Senior Care Facilities

Culture of Safety

• The leadership team plans and implements a strategic vision for the organization.  Leaders have the opportunity to encourage and reinforce clinical risk management with every employee, contractor, and clinician. 
• Prioritize a culture of safety that will mitigate professional liability risk and enhance resident confidence. 
• Leadership establishes a culture of safety through performance improvement, physician and staff engagement, and providing quality clinical care.
• Encourage participation in patient safety education and training for medical staff and employees and support development of new risk mitigation initiatives.
• The  AHRQ culture survey helps identify areas needing improvement, and provides tools to enhance the culture of safety.
• Establish a chain of command (COC) protocol that empowers all employees to raise any perceived patient safety concerns with leadership without fear of retribution. Additional resources are available to assist leadership in developing a chain of command protocol, including: a sample policy and chain of command flowchart.

Falls

• Each facility should have a fall management program in place. Fall management programs can be found at the Agency for Healthcare and Quality (AHRQ) and U.S. Department of Veterans Affairs (VA) websites, among others.
• The facility’s protocols, policies, and procedures should include a post fall huddle (PFH) review. Consider developing a PFH template.
• PFHs are confidential and are not included in the medical record; they provide a template to examine any unanticipated event.
• A case scenario, along with an outline of components of a PFH, have been prepared to augment staff education.

• The Joint Commission  recommends the PFH as a strategy to review fall and injury risk factors with the ultimate goal of prevention.

Suggested Post Fall Huddle Components

• The first action is to determine if emergency care is needed and to act accordingly.
• The team should convene within 15 minutes of the fall event, or in accordance with facility policy.
• The staff member in charge of the resident, designated Post Fall Huddle Team Leader (TL), makes an announcement of an immediate huddle.
• Involve the resident whenever possible.
• Require individuals to gather and use “Group Think” (consensus of a group rather than a decision by an individual) to discover what happened.
• Involve interdisciplinary team members whenever possible (such as RN, NP, MD, PT, members of nursing staff (LPN, CNA), who know the resident (no more than 3-4 people to not overwhelm the resident).
• The TL completes the PFH form.
• The appropriate clinician:
  • Modifies the resident’s plan of care to include identified interventions.
  • Communicates new interventions during resident hand-off reports.
  • Documents the fall event in the EMR per facility policy and guidelines.
• After the post fall huddle, the Nurse Manager should follow-up with staff and the resident to ensure interventions are implemented, and the resident understands the interventions.
• The Nurse Manager should be available to answer any questions or concerns voiced by resident or family.

Post Fall Huddle Scenario

A resident was admitted on day shift to the rehabilitation-nursing unit for post-operative hip replacement care. During the night shift, around 8:30 p.m., the nursing staff heard a loud noise in the resident’s room. When the CNA entered the room, she found the resident on the floor with her foot tangled in the bed sheet near an overturned walker. The CNA then called for assistance. The resident said she was not hurt, and the walker was too far away from the bed. As the resident was reaching for the walker, she lost her balance and fell. Her vital signs were within normal limits, including blood glucose. She denied any dizziness when she attempted to stand. 

The RN arrived and quickly assessed the resident. Together, they assisted the resident to the bed using a lift, placed the call light within reach and re-educated the resident on the use of the call light for assistance.

The RN called team members for a Post Fall Huddle.

Post Fall Huddle Sample Form

 

Communication

Effective communication is integral to quality healthcare. You may have excellent clinical skills and a state-of-the-art facility; however, if communication is not a priority, you may increase your liability exposure. Consider incorporating the following guidelines to further enhance patient safety:

Communication Skills Checklist

Limited English Proficiency Residents

We suggest first determining the need for language services. To help determine your obligation to provide meaningful access, consult HHS.gov for guidelines and answers to frequently asked questions.

The numerous options available may include, but are not limited to:

• Employing bilingual staff
• Enlisting community volunteers to interpret
• Using telephone or video conferencing interpretation services
• Hiring or contracting with qualified on-site interpreters
• Using written transcription and translation services
• Sharing the costs of resources or services with other facilities

The facility may also allow the patient to use family or friends to translate; however, the resident’s potential reluctance to disclose sensitive medical information in the relative’s/friend’s presence should be considered. In addition, the relative or friend may not convey the message objectively and effectively. In many cases, the family member may be a minor child who does not yet have the education or maturity to convey critical information.

The communication method(s) chosen should be accurate, effectively convey medical terminology, and maintain confidentiality.

Document in the medical record the communication method(s) agreed upon by resident and provider, or resident’s refusal of translator services.