Elderly people do fall – Placing a relative into a care home is an emotionally distressing time for all parties concerned, as you relinquish day-to-day care for your relative and hand over the reins of responsibility to a third party and entrust them with your relative’s care. For many, it is the overwhelming realisation that they have tried to do their best for their relative, but the time has come when they need to be looked after by professionals in a specialist care facility.
However, in the current economic climate, where many care homes may be forced to cut corners just to remain open, there will inevitably be staff shortages and the increased risk of neglect – particularly falls.
Falls can be caused by a variety of factors including: impaired vision, hazards, medication (e.g. tranquilizers, sedatives that cause drowsiness and anti-depressants reducing mental alertness), fatigue, confusion, poor concentration, muscle weakness, poor balance, posture or gait, poor mobility, incontinence, urinary tract infections, hypotension (low blood pressure which causes dizziness and fainting), high blood pressures (taking anti-hypertensives), or other chronic conditions such as Parkinson’s, heart disease, diabetes and many more – all of which can increase the risk of falling.
Residents with advanced Dementia can have a loss of perception of depth and distance. For example, they can often misjudge how far they are from an object or be uncertain as to the difference between a flat or raised surface. They may try and avoid a shadow or a dark area on the floor or carpet by going around it, as they perceive it to be a hole in the floor and fear falling into it. This inability to distinguish depth and distance can certainly increase the risk of falling.
It has been said that one out of every three people 65 years and older fall each year, and once they’ve fallen, they’re two to three times more likely to fall again within a short space of time.
The question is whether the fall was merely an isolated incident or accident, just part of the ageing process or an indication of a change in their cognitive functioning or general well-being? You need to know what caused their fall. Multiple falls in a short space of time are a matter of even greater concern.
At best, elderly and frail residents in a care home facility might get away with suffering minor soft tissue injuries, bumps and bruises – which is bad enough. In more serious falls, fractures, dislocations and head injuries are common. In vulnerable patients, such injuries can lead to physical long-term disability, restriction of movement, impairment, loss of independence, distress, and a loss of confidence through fear of falling again. Psychologically, they can become introverted, reclusive and depressed. Even if they weren’t injured, the fear of falling itself can lead to a reduction of everyday activities and inactivity, gradually becoming weaker and increasing their risk of falling.
Sadly, falls can often become a turning point and the catalyst for the onset of other life-changing medical conditions and complications, and the start of a downward spiral of deteriorating health. Some falls can be catastrophic. How often do we hear heart-breaking accounts from children telling us how mobile and independent their parents were before they fell, and how rapidly they declined afterwards.
The older the individual, the longer it generally takes to recover from a nasty fall. In some instances, residents may be too frail or elderly to run the risk of surgery and general anaesthetic and are left to suffer in pain. What starts with a fractured hip or pelvis can lead to reduced mobility, becoming bed-bound, incontinence, UTI’s and pressure sores.
There is a clearly a need to improve the care for the elderly and especially those who are at high risk of falling. Elderly people and those with balance issues such as Parkinson’s, do and will fall. The risks of falling increases with age and frailty. However, the greater the risk, the greater the need to protect them and implement precautions, frequent assessment and monitoring.
When your relative enters into a care home, staff should carry out a full risk assessment which will include a Falls Risk Assessment – a tool to assess their likelihood, risk and consequences of falling. This will enable the care home to create a strategic risk prevention Care Plan to minimise (or hopefully, eradicate!) the risk of them falling and causing injury.
Accidents can happen, but here are a few things to ask yourself when next visiting your relative in their care home:
- Has your relative fallen before, how often and are they known to be at risk of falling?
- Do they have mental capacity to appreciate risk and dangers?
- Do they hallucinate or exhibit inappropriate behaviour or aggression that could increase their chance of falling?
- Is their medication likely to make them prone to falling or increase the risk of falling?
- Does their medication need reviewing, changing or even discontinuing?
- Are they eating properly? Look out for weight loss as this can cause reduced muscle strength.
- Is their diet right? Low energy levels and low blood sugar can cause fainting and dizziness, especially in diabetics.
- Do they need to mobilise or exercise more?
- Is their footwear appropriate or even missing?
- Is their balance off kilter?
- Are they prone to wandering (unobserved)?
- Does their room need any hand/grab rails?
- Does their bedroom need better lighting?
- Do they need a walking aid for support and confidence?
- Has their vision altered, and does it need reassessing?
- Are they unsteady on their feet and need to be observed more often?
- Is their Falls Risk Assessment and/or Care Plan accurate or does it need updating? When was it last reviewed?
- Do they need closer supervision and assessing for 1: 1 care?
- Do they fear falling?
- Is there a pattern as to when they fall e.g. at night-time when there are reduced staff on duty?
Watch out! Unsupervised falls could be an indication of a lack of staffing and neglect.
We often hear from our readers that their parent or spouse fell several times in a very short space of time, and naturally that leads them to question the adequacy of care and supervision in place.
If this happens to your relative, ask to speak to the care home manager and get an explanation as to when and how the fall occurred. Could the care home have done more? Is there neglect?
Ask to see their Care Plans and Falls Risk Policy. Check whether they are being adhered to or need updating and whether they accurately reflect the nature and characteristics of the risks to your relative?
Don’t rely on the care home to keep accurate records. They are often too busy to make good notes. Keep a log of all falls, actual or near misses, as evidence of the standard of care provided and potential neglect.
Enquire as to what precautions are going to be instigated to prevent similar occurrences in the future.
Get confirmation of your discussion and the care home’s assurances in writing.
Hold the care home to account and ensure that they implement and monitor the agreed plan of action and consult you when any changes are made.
Handle the matter with sensitivity, but above all, don’t be fobbed off or afraid of rocking the boat! This is your relative’s health at stake. If you have concerns, then you must speak up! Don’t leave it until it’s too late and they’ve had another fall or been admitted to hospital.
What is not acceptable is for the care home to say in their defence is:
- ‘Well elderly people do fall, don’t they!’
- People with Dementia will fall’
- ‘We’re doing our best but we can’t prevent every resident from falling’’
- ‘We cannot watch your mother 24 hours a day’
- ‘Your father falls at night when we have fewer staff on duty’
You have entrusted your relative into their care and the care home has a duty to ensure their safety and well-being at all times.
If you are really unhappy with the situation, you can always report the matter to the Care Quality Commission (CQC) who may decide to carry out an investigation and conduct a safe-guarding report.
Quite often, family members aren’t told about their relative’s fall at the time (or at all!) unless they happen to find out by chance. So, much can go unnoticed and even covered up – not wanting to alert or distress the family – particularly in the current COVID climate where close family have been excluded from visiting relatives in care homes.
Incidents of falling may not appear in the care records for a variety of reasons – not least perhaps because of simple unintentional omission, or the fall was unwitnessed and no one picked it up, or the resident was unable to communicate their pain from the injuries sustained, or out of staff embarrassment that a resident in their care has fallen on their watch.
However, care homes can take some simple but effective measures to reduce the risk of their residents from falling. Such as, fitting sensors or an alarm if the patient leaves their room unassisted, and putting crash mats by the bed (with sensors) to alert staff in the event of a fall.
There are various falls risk assessment tools, but whichever one the care home uses, it should be compliant with the NICE guidelines: Here’s a helpful link:
https://www.nice.org.uk/guidance/cg161/chapter/recommendations#extended-care
Summary
We looked at this issue of the elderly falling over a year ago in our blog:
Focus: Falling at the care home
But, with an ageing population, the problem isn’t going to go away soon and judging by the enquiries and comments we receive, it is only getting worse.
Falling at a care home could be an indication of your relative’s deteriorating health and be part of the ageing process or advancement of an existing condition – but that just increases the need to be vigilant and monitor their surroundings and physical and psychological well-being more closely. Investigate the cause of the fall. But, regardless, ensure that the care home puts in place adequate safety measures immediately to avoid a similar repeat occurrence happening or worse.
If you believe there has been clear neglect, we recommend that you seek specialist legal advice.
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I agree entirely Michelle. I feel the same that during Covid there could be abuse going un noticed and we as relatives are powerless to know about it or act on it. It is a dreadful and distressing situation to be in.
My experience after putting Mum into a care home in 2018 should be a warning to all. Whilst at home she had bed rails and the care workers ensured they were put in place every night even if she said she did not want them up as it was essential she did not fall out which was the NHS advice following her coming out of hospital back to her home.. We had a visit from nursing home supervisor prior to moving Mum to care home when she clearly knew what the procedure was and it was signed off. However, several weeks after she moved into care home she fell out of bed and it was only after she died following her fall out of bed did we ascertain that if she said she did not want they put up they did not. They insisted that they had to follow her personal instructions irrespective of what was in her best interest and that overruled what we agreed with the supervisor in the acceptance when she moved into care home. We were shocked but did not pursue legally as money would not bring Mum back. The lesson is that even the obvious should not be taken for granted and we feel so bad even to this day although we had done everything we felt was necessary to ensure she would be safe.
Over the years spent managing care, training staff, working in safeguarding and compliance inspection the one area that repeatedly brings up problems is care homes not actually grasping the need for ensuring every trip, knock or tumble is recorded whether witnessed or otherwise.
The most common reason care staff give for not reporting and recording is that if they note every accident, injury or fall would look bad. The second was falsely believing only witnessed falls and accidents should be reported. The third was just a complete lack of awareness, experience or knowledge of it being a legal requirement.
Night is when most falls occur not necessarily because of outright negligence or failure to supervise and keep safe but due to residents inevitably being spread out across the entire building, staff not having eyes on everyone constantly and it still requiring some time to attend to buzzers triggered by a pressure sensor mat or similar.
There are some fiercely independent folk that just will not allow staff to help and even bypass the pressure mats to avoid alerting staff which leaves you tearing out hair and teeth in frustration but the key thing is taking every step necessary to reduce the risk, level and severity of injury they can potentially suffer if they do fall. That can be something as simple as making sure tissues, water jugs and buzzer cords are within reach, shifting furniture around in bedrooms, regular checks of carpet, flooring and having a schedule of maintenance.
Lowering beds or having a soft “crash mat” to the side of beds can help but on the other hand that itself can present an additional trips hazard and if the person is mobile and able to get in and out of bed independently, the last thing you want is something directly beside the bed they can fall over.
Same applies if someone is at risk or has previously fallen trying to get on and off a commode during the night and before staff are able to respond to buzzers and pressure mats. On the one hand it is often safer to place the commode directly beside the bed in a position that allows them to get in / out but on the other, being within reach might mean it’s more tempting for them to attempt getting on without buzzing for staff.
Bed rails are often used in hospital wards but I never had them in care homes I managed. If someone is mobile enough to manage wriggling and climb out of bed they shouldn’t be given an extra 1-2ft of height to fall which is the case should they get above and over bed rails. The additional risk of entrapment and potentially considered as unlawful restraint also creates issues.
I knew a gent that refused to sleep in a bed and would throw himself clean off it and curl up on the floor instead. He was a former Navy officer and no matter what you said or how you tired to meet him halfway he was adamant it was his preference to “sleep on the deck” and staff reported that he screamed the place down if they tried to help him back onto the bed again.
Trying to keep him anywhere else was a far greater risk and one we could remove entirely by just making adjustments to his room, updating and recording his care plan and assessments to reflect the same and provide full rationale as to why this chap didn’t have a bed.
There’s no simple way around it and every person is entirely different and needs to be assessed individually but generally speaking, if you can’t remove the risk of fall, you must reduce the likelihood and severity of any injury.
Hello Charlotte,
I read your post with interest, especially as you have worked and trained others in safeguarding.
It’s concerning to read that you found incidents of falls, and accidents go unreported because “It looks bad!”
Bad for whom? Bad for the provider? Bad for the resident? Bad for the manager?
This reinforces my belief that families have only a glimpse at what actually happens to their loved ones behind closed doors.
So much of the CHC assessment is based on the evidence of good quality care home notes. If as you say, repeated falls look bad on the provider, then they are failing in their duty to provide this crucial evidence.
I know many incidents and falls went unreported for my father that I then had to follow up to ensure was documented. At times it felt like I was policing the setting.
My other frustration is the view that homes take with the lower level of staffing during the night. There should be no distinction in day or night time staffing.
In my father’s case the level of staffing was halved at night.
The workload in my opinion is not halved during darkness. With my father and many of the residents their most active period was throughout the night.
Dad was made ready for bed and placed in his bed sometimes as early as 7pm. He didn’t want to go to bed or his room, yet because it was “bedtime” he was treated like a child and put to bed!
I never understood it.
I accept that it is impossible to prevent every incident or accident, but I don’t accept that it goes deliberately unreported.
Families are relying on comprehensive notes. If it “looks bad” reinforces the amount/quality of care that individual needs to keep them safe….surely?
But then the cynic in me also believes that the reason incidents/accidents/falls go unreported is because the evidence would be overwhelming for CHC eligibility …..and of course the home would then lose the higher rate of funding paid by private residents.
The clip I made reference to is of ex Corrie St actress Leandra Ashton and her grandmother. It’s shocking footage of a carehome who refused to listen to the concerns of a daughter who was then arrested!!!
Reinforces my belief that relatives have no control or authority in what happens to their loved ones in certain homes!
This another helpful article and as I now reflect upon the experiences of having my late father in a nursing home where I was able to visit daily and see the injuries sustained from numerous falls I was able to question and monitor every incident to make sure dad was being kept safe. I remember vividly being called a habitual complainer by one member of staff!!!
One of the biggest issues with dad’s illness (Parkinson’s disease dementia ) was his night time waking and hallucinations and night terrors which resulted in many incidents that simply weren’t recorded because the staff viewed it as a normal event with someone suffering from the disease. I got comments from carers such as “Well, he won’t stay in bed and he plays us up all night, shouting and screaming and he then falls out of bed on to the mat on purpose and crawls about like a baby!” The frail skin on his arms and elbows were made worse by staff allowing my father to crawl about the bedroom floor using his arms to drag himself! Tears fill my eyes as i wonder what he must have felt during these times.
I was able to deal with these issues immediately and forcefully by complaining to management but I fear with the Covid virus holding the elderly to ransom and relatives not being able to get inside homes, then this standard of care could easily go unnoticed and unreported. The only way to be sure your loved one is getting the best possible care is to surely see/examine their face/arms/legs/hands etc. Not being able to do that because of restrictions puts patients at risk and poor care going unchecked.
I don’t advocate undercover surveillance but I do think that homes should make it compulsory to protect everyone….residents & staff alike. We loose the right to privacy but I would have preferred that to have dad kept safe! There is a recent heartbreaking clip on line (I can’t find it right now!) with a daughter visiting her mother at a care home and the daughter tells the staff she is worried because her mother is looking gravely ill and she wants a doctor called. The staff refuse and shut the blinds down and the daughter is left absolutely distraught……this must be happening up and down the country? Relatives are being left powerless and held to ransom over Covid!
I agree entirely Michelle. I feel the same that during Covid there could be abuse going un noticed and we as relatives are powerless to know about it or act on it. It is a dreadful and distressing situation to be in.
Not just abuse but clinical negligence. Over Christmas my friend’s mother died suddenly. Not of Covid but Sepsis! The elderly lady had been in a care home for 7/8 years and my friend visited her mother at least 3 or 4 times a week and always made sure things were being done properly. However, since the start of the pandemic my neighbour was only able to physically get inside the home several times and even then, she was not allowed near her mother, so couldn’t see if her mum had any unexplained bruising etc. The home had suffered numerous deaths from Covid but my friend’s mum escaped the virus, until she became unwell during December and was admitted to hospital. On admission the Doctors/Staff were horrified to see the disgusting state of her legs, which were black and oozing fluid. The hospital asked my neighbour to attend immediately as they were going to amputate both legs!! Photographs were taken of her legs by the Doctors treating her. My friend was absolutely distraught and heartbroken to see the state that her mother had been allowed to get to before intervention.
The lady sadly died that night and the death certificate stated: Cellulitis as major cause.
My friend has written to the home, the GP and our local CCG, who have taken up her case.
I am furious, but not surprised that such negligence is taking place during these times. It is absolutely disgraceful, that no one from the home made my friend aware that her mother was suffering from cellulitis until it was too late! There is definitely a case of Clinical Negligence to answer to, but sadly it wont bring my friend’s mother back.
I urge families to be vigilant. Don’t assume your loved one is safe because there isn’t Covid in the home. They aren’t safe from those who are supposed to be nursing/caring for them!