify prone-to-fall patients;
• Communicate a patient's fall risk to the patient and family and remind patients to call for assistance before getting out of bed or getting up from a chair (reassure them that this does not bother the staff);
• Understand the patient by knowing that some are prone to falls because of recent changes in levels of independence, slow adaptation to environmental changes, short-term memory changes, poor impulse control, sensory changes (for example visual, auditory, balance, awareness of elimination needs), fine motor changes, and communication difficulties;
• Make sure there is enough staff coverage during the shift changes;
• Consider the environment of care by: 1) making sure the patient's needed objects are accessible at all times; 2) improving lighting; 3) controlling noise; and 4) moving higher-risk patients closer to the nurses' station; and
• Provide visual cueing (for example, special colored ID bands, identifier on the door or bed) for staff members so that they know which patients are at high risk for falls.”

'Id.

In 2008, National Patient Safety Goal 9 was again revised to include the following “Implementation Expectations” under Requirement 9B: 1) The organization establishes a fall reduction program; 2) The fall reduction program includes an evaluation as appropriate to the patient population, settings, and services provided; 3) The fall reduction program includes interventions to reduce the [patient's] fall risk factors; 4) Staff receive education and training for the fall reduction program; 5) The [patient] and [patient's] family are educated on the fall reduction program and any individualized fall reduction strategies; and 6) The fall reduction program is evaluated to determine the effectiveness of the program.

2008 National Patient Safety Goals ' Joint Commission Resources, Joint Commission Perspectives, Vol. 27, Issue 7, p. 16 (July 2007).”

The Commission further advised that a hospital's evaluation of its fall program could include an evaluation of a patient's “fall history, medications and alcohol consumption review, gait and balance screening, walking aids, assistive technologies and protective device assessment, and environmental assessments.” Id.'

In 2010, NPSG 09.02.01 was upgraded from a National Patient Safety Goal in hospitals to a Provision of Care Standard. Jorgensen, supra, at 2. The Provision of Care Standards that address reducing the risk of patient harm resulting from falls in hospitals are as follows:

1. PC (Provision of Care).01.02.08 EP (Element of Performance) 1 and 2 (Element of Performance 1 ' The hospital assesses and manages the patient's risk for falls based on the patient population and setting; and Element of Performance 2 ' The hospital implements individualized strategies to reduce falls based on the patient's assessed risk for falls.)
2. PC (Provision of Care).02.03.01 EP 101. Based on the patient's condition and assessed needs, the education and training provided to the patient include'fall reduction strategies.
3. HR (Human Resources).01.05.03 EP 8 (Staff participates in education and training on fall reduction activities. Staff participation is documented).
4. PI (Performance Improvement).01.01.01 EP 38 (The hospital evaluates the effectiveness of all fall reduction activities, including assessment, intervention, and education).

Joint Commission Requirement, Approved: 2010 National Patient Safety Goals, Joint Commission Perspectives, Vol. 29. Issue 10 (October 2010).

Conclusion

Attorneys representing clients who suffer injuries resulting from an in-hospital fall should familiarize themselves with the Joint Commission's Provision of Care Standards applicable to a patient's fall to ascertain whether a defendant hospital maintained a fall prevention program consistent with applicable standards of care. In addition, by arming themselves with the applicable compliance suggestions, expectations, and solutions offered by the Commission, attorneys will be prepared to propound valuable discovery demands and effectively question physicians, nurses, representatives of the hospital and experts during depositions.'

Robert Sanfilippo is an Associate at the Roseland, NJ, firm of Starr, Gern, Davison & Rubin P.C. John Ratkowitz, a member of this newsletter's Board of Editors, is a partner at the firm.'