When assessing a resident fall, sometimes it is apparent that if the resident would have used the call light and waited for help, the fall could have been avoided. Seems obvious, right? So our intervention becomes, “Educate resident to use call light.”
The problem is, we’re supposed to be determining the root cause of the fall. In this case, the question shouldn’t be, “What did the resident do wrong?” Instead we must ask, “What was the resident trying to do? How could we have better anticipated that resident’s needs?”
Suddenly “educate resident to use call light” doesn’t make as much sense. Instead, consider:
“Keep bedside table within reach.”
“Change timing of bathroom schedule to better anticipate resident’s needs.”
“Ask resident if they need to use bathroom after meals and 60 minutes after going to bed.”
“Set sleep timer on resident television to keep him from getting up to turn off.”
“Leave bathroom light on for safer way-finding to bathroom.”
Each of these interventions would have to be specific to the question, “what was the resident trying to do,” but hopefully you understand the rationale behind these examples.
There are other reasons to avoid the “educate on call light use” intervention. The MDS must indicate that the resident has perfect short term and long term memory, has full physical ability to use the call light, and that the same intervention has not been listed previously. It’s a tough battle with surveyors, one I’ve lost in the past. Finally, resident education should be documented in the record or in the incident report – and usually is not.
Avoid this ineffective intervention and keep your team focused on root cause analysis when analyzing a resident fall or updating their care plan.