Reasons it is difficult to let go

  • Average census ~128
  • Skilled census ranges from 16 to 20 skilled beds
  • High number of custodial patients
  • 51 patients with a dx of dementia
  • 20 patients on antipsychotic medications

Why we did it

  • Staff was showing “Alarm Fatigue” (desensitization to alarms due to a high rate of false alarms resulting in ignoring or a delay in addressing alarms)
  • Research indicated that fall rates do not decrease with increased use of alarms (Shorr et. al)
  • It increases agitation with some residents and disturbs sleep during the night
  • Regulations and possible F tags:
    • F242 Self-determination and participation
    • F250 Environment
    • F240 Quality of life
    • F309 Quality of care
    • F272 Resident assessment
    • F279 Comprehensive care plan
    • F353 Sufficient staff

How we did it

  • All staff were educated regarding the 5 P’s related to falls and how to address them:
    • Potty
    • Pain
    • Placement (of objects in the room, i.e., water)
    • Position (in bed, wheelchair, etc.)
    • Participation (in activities; are they restless and/or self-isolating)
  • Falling star program was rolled out:
    • Patient enrolled after a fall and monitored for the next 90 days
    • Patient identified with a star sticker outside of room and on wheelchair/wristband
    • Increased rounding on patients enrolled in falling star
    • After 90 days free of falls, they graduated and a ceremony was held in which they get a certificate for safety
  • Alarms were removed gradually starting with the lowest risk residents

Maintenance of Program

  • Fall rounds are completed after each fall with IDT members including DON, DOR, charge nurse, CNA and patient to discuss route cause analysis of fall and potential interventions
  • Resident safety committee is completed as an IDT on the floor with charge nurses and CNAs to discuss high fall risk patients
  • At the end of each month, DOR completes an analysis of all falls for QA to identify trends and implement training/interventions as necessary (i.e., what shift/time of day, what hallway, manner of fall, avoidable versus unavoidable, etc.)
  • Continued implementation of falling star program and 5 P’s
  • Staff huddles at shift change to discuss high-risk patients and pass on pertinent information

Therapy’s Role

  • Screens are completed following falls
  • Analysis of contributing factors include increased weakness, balance, cognition, environment set-up, and the appropriate discipline picks up patients when indicated
  • Therapy pick-ups fluctuate based on patient need but average two to three (or more) per month and contribute to our long term care programming
  • Rehab department has a vital role in further fall prevention and development of RNA/FMP to decrease risk for falls in the future


  • Residents are less agitated related to alarms (because there are none!)
  • Average falls for the eight months prior to going alarm-free: 16 falls/month
  • Average falls for the eight months after being alarm-free: 14 falls/month
  • Decreased “alarm fatigue” for caregivers
  • Better sleep for residents resulting in better outcomes for therapy
  • Decreased behaviors
  • Less noise in the facility

View poster: Going Alarm-Free (PDF format)

By Nicole Onizuka, DOR/SLP, Broadway Villa Post-Acute, Sonoma, CA