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~ Multidisciplinary Approach to Fall
THE CASE OF MS. KELLY
Barbara Riley-Baker, BA, MA, CMC, C.P.G.
Mease Countryside Hospital, the
rehabilitation program’s social worker
calls in the multidisciplinary discharge
planning team to review the case of Ms.
Kelly is an 80 year-old female African
American. She is a recent widow who
lives alone in a single family home. Her
medical history includes; diabetes, low
blood pressure, and osteoarthritis.
Twice, within the past month, Ms. K. has
been brought to the hospital’s emergency
room for fall related injuries that
occurred in her home. The most recent
and serious fall resulted in a fractured
hip and surgery. Ms. Kelly is about to
begin the hospital’s physical therapy
obvious Ms. Kelly’s first discharge was
not successful. She returned to hospital
for a second time in one month with a
far more serious injury. A
multidisciplinary team approach will
search for the etiology of Ms. Kelly’s
falls and take preventative measures to
reduce the probability of another injury
and a return to hospital.
Countryside Hospital’s multidisciplinary
teams are based on the qualitative
methodology approach of Janice M. Morse
from the University of Alberta. Ms.
Morse has stated, “…falls are (now)
considered an event that may be
predicted …and prevented.” Falls are no
longer thought of as unavoidable
accidents or as a normal result of
illness. The multidisciplinary discharge
planning team consists of its
chairperson, the rehabilitation social
worker, the hospital pharmacist, the
medical director for the falls team, the
director of the gait and balance
program, and the deputy director of the
patient safety center.
team will assess for any active or
latent errors in Ms. Kelly’s care as
well a complete assessment of Ms.
Kelly’s physical condition, limitations
and abilities. The team concluded if Ms.
Kelly were sent home without
interventions in place, it would not be
long before she would return to hospital
and then to a long-term care facility
and would probably never go home again.
Kelly’s home will also be assessed for
patient safety. Using the Root Cause
Analysis approach, the team hopes to
improve patient outcomes and reduce
expenditures. Ms. Kelly’s evaluation
will take into account normal aging
changes, intrinsic risk factors
(physical conditions), extrinsic risk
factors (polypharmacy, polymedicine,
restraints, environmental risk factors),
and current medical conditions acute and
chronic, (diagnosed and undiagnosed).
falls assessment includes; vital signs,
visual acuity, depth perception, Mental
Status Examination, neurological exam
including proprioception and cerebellar
function, fall history, medication
review, physical examination, functional
assessment and environmental review.
Depression screening will also be
conducted due to the recent loss of Ms.
Kelly’s husband, possible fear of
falling again, and any independence
multidisciplinary team uses Root Cause
Analysis to discover the cause of Ms.
Kelly’s falls. What predicated the
falls? Were the falls due to her
physical conditions or environmental
factors or both? When did the falls
happen, the same time of day, in the
same room of the house, what was Ms. K.
doing at the time of the fall. Was she
wearing sensible shoes or shoes with
unsafe bottoms? Is Ms. K. taking her
medications as prescribed? Has the
assessment discovered other health
conditions that have not been
addressed? The assessment data is
Depression was an additional diagnosis
revealed by the team. Ms. Kelly was
started on an antidepressant. Her lab
work was completed and other medications
were reviewed and adjustments were made,
bringing her low blood pressure into a
more-normal range. The team also
discovered Ms. Kelly had not had a
vision exam in years. There had been
definite changes in her eyes due to her
diabetes. These changes were addressed
including new eyeglasses.
team recognized the need for immediate
education. Ms Kelly attended diabetes
education classes while in the hospital
rehabilitation program. Classes included
meal planning, monitoring blood sugar
levels, exercise tips, and social
support. The hospital-based support
group was culturally diverse and Ms. K.
soon made new friends. She received
safety training on changes in posture,
e.g. safely rising from a seated
Kelly also attended arthritis classes.
She learned about osteoarthritis in
particular and discovered she was not
alone in her suffering. There is no cure
for osteoarthritis, but the condition is
treatable with medication, exercise,
rest, weight control, alternative
therapies, coping skills, and surgery.
Ms. K. received information about her
all chronic conditions and was taught
active coping skills and positive
Kelly’s adult children, a son and
daughter who live nearby, were invited
to attend the same educational classes
in the evening. The family support
members were apprised of fall statistics
and the need for interventions. Falls
are the leading cause of injury deaths,
nonfatal injuries and hospital
admissions for trauma for older adults.
the end of Ms. Kelly’s in-hospital
therapy program the physical therapist,
and her daughter visited her home with
her for a safety evaluation and the root
cause of her falls. Combined with Ms.
Kelly’s personal fall history, as well
as an environmental review,
recommendations were made. The home
revealed safety issues that needed to be
addressed prior to discharge.
the SPLATT test; symptoms, previous
falls, location, activity, time, and
trauma, the team deduced the cause of
Ms. Kelly’s falls. Both of her falls
happened in the bedroom. The falls
occurred when she was getting out of bed
in the morning. Ms. K. informed the team
that she had had other falls and near
falls but without injury. The home
contained a number of fall risks throw
rugs, clutter, and in several places,
power cords on the floor. The lighting
in the home was insufficient including
the home needed more nightlights. In the
bathroom, a nonskid bathmat was needed,
along with grab bars, shower chair,
handheld showerhead, and a raised toilet
seat with handrails.
team concluded that a combination of
conditions and factors were behind Ms.
K’s falls; orthostatic hypotension,
vision changes, probable abnormal blood
sugar levels, morning joint stiffness,
and poor balance caused her to become
dizzy and unable catch herself resulting
in falls. The home inspection also
revealed Ms. Kelly was not taking her
medications as directed. Staff compared
the date on the pill bottle to the
number of pills remaining; taking into
consideration the date Ms. K. entered
the hospital. Some medications were
taken too often and some not often
Ms. Kelly’s permission, the team’s
findings were shared with her adult
children and her primary care physician.
Her children addressed all suggested
home safety modifications and stocked
the refrigerator with healthy choices
for their mother’s homecoming.
Kelly’s discharge plan included two pair
of hip protectors to reduce future
fractures, diabetic Meals on Wheels for
nutrition, Home Health therapies;
physical and occupational, balance and
gait training, strengthening exercises,
and safety training for walker and cane
to enhance independence in Ms. K’s
environment. Ms. K’s medications will
now be prepared monthly in bubble packs
and delivered by her local pharmacy.
Each adult child will visit Ms. Kelly at
least once a week and monitor her safety
and medications. Ms. K has expressed a
desire to continue educational training
and support group attendance at the
hospital. Her name will be added to the
hospital’s outreach monthly mailings.
The adult children have offered to
provide transportation and may even
partake of the training. Any changes in
Ms. K’s status will be reported to the
will also receive a safety monitoring
system, such as Live Line, and training
in its use. Her name will be added to
hospital’s volunteer call list. Ms. K
will be called every morning to monitor
her health and safety. Any negative
reports will be sent to the team and
addressed as soon as possible.
Kelly is competent and values her
independence. The interventions put in
place by the hospital social worker, the
multidisciplinary discharge planning
team, Ms. K’s adult children, Home
Health, communication network and Ms. K.
herself will address her needs upon
Kelly and her children have also
received education in advanced
directives. The family will consult with
an elder law attorney to prepare these
legal documents as soon as Ms. K. is
able. Should she no longer be able to
live alone, her daughter has agreed to
care for her mother in her home. Ms. K.
has agreed but hopes that that move will
not be necessary.
member will make monthly home visits to
Ms. Kelly to assess her progress as well
as the program. The team’s motto is, “an
ounce of prevention is worth a pound of
Tatjana, (2005). Fall Prevention in
the Elderly. Lecture.
Lora. (2005). Getting to the Heart
of Diabetes. Lecture.
Hart-Hughes, Stephanie. (2005). Fall
Prevention in the Elderly. Lecture.
McIlvance, Jessica, (2005). Coping
With Arthritis in Diverse Elders. Lecture.
National Center for Injury Prevention
2005. 19 June 2005 http://www.cdc.gov/ncipc/factsheets/falls.htm
Rutledge, Michelle. (2005). Fall
Prevention in the Elderly. Lecture.