The Care Home Falls Review
A 78-year-old resident of a care home has had three falls in eight weeks. She has osteoarthritis in both knees, takes a sedating antihistamine at night for itching, and has had two recent urinary tract infections. Her GP has asked the home to complete a falls review. Staff report she is unsteady when walking to the bathroom at night and often does not use her walking frame because 'it is too slow'. The home has one night-time carer for 20 residents. The manager wants a quick fix - a bed rail and a sensor mat - and asks you to sign off the care plan change today.
1. Using a multifactorial falls risk framework, identify the contributing factors in this case and explain why a single intervention is unlikely to be adequate.
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Falls in older adults are usually multifactorial, and the assessment should map intrinsic, extrinsic and situational factors.
Intrinsic. Age and osteoarthritis in both knees cause pain, reduced range of movement and altered gait, which increase fall risk. Two recent UTIs suggest possible delirium, post-infection weakness, or urinary urgency driving hurried night-time trips. The sedating antihistamine is a likely contributor: sedation, impaired alertness and possible orthostatic effects increase risk, especially at night. Her stated reason for not using the frame - 'too slow' - signals a mismatch between the aid and her priorities, which is itself a risk factor because an unused aid offers no protection.
Extrinsic and situational. Night-time staffing of one carer for 20 residents means assistance may not be available promptly when urgency drives her to walk unaided. The route to the bathroom at night, lighting, footwear and the height of the bed and toilet all matter.
Why one intervention is inadequate. A bed rail addresses only the moment of getting out of bed and may increase risk if she climbs over it; a sensor mat alerts staff but does not prevent the fall and depends on a carer being free to respond. Neither addresses pain, medication, infection, urgency or the walking aid. Effective falls care is multifactorial and individualised: review the antihistamine with the GP, optimise analgesia, treat and prevent UTIs, arrange a physiotherapy review of the walking aid (and consider a lighter or better-suited frame she will actually use), address night-time toileting (commode, route lighting, timed assistance), and review footwear. The care plan should record who is responsible for each action and when it will be reviewed.
2. The manager wants the change signed off today. What is your professional response, and what should be documented?
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Signing off today would be premature because the assessment is incomplete and the proposed measures are not risk-free. The professional response is to be clear, constructive and documented: agree that action is needed now, distinguish urgent interim measures from the full plan, and state what must happen before the plan is finalised.
Immediate, defensible actions. Ensure night staff are aware of the increased risk and that the bathroom route is lit and clear; discuss the sedating antihistamine with the GP the same day (this is a medication review, not a decision for the home alone); consider a commode at night to reduce unaided trips; and agree a temporary observation plan proportionate to risk. A bed rail should not be installed without checking it is safe for her - rails carry entrapment and climbing-over risks and need an individual assessment.
What must be documented. The falls history (three in eight weeks, dates, circumstances, injuries); the multifactorial assessment and identified factors; the resident's own views, including why she avoids the frame; decisions made and the rationale, including any intervention declined or deferred and why; who is responsible for each action and by when; consent and mental capacity considerations; and a review date. Record that the full plan awaits GP medication review and physiotherapy assessment, so the file shows a reasoned, person-centred decision rather than a delay. Escalate through the manager and, if necessary, the safeguarding or clinical governance route if the resident remains at avoidable risk.