March 01, 2010

Mrs. KL is a petite 95-year-old woman with advanced dementia. She is a pleasant woman who smiles easily and answers yes-or-no questions. But beyond those simple answers, her conversation is unintelligible.

Her favorite activity is propelling herself around our building, using her feet to move her wheelchair forward. She makes laps around the building, she watches the birds, and she often seems to be in search of something she never finds. Because her dementia is so advanced, she finds no enjoyment in the usual activities presented to the nursing home residents.

One of her other medical conditions is osteoporosis, which has caused a significant kyphosis. Multiple times, Mrs. KL has fallen forward, tumbling out of her wheelchair and striking the floor face first. Most falls have been without injury, but several have caused a trip to the emergency department. Luckily, she does not take anticoagulant medications.

In a fall about 6 months ago, she sustained lacerations requiring sutures to her eyebrow, cheek, and fifth finger. Her eyes were swollen shut for days, and the facial bruises were prominent for weeks. The interdisciplinary team at our facility met at that time and made changes to her care plan.

Last week, however, I was called as the facility's medical director to see her following another fall. Once again, she had pitched forward out of her wheelchair. She hit the left side of her forehead on the floor. She did not lose consciousness.

She again looked miserable. Her forehead had a 2.5-cm laceration atop a 4-cm hematoma. Her left eye was swollen shut, and the entire left half of her face came in shades of purple and maroon. When asked, she admitted to pain.

It turns out that between the two injury-provoking falls, Mrs. KL had fallen multiple times without injury. During her waking hours, the nursing staff now keeps her wheelchair parked at the nursing station, where they can prevent a fall if she slowly stands up or leans forward. If Mrs. KL moves quickly, as she has been known to do, a fall can take place in front of an incredulous staff. Mrs. KL has been averaging two or three falls per month.

Interdisciplinary Team Meeting

Medical Director: Mrs. KL has now had two very serious falls, either one of which could have caused fatal intracranial hemorrhage. What are we to do so that she doesn't fall again?

Certified Nursing Assistant: We keep her close; we are able to keep our eye on her when she is in the lounge adjacent to the nurses' station. She is in the closest room. We do 15-minute checks throughout the day and night. It is when she leans forward that she falls out of her chair.

Unit Nurse: Mrs. KL is a very pleasant woman, but her short-term memory loss is profound. With each fall she has had during the time she has been here, we have attempted to educate her to “call for assistance” and told her “let us help you get up” and so forth. But since she can't remember, our efforts fail.

We have insisted she have a bed alarm and a chair alarm. What these devices do is to let us know that she has fallen, not that she is about to fall. We aren't allowed by regulations to restrain her, and we are frustrated that we can't seem to catch her before she falls.

Physical Therapist: At the request of the medical director we performed a fall-balance evaluation. It identified multiple fall risks for Mrs. KL: cognitive impairment, vision and hearing deficits, incontinence, recent medical illness, and of course, past history of falls.

We assessed that she needs a maximum assist [75% assistance] in transfers between wheelchair and bed. Although she has good sitting balance, her static and dynamic standing balance is poor.

We assessed her posture: She has forward head position, forward and round shoulders, kyphosis, and hip flexion. She has gait abnormalities that include decreased heel strike, shortened steps, and narrow-based discontinuous steps.

We performed a Tinetti [timed get up and go test] in which we had her get up from a chair, walk 10 feet, turn around, and sit down. For her safety, we performed this test with her wheeled walker, an assistant standing by, and Mrs. KL wearing a gait belt. A person with a low fall risk can perform this maneuver in less than 12 seconds; a person is considered to have very high fall risk if the Tinetti test takes longer than 30 seconds. Mrs. KL completed the maneuver in 54 seconds, one of the worst scores we've ever seen.

We can enroll her in therapy to attempt to improve on her balance and ambulation.

Director of Nursing: We could request a seatbelt for her wheelchair, but with her short-term memory problems, she might not be able to remember how to open it and then it would be considered a restraint.

Also, if she would lean too far forward while wearing the seatbelt she could easily fall face-first with her wheelchair atop her. So we would want to add forward antitip bars to her wheelchair. We would want physical therapy to assess this.

The interdisciplinary team agreed to recommend to Mrs. KL's attending physician physical therapy for balance and gait training, a snap-type seat belt and forward antitip bars. The physician agreed.

Two Months Later

In the past 2 months, Mrs. KL has had three falls. In every case, she fell forward out of her wheelchair. Two were without injury, but in her most recent fall she sustained a skin tear to her ankle.

Unit Nurse: We found out that Mrs. KL can unsnap her seat belt, because she did it and then fell out of her wheelchair. We still keep her at the nurses' station during waking hours, but she wanders off by pushing her wheelchair with her feet. With one of the falls, the chair alarm pad came with her—so it didn't function.

Physical Therapist: We had Mrs. KL in therapy but only for a short time. We tried to work with her on balance and gait but usually she indicated that she wasn't up to a session.

We made no demonstrable progress. We noticed that after her last fall, her seat belt has been changed from a snap-closure one to a Velcro-fastened seatbelt. Does Mrs. KL have the hand strength to pull open 18 inches of Velcro? I doubt that she does. Therefore, this kind of seatbelt would be a restraint.

Director of Nursing: I am concerned that this restraint could be an issue when we have our next state survey.

Medical Director: Yes the Velcro seatbelt is a restraint, but this resident has had multiple falls, including two serious ones. It's our responsibility to keep her safe. Does she have to have a fall with intracranial bleeding before we keep her safe? Restraint or no restraint, she needs to be kept safe—even if she can't remember how to do so herself.

I understand that this is a restraint and that it can been cited as a quality of life issue, but I want to make an argument here that falling and having prominent black eyes and bruises lasting for weeks is also a quality of life issue, as is risking intracranial bleeding.

If the administrator is willing to make the call, I would be happy to confer with the attending physician and then document thoroughly why we have made this decision.

Nursing Home Administrator: Putting a Velcro seat belt on Mrs. KL when we know that she doesn't have the strength to undo it is clearly a restraint and definitely puts us at risk of an F-221 citation [restraints]. But failing to provide for her safety puts us at risk of F-324 [prevention of accidents].

Either way, we have a difficult situation.

I want everyone—CNA, nurse, physical therapist, and medical director—to document why we came to this decision. In addition we will need regular reassessment and documentation of her status. No matter what decision we make, we could be in violation. However, in this situation I choose to err on the side of patient safety.

Follow-Up and Discussion

Shortly after this interdisciplinary team meeting, Mrs. KL became ill with pneumonia. She has entered hospice and now spends much of her day in a special reclining chair. She can no longer propel herself in her wheelchair. She has had no further falls, and she stills smiles at everyone who speaks to her.

This IDT case demonstrates the tension felt in caring for long-term care residents.

In care planning for Mrs. KL, we needed to ask many questions about safety vs. independence: Is the seatbelt for staff convenience? Has the staff ruled out anticipatable causes of falls (e.g. toileting)? Does propelling herself around in her wheelchair add value to Mrs. KL's day? Can the seatbelt prevent unnecessary injury? Is the person with Mrs. KL's power of attorney in agreement with our plan? Have we clearly documented our decision making? Have we made plans to reassess the restraint?

If we decide on restraints only after such care-planning discussions, we will take good care of residents such as Mrs. KL.

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