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Improving Resident Safety In Long-term Care Facilities

-- Eighty-year-old Elizabeth M. has eloped from the long-term care facility she has called home for two years. This isn’t the first time she has left the building, but this time she stumbled into traffic and was almost struck by a vehicle at midnight.

-- Seventy-five year old Gus S. suffered a broken arm and numerous bumps and bruises when he fell out of bed in an attempt to relieve himself on his own.

-- Norma J. suffered a deep cut above her eye when she fell against a wheelchair after being pushed from behind by a fellow resident.

The above incidents are just a few examples of the injuries that occur in long-term care facilities across the country. These injuries are more common than we would like to think. When a resident is injured, everyone feels bad and wants to know what they can do to prevent it from happening the next time. But why does it occur, and what can we do to reduce the risk?

Voices from the frontline:

P. Bodin, an RN who worked in a nursing home for almost five years, puts it this way: “It’s the old cliché, but it’s true. There isn’t enough staff. It all comes down to money. If more staff were available to supervise the residents, then the incidents of resident injury would dramatically decrease. One RN shouldn’t be responsible for the safety of fifty residents, but it’s happened. Some injuries occur at night when there is less staff. These are the things that management should be thinking about. It’s no wonder we nurses are leaving our beloved profession in droves. Sometimes it just isn’t worth it anymore.”

Lynn R., a social worker who has investigated resident abuse and injuries in nursing homes, adds, “Our elders have paid a lot of taxes. They’ve contributed. Now they’re frail and sick and in need of care. They are highly vulnerable to accidents and neglect. They deserve more respect than that. Some of these injuries border on caretaker neglect, because if there were enough qualified staff to provide direct care, a lot of this wouldn’t be happening. I don’t blame the nurses and staff. They are low on the totem pole and can only do what they’re told. I question management and the people who allocate the funding. If it were their elderly parents lying in that bed, what kind of care would they expect?”

“The nursing home can only do so much” says an anonymous CNA. “I worked in one. I know. It’s not logical or realistic to think that there won’t be any injuries ever. But I think there are too many right now, and a lot of it has to do with the nursing shortage. If we had more nurses that are paid what they’re worth, the patients would be safer. Instead, because we don’t have enough RN’s, we have LPN’s doing RN work, CNA’s doing LPN work, and social workers doing a little bit of everything. Why should committed and compassionate nurses carry all the burden, and get all the blame, for something that is beyond their control?”

“If I made the rules,” Nurse Bodin continues, “I would have one nurse for every four to five patients. That’s a fantasy, but that would be ideal. But no. It’s become an assembly line. The government doesn’t want to provide frontline workers because they would have to pay them. I ask, where are your priorities? What about the residents? They’re people. At the mercy of a system that sees only the dollar sign.”

“We have a committee to review incidents of injury,” Robin, Social Services Coordinator stated. “We do ongoing assessments for every resident, but especially those at a higher risk.”

“We assess the residents for risk when they are first admitted,” explains Malina Frame, who is an RN and Director of Admissions at the Ohio Valley Manor Nursing And Rehabilitation Center. “And then we continue to assess them on a regular basis. We have intervention strategies in place when an incident does occur. We have beds that lower, and mats on the floor by the beds to cushion a fall, as well as alarms on our chairs and beds. We use short side rails on our beds, because the higher rails present a greater risk of injury to a resident trying to climb out. The higher rails also have gaps that can trap a resident. We have an Alzheimer’s unit with doors that are operated by a keypad, plus a gated area outside where these residents can go to walk or get exercise. ”

Long-term care facilities already have safety measures in place, so what more can we do to minimize injuries?

Some common injuries found in nursing homes:

-- Falls ( a typical nursing home can experience 100-200 falls per year………….75% of nursing home residents fall each year-twice as many as community -based seniors………….there are approximately 1800 fall-related death in nursing homes annually). (Source: Center For Disease Control).

-- Skin breakdown

-- Bed injuries (accidental suffocation or strangling, becoming trapped between rail and bed).

-- Dehydration/malnutrition due to improper training in nutrition and individual patient needs

-- Injuries during wandering or elopement.

-- The nurses aren’t to blame. They do the best they can within the parameters they’re given. Most nurses have stayed in their job a lot longer than they really wanted to. Why? For love of their patients. Some would have left a long time ago were it not for the dedication and loyalty they feel for the residents they serve.


-- Keep a “Fall list” at the nurse’s station. This is a list of residents who have a history of, or are prone to, falling. Put these residents, as well as those that are confused or demented, in rooms closest to the nurse’s station.

-- Have low beds for those residents who fall or climb out of them. Have proper lifting equipment, and make sure it‘s used correctly.

-- Use slip-resistant floors, or put slip-resistant adhesive strips and slip-resistant paint on floor and walls. Provide grab bars, raised toilet seats, handrails in corridors. Provide hip pads to reduce risk of hip fractures.

-- Provide adequate lighting and reduce clutter, provide proper fit and maintenance of wheelchairs. (Source: OSHA).


-- Clip “shirt alarms” and put “alarm bracelets/watches” on the residents who tend to wander. Transmitting devices can also alert staff that a resident has removed covers, stepped on a mat next to their bed, opens a door, or leaves a chair. This not only alerts staff to wanderers, but gives wanderers more freedom of movement and raises quality of life.

-- Put padded or Velcro barriers or bars across the doorways of residents who are at risk for wandering.

-- Have a “walking space” or “walking room” for wanderers, so that they will have a place to walk when they so desire. These can be indoors and out.

-- Provide a lot of activities for the residents. They will be too occupied to get into idle conflicts with one another. Activities will keep wanderers more interested in their present surroundings.

-- Meet the needs that often drive wanderers--Physical needs such as hunger, thirst, toileting, temperature and noise, exercise and movement--Emotional needs such as interaction with staff, family, friends, and fellow residents.

-- Train staff in the warning signs of wandering--restlessness, excessive movement, an expressed desire to “go home”. Make sure all staff members are trained in the handling of wanderers and elopers.

-- Use transmitting devices that alert staff when a resident has entered an unsafe area or exit.

-- Use doors that can only be opened by key, code, or card. Use door alarms, and consider putting them on windows and loading docks. Some devices sound an alarm and lock the door at the same time. The alarms are disabled in the event of fire or other emergency


-- Exercise extra care while dispensing medicine.

-- Organize community volunteers to help with feeding at mealtimes, to decrease incidents of malnutrition or dehydration.

-- Make sure all staff members are trained in the recognition and reporting of abuse, neglect, and sexual abuse.

Offerings from an Ombudsman:

“Under the federal Older Americans Act, every state is required to have an ombudsman program that addresses complaints and advocates for improvements in the long-term care system. The top three complaints investigated by the Kentucky Long-Term Care Ombudsman program in 2002, involved issues surrounding dignity, respect and staff attitudes toward residents; staff being unresponsive or unavailable; and staff training or lack of screening of staff.

Ombudsmen and other advocates believe that hands-on, direct care, provided by a well-supervised nursing staff is the key to providing quality care of residents. Stated another way, advocates believe that poor staffing will most likely lead to neglectful care.

Also, in light of the recent fires in nursing homes:

The National Fire Protection Agency has a message for families and staff about what to look for in facilities in terms of fire safety: www.nfpa.org

Suggested questions include

-- Check to make sure that there is an evacuation plan in place and that staff have practiced it regularly.

-- Are there safety systems such as alternative exits, smoke detectors and sprinklers?

-- Check on the staff to resident ratio, especially nights, weekends and holidays.

And, NFPA has a fact sheet regarding fire safety in nursing homes. The fact sheet can be accessed at: http://www.nfpa.org/assets/files/PDF/NursingHomesFactSheet.pdf--

John M. Sammons, MSW
State Long-Term Care Ombudsman
CHS/Office of Aging Services
275 East Main Street, 5C-D
Frankfort, KY 40621


Safety devices can be expensive. Alarm bracelets can range from $30-$220. Locking systems and alarms can start at $800. Transmitting systems can be as high as $10,000.

No one can guarantee 0 injuries. They will happen, under the best of circumstances. But providing the best safety measures possible will give staff and family peace of mind, and the residents the security they deserve.

Is the price really too high?

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