Improving Fall Risk Assessment to Reduce Falls in Assisted Living Communities

Barbara M. De Groot, DNP, MSN(Ed.), RN, CMGT-BC, CNE

ucjournals January 10, 2024

999 34 minutes read

Unified Nursing Research, Midwifery & Women’s Health Journal
Author Name : Barbara M. De Groot, DNP, MSN(Ed.), RN, CMGT-BC, CNE
Category: Original research
Country: United States
Address: 2307 Cardenas Drive NE, Albuquerque, NM 87110
Journals Short Code: UNRMWHJ
ORCHID: 0000-0002-9025-5220

Keywords: adults, assessment, assisted living, community-dwelling adults, falls, fall risk
assessment, older adults, reducing falls, and risk factors.

Unified Citation Journals, 1(4) 11-45; https://doi.org/10.52402/Nursing2023
ISSN 2754-0944

Abstract

Falls in older adults are a safety issue in all healthcare settings, one measure of quality care, and the primary cause of unintended death among New Mexican adults aged 65 and older. Falls and fall-related interventions have been extensively investigated in acute and post-acute care settings. However, limited evidence exists regarding the importance of falls and fall reduction practices in assisted living communities. Five residents and 12 assisted living staff participated in the study. A prospective, quasi-experimental, repeated measures study was used to determine if using the Morse Fall Scale, Medication Risk Score, and universal or individualized fall reduction strategies reduced falls in adults aged 65 and older in a New Mexico assisted living community. The results of the study demonstrated one fall in the five residents. Continued use of fall interventions in this study may reduce falls and fall-related injuries, decrease emergency department and hospital overcrowding, and reduce costs associated with fall-related injuries. Reducing falls will improve morbidity and mortality rates, elevate the safety and quality of life for adults 65 and older, and preserve the dignity of our aging population.

Improving Fall Risk Assessment to Reduce Falls in Assisted Living Communities
Falls are a safety issue in all healthcare areas and a problem for individuals in assisted living
communities (ALCs) [1 Falls and fall-related injuries comprise nearly one-third of all incident
reports [2] and occur more than one million times yearly in the United States [3]. However, falls
are not part of normal aging. According to the Centers for Disease Control and Prevention [4],
falls in adults aged 65 and older are often preventable. Healthcare providers are critical in risk
assessment by reviewing falls with older adults and offering fall prevention interventions. The
American and British Geriatrics Societies Clinical Practice Guidelines ([5] suggest that
healthcare providers use multiple fall assessment approaches to reduce the risk of falls. This
multidimensional approach can reduce falls by 24% [6].

1.1 Significance of Falls
Epidemiologic evidence indicates that one in three adults aged 65 or older falls every year [7] from physiologic conditions, such as chronic health conditions [8], obesity [9], physical
condition [10], age-related muscle and joint weakness [7], deficits in balance and gait [11], and
visual changes, incontinence, or cognitive decline [12]. In addition, pharmacologic influences,
such as the consumption of cardiovascular or psychotropic medications (3, 8, 12, 13, 14, 15),
psychologic factors, such as the fear of falling [16, 17, 18, 19] or environmental factors [8, 11] are noted as increasing fall risk in older adults. Evidence shows that the risk factors and the
number of falls experienced by older adults lead to decreased quality of life [17, 18, 19, 20].
In 2014, about 2.8 million adults aged 65 and older were treated for fall-related injuries in
emergency rooms in the United States, and almost 800,000 were hospitalized [5]. In 2012, total
direct medical costs associated with fatal falls were $616.5 million, and $30.3 billion for nonfatal fall-related injuries [21]. In 2015, total direct medical costs associated with fatal falls rose to
$637.5 million and $31.3 billion for non-fatal fall-related injuries [21].

1.2 Problems Created by Falls
Falls remain the leading cause of unintentional injury deaths among adults aged 65 and older in
New Mexico [22]. In 2014, the cost of falls in New Mexico totaled $257,000,000 [4]. Inflated to
2023 dollars [23], the projected cost of falls in New Mexico rose to $317,705,524, an increase of
$60,705,524. Assuming falls could be reduced by 10%, a savings of $6,070,552 exists. That
savings could be reinvested in other programs to benefit older New Mexican adults.
Falls also contribute to hospital overcrowding. Residents who fall often require medical attention
not available in the ALC, resulting in the residents receiving medical care through emergency
departments. The COVID-19 pandemic forced hospitals to board many admitted patients in hall
beds distributed throughout the hospital to accommodate the need for isolation rooms. Boarding
in hall beds leaves fall victims in disorienting, unfamiliar environments, increasing the risk of
additional falls and exacerbating overcrowding.
Falls often lead to fear of falling [16, 17, 18, 19, 20], which initiates a cycle of limiting physical
and social activity resulting in muscle and joint weakness [7], deficits in balance and gait [11],
and depression [18]. Restricted physical and social activity decreases residents’ quality of life
[16, 17, 18, 19, 20].

1.3 Purpose of the Study
This study aimed to determine if using the Morse Fall Scale, Medication Risk Score, and
implementing standard or individualized fall reduction strategies reduced falls in adults aged 65
and older in a New Mexico ALC.

1.4 Inquiry
In adults aged 65 and older, does using the Morse Fall Scale, the Medication Risk Score, and
universal or individualized fall reduction strategies, compared to using the Morse Fall Scale
alone, reduce falls over three months in an ALC?

1.5 Nursing, Evidence-Based Practice, and Change Theories
Orlando’s Deliberative Nursing Process was used as the theoretical framework for this study.
Orlando’s Deliberative Nursing Process promotes comfort and relieves patient distress from fear
of falling or anxiety [24]. In Orlando’s theoretical framework, all nursing situations result from
the individual’s behavior, the nurse’s response, and nursing actions to relieve the individual’s
distress [24, 25]. According to Orlando’s theory, it is up to the nurse to interpret individual
behavior, determine the individual’s needs, and act deliberately to address them. This way, a
nurse delivers care designed to meet each person’s unique needs. Nurses can apply Orlando’s
nursing process to different residents with different problems.

The Promoting Action on Research Implementation in Health Services (PARiHS) model
suggests that the successful implementation of practice changes are a function of the nature and
type of evidence, the qualities of the context of implementation, and how the implementation
process is facilitated [26, p.2]. Grounded in organizational theories in the social sciences, the
PARiHS model enables researchers to make sense of the complex relationships inherent to
change implementation and the elements required to support the implementation of changes. The
model also shows staff how to implement changes [27]. Evidence is the source of knowledge
perceived by multiple stakeholders [27]. Context (is the quality of the setting where the change is
implemented. Facilitation is a technique by which one person makes things easier for others,
achieved through support that helps people change their attitudes, habits, skills, ways of thinking,
and working [27].

Rogers’ Diffusion of Innovation theory focuses on five aspects of spreading new ideas through a
group or community: relative advantage, compatibility, simplicity, observability, and trialability.
Rogers’ Diffusion of Innovation theory has been shown to positively influence support for
sustaining the change in practice [28]. The community staff understood how easy the change was
to implement when Rogers’ five attributes were addressed and the simple protocol for the study
was explained and used in practice. Successfully navigating these aspects strengthened the
sustainability of the study.

1.6 Search for Evidence
A literature search of PubMed, Cumulative Index of Nursing and Allied Health Literature,
Medline, Google Scholar, and Cochrane Database of Systematic Reviews was used to locate
English-language articles published in peer-reviewed U.S. journals between 2012 and 2022 for
adults aged 65 and older. Keywords used individually or in combination included adults,
assessment, ALC-dwelling adults, falls, fall risk assessment, older adults, reducing falls, and risk
factors. The initial retrieval produced 943 studies (Appendix A). Eight hundred fifty-one articles
were excluded due to non-relevance, editorials, reviews, case reports, or studies published in a
foreign language. A secondary review of 92 articles eliminated 56 due to duplication or lack of
full-text access, resulting in 36 articles in the evidence synthesis (Appendix B). The themes
identified in the 36 studies included fall risk assessment tools, fall risk factors, consequences of
falls, and strategies to reduce falls in older adults, as represented in the Evidence Grid (Appendix
C).
Of the 36 studies reviewed for levels of evidence, eight studies identified fall-risk assessment
using reliable and validated tools to aid in reducing falls in older adults, including three level-I
systematic reviews, one level-I study, three level-IV cohort studies, and one level-VI descriptive
study. Thirteen studies identified intrinsic and extrinsic risk factors that place older adults at risk
for falls. These included two level-I systematic reviews, one level-I umbrella review, seven
level-IV studies, and three level-IV studies. Three level-IV and two level-VI studies noted that
thorough fall-risk assessment and interventions could reduce human and economic costs of falls
and fall-related injuries. Twelve studies, including four level-I evidence-based guidelines, one
level-II randomized controlled trial, one level-IV study, two level-VI studies, and two level-VII
studies, recommended multifactorial fall reduction strategies to reduce falls in older adults.
Failure to specify an operational definition of a fall leads to different interpretations and fosters
questions about the studies’ validity [29].
1.7 Themes

1.7.1Assessment Tools
Using reliable and valid assessment tools is key to identifying residents at increased fall risk.
Borikova et al. [30] noted that a clinically useful predictive tool should be simple, have a limited
number of items, not require specialized assessment skills or technology, and be consistent for
the target group. The Morse Fall Scale appears most frequently in the literature and has been
judged valid and reliable for predicting fall risk across multiple settings [31].
Incorrectly identifying residents at risk for falls shifts resources from high-priority residents,
leaving them unidentified and at risk for falls or fall-related injuries [7, 31]. Incorrect fall risk
identification negatively impacts the quality of nursing care and the resident’s quality of life [17,
18, 19].
Medication risk assessments help identify medications that increase the risk of falls in older
adults. Three systematic reviews [32, 33, 34] and four cohort studies [13, 14, 15, 35] supported
assessing medication use in adults aged 65 and older to identify fall-risk-increasing drugs and
suggest alternatives to prescribers for residents considered as high fall risks.

1.7.2 Fall-Risk Factors
Fall risk factors in older adults originate from many sources, including chronic health conditions
[8], physical conditions [10], obesity [9], age-related muscle and joint weakness [7], deficits in
balance and gait [11], or visual changes, incontinence, and cognitive decline (Blalock et al.,
2020). Pharmacologic influences, such as the consumption of cardiovascular or psychotropic
medications (3, 8, 12; 13, 14, 15], psychologic effects such as the fear of falling [16, 17, 18, 19,
20] or environmental factors [8, 11] are also noted as increasing fall risk in older adults.
Regardless of the source of fall risk, the evidence shows that the risk factors and the number of
falls experienced by older adults lead to decreased quality of life and depression [18, 19, 20].

1.7.3 Consequences of Falls
Three level-I studies [3, 7, 34], three level-IV studies [17, 18, 19], and three level-VI studies [5,
21, 35] discussed the consequences of falls. Two studies [20, 34] noted that in addition to the
financial burden of falls in adults 65 and older, anxiety, lower confidence levels, and fear of
falling restricted participation in daily living and social activities, leading to the loss of
independence and reduced quality of life. Four level-IV studies [16, 17, 18, 19] and one level-IV
study [20] supported the fear of falling and reduced quality of life. Ruggieri et al. [7] and Viera
et al. [3] also noted restrictions in daily living and social activities. Three level-VI studies [5, 21,
35] addressed the economic impact of falls on adults aged 65 and older.

1.7.4 Fall-Reduction Interventions
The human and economic costs of falls are evident in the literature, as are numerous risk factors
associated with falls and fall-related injuries. Therefore, determining which fall prevention
interventions to use, alone or in combination with other interventions, in adults aged 65 and older
at risk for falling is essential to reducing falls in the population. Three level-I systematic reviews
[6, 32, 34], one level-II trial [36], three level-IV studies [37, 38, 39], three level-VI studies [33,
40, 41], and three level-VII articles (2, 41, 42] addressed fall-reduction strategies.
1.8 Evidence Strengths, Weaknesses, and Limitations
The systematic reviews, meta-analyses, and studies presented in the synthesis support the
research inquiry. Eleven of the 36 studies included in this summary (34.2%) provide robust,
level-I evidence for fall-risk assessment and reduction strategies. Including qualitative studies
provides insight into the experiences of providers and residents related to implementing fall
assessment and reduction strategies.
Weaknesses and limitations are noted in the literature related to the inquiry, primarily the need
for a fall definition in most studies. Failing to specify an operational description of a fall leaves
room for different interpretations and, consequently, questions the accuracy of fall reporting
[43]. Likewise, inconsistencies in the use of data collection tools [36, 37], single-site studies [40,
44], inter-rater reliability [20], the possibility of residual and unmeasured confounders [8], and
low adoption rate of interventions [39] limit the studies’ validities.
Few studies in the synthesis specifically identified a nursing theoretical model or change theory.
Nursing theories function as guides across stages of research, offering ideas and suggestions that
can be regularly applied and systematically assessed across studies relating to clinical problems.
Without applying a theory, the development of the knowledge used to guide nursing practice is
impeded. Likewise, not referencing a change theory leaves readers wondering how the change
was implemented. Using the best practices drawn from change theories helps increase the
potential success and sustainment of a practice improvement.

1.9 Gaps in Evidence
The evidence synthesis presented several systematic reviews, meta-analyses, and studies on fall
risk assessment tools, risk factors for falls, consequences, and fall reduction strategies. Only four
specifically address these issues in ALCs. Individuals living in ALCs do so because they can no
longer live independently yet do not require nursing home placement.
The investigator found no evidence that discussed the importance of falls in ALCs, current fall
reduction practices, or the number of and consequences of falls. Without understanding the
significance of falls and fall reduction in ALCs, the inquiry results may not inform or influence
organizations to change their practices. Thus, gaps in knowledge about attitudes toward falls, the
number of falls, fall risk assessment practices, and fall reduction strategies in ALCs remain.

2. Methods
2.1 Community Approval and Ethical Concerns
The executive leadership of the ALC approved the intervention in the AL area of a life-plan
retirement community in New Mexico. The participants received no compensation, reward, or
incentive for participation in the study, which presented minimal risk to the residents as they
were not required to change anything about their daily activities. Residents may have
experienced a fall or fall-related injury, but the risk of these happening was no more than if they
did not participate in the study.

2.2 Setting and Participants
The study occurred in the AL area of a life-plan retirement community in New Mexico that
offered members different levels of care in one location. The AL area of the community has a
total occupancy capacity of 60 residents and had an occupancy rate of 48 during the study.
Resident participation was voluntary. Residents wishing to participate attended an informational
meeting discussing the reasons for the study, what they could expect in terms of assessments and
interventions, the tools used to gather fall risk and fall data, the length of the study, the benefits
and harms of participation, and how the student investigator will maintain participant
confidentiality. Residents were eligible to participate in the research if they (a) were aged 65 or
older, (b) were current residents of the participating LC, (c) attended the informational meeting,
(d) were not hospice patients at the time of consent, (e) did not have a diagnosis of dementia or a
confirmed neurocognitive disorder, and (f) did not reside in a memory care unit. New residents
who met eligibility criteria and those who met eligibility criteria but deferred initial participation
were eligible to join the study once in progress. Resident demographic data were collected to
define the population of the ALC, and staff demographic data were collected to define the
staffing mix of the community.

A comparison group consisted of residents who fell between October 1, 2021, and December 31, 2021. Community residents who met eligibility requirements and wished to participate in the research acknowledged their agreement by completing the Resident Demographic Information form (Appendix B). Staff demographic data (Appendix B) were also collected to define the staffing mix of the community.

2.3 Evidence-Based Practice Intervention
The study intervention used the Morse Fall Scale (Appendix B) and Medication Risk Score
(Appendix B) to identify residents at increased fall risk and the application of universal or
individualized fall reduction strategies to reduce falls in participating ALC residents. In addition,
fall Knowledge Tests (Appendix B) measured staff fall knowledge pre- and post-study
implementation.

2.3.1 Recruitment
An informational meeting was held in the community in September 2022. The student researcher
provided a full, detailed description of the study to staff and residents, including the purpose of
the research, the anticipated outcomes, role responsibilities, and how the study may benefit
current and future residents and staff. Residents indicated their willingness to participate in the
study by completing the Resident Demographic form.

2.3.2 Intervention Protocol
Participants were assessed by the community nurse using the Morse Fall Scale and the
Medication Risk Score between September 10 and September 30, 2022. The community nurses
calculated Morse Fall Scale and Medication Risk Scores and identified residents as low/moderate
or high risk for falls. The community nurses added fall reduction interventions to resident service
plans based on fall and medication risk scores and monitored residents for falls. Following a fall,
the community nurses completed the community incident report, reassessed the resident for fall
risk using the Morse Fall Scale and the Medication Risk Score, recalculated new fall-risk scores,
and modified the service plan to reflect the latest score and fall reduction interventions. The
study was conducted from October 1 through December 31, 2022.

2.3.3 Role Responsibilities
The researcher met separately with the AL residents and staff, who were educated on the purpose
of the research, the anticipated outcomes, role responsibilities, and how the study would benefit
current and future staff. The student investigator also collected, reviewed, analyzed, and
compared fall data. The community nurses and staff were provided with a study algorithm
(Appendix C) outlining the steps and processes of the study. The community nurses conducted
resident assessments between September 10 and September 30, 2022. The nurses calculated and
documented the Morse Fall Scale and the Medication Risk Scores before the start of the study on
October 1, 2022. The community nurses reassessed residents following a fall, change in
condition or medication, or hospitalization. The community nurses filed incident reports but
failed to notify the student investigator of falls via HIPAA-compliant voicemail, text, or email.
The community leadership documented reported falls and provided current and historical fall
data for comparison from October 1 through December 31, 2022. The caregiving staff reported
new resident fall(s) to the community nurses.

2.4 Study Design
The study used a prospective, quasi-experimental, repeated measures design to evaluate the
benefits of using the Morse Fall Scale and the Medication Risk Score in reducing falls.
Participating residents were assessed for fall risk before the study began; following a fall, change
in condition or medication, or hospitalization; and after the study. The community nurses added
universal or individualized fall reduction strategies to the resident’s service plan based on the fall
risk and medication risk scores.

2.5 Assessment Measures
2.5.1 Morse Fall Scale
The Morse Fall Scale has an established sensitivity of 78% and specificity of 83% [45] and assesses fall risk in six areas. Each question is assigned a point value ranging from zero to 30 points, with an overall possible score of zero to 125 [45, 46]. In alignment with Bagui et al. [47], the student investigator used 45 as the optimal cutoff point for identifying participants at high risk for falls.

2.5.2 Medication Risk Score
The Medication Risk Score is not validated for stand-alone use. However, when investigators
used the Medication Risk Score and Morse Fall Scale together, sensitivity and specificity for the
Medication Risk Score increased to 82.42% and 66.65%, respectively [48]. The Medication Risk
Score is recommended for use with other fall risk assessment tools, such as the Morse Fall Scale
[36].

2.5.3 Community Incident Reports
While community incident reports are a convenient means of reporting falls, they may provide
inaccurate fall information, as discrepancies in fall definitions have been shown to affect
reporting accuracy. A systematic review by Hauer et al. (2006) noted that 44 of 90 included
studies failed to specify an operational definition of falls. Failing to provide a fall definition
would have left the staff to use her definition, possibly altering study results. Hence, the study
used the World Health Organization’s definition of a fall, and staff reported all falls for analysis
[49]. During the one orientation meeting, the student researcher shared definitions of a fall and a
repeat fall with staff.

2.5.4 Fall Knowledge Test
The Fall Knowledge Test [36] is a 13-item examination of staff knowledge of falls, fall-related risks, and interventions. The student investigator eliminated three questions that did not apply to the AL setting. The student investigator could not administer or proctor the tests at the study’s outset, nor was the educational intervention implemented. The staff self-administered Fall Knowledge Tests without direction or education at the beginning and completion of the study. 2.5.6 Resident and Staff Demographic Information Resident and staff demographic information was collected to define the populations.

2.6 Data Quality
Non-randomization cannot account for confounding variables and alternative explanations for the cause and effect in quasi-experimental studies. Differences in participant characteristics could influence the cause of the observed effects. This study attempted to limit unidentified confounders that could affect the study outcomes by excluding residents with memory or neurocognitive disorders and residents not on hospice programs. An a priori power analysis showed that at least 27 participants were needed to attain a power of .8, medium effect, and an alpha of .05 in a paired t-test.

3. Results
3.1 Setting and Participants
Four of the five resident participants identified as female, and one as male. Residents’ mean age and income levels were 90.2 years and $65,000, respectively. Four residents held undergraduate college degrees, and one resident was a high school graduate. One resident fell during the study. Analysis data are presented in Appendix D.
All staff participants (n=12) identified as female. The mean age for the staff was 38.1 years. Fifty percent of staff identified as Hispanic, 8.3% as Caucasian, 8.3% as Native American, and 16.6% as Asian. One staff member (8.3%) reported having a high school GED, 50% were high school graduates, 25% had some college education, and 16.6% were college graduates. Seventy-five percent of staff members were unlicensed resident aides, 16.6% were Certified Nursing Assistants, and 8.3% were Licensed Practice Nurses. The length of time staff reported in their work roles ranged from 6 months to 22 years, with the mean length of time in their respective work roles being 5.1 years. Seventy-five percent of staff reported that they felt falls were a normal part of aging, and 25% felt falls were not normal. One hundred percent agreed that falls were preventable. Seventy-five percent felt that falls were a problem that needed to be addressed in the community, and 25% felt that falls were not a problem. Twelve staff completed the preimplementation Fall Knowledge Test, and six completed the post-test. The mean scores on preand post-implementation Fall Knowledge Tests were 41.8% and 55%, respectively

3.2 Outcomes
3.2.1 Falls
One participating resident fell during the study, accounting for 0.03% of total falls and 20% of the study population. Total community falls were higher in the study period (34 falls) than in the comparison group (29 falls). The calculated falls per 1000-bed-day rate for the study group was 7.7, and the calculated falls per 1000-bed-day rate for the comparison group was 5.5, demonstrating an increase of 2.2 falls per 1000-bed days during the study period.

3.2.2 Morse Fall Scale Scores
Mean Morse Fall Risk Scores improved from 66.25 pre-study implementation to 61 post-study implementation. Pre-study implementation Morse Fall Risk scores ranged from 40 to 90, identifying four participants as at high risk for falls. Post-study implementation Morse Fall Risk scores ranged from 40 to 80. One resident improved in gait, reducing the Score by 20 points. Another resident had a 25-point increase in the history of falling, increasing the fall risk score.

3.2.3 Medication Risk Scores
Mean Medication Risk Scores also improved from 7.5 pre-study implementation to 5.8 poststudy implementation. Pre-study implementation Medication Risk scores ranged from 0 to 10, identifying two residents with Medication Risk Scores greater than five. The median Medication Risk Score was 5. Post-study implementation Medication Risk Scores ranged from 2 to 10. Two participants decreased their Medication Risk Scores, while one resident increased the Score but remained in the low-medium risk category. The median Medication Risk Score post-study implementation was 5.

3.2.4 Staff Fall Knowledge
Staff fall knowledge rose from 41.8% pre-study implementation to 55% post-study implementation. Pre-study implementation staff Fall Knowledge Test scores ranged from 10% to 90%. The mean Score was 41.8. The median Score was 30, and the standard deviation was 31.2. Post-study implementation staff Fall Knowledge Test scores ranged from 10% to 90%; however, six staff were lost to attrition. The mean Score for the post-study implementation Fall Knowledge Test was 55, the median Score was 60, and the standard deviation was 30.2.

4. Discussion
A primary function of fall reduction programs in ALCS should be preventing resident harm. Thus, fall reduction interventions aim to enhance or maintain resident safety ([36]. A fall reduction program should not aim for a zero-fall rate but should concentrate on sustaining fall rates as low as possible [36].
Assisted living communities could reduce falls by requiring all residents to use assistive devices for transfers and ambulation [36]. However, this action would be unethical because it infringes on a resident’s autonomy and self-determination. Likewise, categorizing all residents as high-risk would create unnecessary costs for fall-risk interventions and limit the mobility and autonomy of residents at low or medium risk of falling, with detrimental consequences on their physical and mental health. Instead, a fall reduction program should focus on identifying those residents at risk for falls and implementing individualized fall reduction strategies to reduce falls, improve function, prevent negative feelings associated with falls, and preserve autonomy and selfdetermination.

4.1 Successes Fall-risk-increasing medications were reduced in one participating resident resulting in a lower post-study Medication Risk Score. Likewise, post-study Morse Fall Risk scores were lower, although there were no changes in low or high fall risk classification among residents. Staff fall knowledge also improved, but the reason for the improvement is unclear, as no educational intervention occurred other than learning through applying the fall tools.

4.2 Study Strengths and Weaknesses
Factors influencing the study outcomes included the sample population and the structured activities in the community. For example, the ALC holds daily exercise sessions that are open to all residents. Activities performed during the sessions are based on the resident’s abilities and focus on improving strength, balance, and mobility. Access and entry to the community were limited. No planned educational sessions occurred due to a re-emergence of COVID-19 in the community. Communication with the facility was limited as the student researcher received no responses to telephone calls, emails, or texts. The lack of communication and the inability to monitor whether the established protocol for the study was followed may have limited the overall success of the study.

4.3 Results Compared to Evidence in the Literature
A synthesis of the evidence in the literature found that physiologic conditions [7], obesity [9], physical condition [10], age-related muscle and joint weakness [7], and deficits in balance and gait [11] place older adults at risk for increased falls. Pharmacologic influences, such as the consumption of cardiovascular or psychotropic medications [3, 8. 12, 13, 14], and psychologic effects, such as the fear of falling [16, 17, 18, 19], are also noted to be associated with increased fall risk. These data support the results of the current study.
Likewise, evidence supports using reliable and validated tools to reduce falls in older adults [7, 31]. The mean pre- and post-study implementation Morse Fall Scale scores and the mean preand post-study implementation Medication Risk Scores fell within the high-risk classification. Guirguis et al. (2018), Lach and Noimontree (2018), Montero-Odasso (2021), de Vries et al. (2018), George and Verghese (2017), Seppala et al. (2018), and Strini et al. (2021) supported assessing medication use in adults aged 65 and older to identify fall-risk-increasing drugs. Two residents reported falls in the past year and indicated that those falls had increased their fear of future falls. These findings are consistent with the findings of Cinarli et al. (2017), Hoang et al. (2016), Lavedan et al. (2018), and Perez-Ros et al. (2019). Although there was an increase in the number of falls per 1000-bed days in the current study, the increase may be the result of the small sample size (n = 5)

5. Limitations
5.1 Internal Validity Effects
The study was carefully planned to address internal validity. Recruitment strategies were selected to include a sample that adequately reflected the population being studied. Attempts to manage quality control, including frequent meetings with staff and monitoring, were unsuccessful due to the inability to access the staff. Identifying the current fall risk assessment and reduction practices was not achieved, as the ALC submitted no written documentation outlining these practices. When questioned about their current practices, it was apparent to the student researcher that differences in practices and fall definitions existed among nursing and caregiver staff.

5.2 External Validity Effects
Attempts to manage the effects of external validity included comprehensive inclusion criteria that resulted in a study population that closely resembled the AL population but did not necessarily represent the older adult population of New Mexico. External validity was also affected by the small sample size. A power analysis for sample size showed that at least 27 participants were needed to attain a power of .8. A larger sample size of at least 27 residents would have supported the transferability of the interventions to other groups. Notwithstanding the current outcomes, the study remains essential in that, given a larger sample size, the true value of the interventions could be revealed.

5.3 Efforts to Minimize the Study Limitations
The main limitation of the study processes was the inability to enter the facility and administer the planned educational intervention and monitor adherence to the study protocol, which may have impacted the study outcomes. Attempts were made to conduct the education sessions via an online videoconferencing platform; however, the community provided no date or time to conduct the sessions. Nor, despite repeated efforts, did the community produce documentation of current fall risk assessment and reduction practices.

6. Interpretation
6.1 Expected and Actual Outcomes
The researcher anticipated that using the Morse Fall Scale in combination with the Medication Risk Score and universal or individualized fall reduction strategies would reduce falls by 20% throughout the study compared to the same timeframe from the previous year. One of the participating residents fell during the study accounting for 0.03% of total falls and 20% of the study population. Total community falls were higher during the study period (34 falls) than in the comparison group (29 falls). The calculated fall rate per 1000 bed days for the study period was 7.7 falls. Compared to the fall rate per 1000 bed-days in the comparison group of 5.5 falls, there was an increase of 2.2 falls per 1000 bed-days during the study period.
Staff fall knowledge improved slightly from 41.8% pre-study implementation to 55% post-study implementation. Pre-study implementation staff Fall Knowledge Test scores ranged from 10% to 90%. The mean Score was 41.8. The median Score was 30, and the standard deviation was 31.2. Post-study implementation staff Fall Knowledge Test scores also ranged from 10% to 90%; however, six staff were lost to attrition. The mean Score for the post-study implementation Fall Knowledge Test was 55, the median Score was 60, and the standard deviation was 30.2. The researcher did not anticipate any changes in pre- and post-study intervention Morse Fall Scale or Medication Risk Scores. However, both these measures also improved. Mean Morse Fall Risk Scores decreased from 66.25 pre-study implementation to 61 post-study implementation. Pre-study implementation Morse Fall Risk Scores ranged from 40 to 90, identifying four participants as at high risk for falls. Post-study implementation Morse Fall Risk scores ranged from 40 to 80. One resident improved in gait, reducing the Score by 20 points. The other resident had a 25-point increase in the history of falling, increasing the fall risk score. Mean Medication Risk Scores also improved from 7.5 pre-study implementation to 5.8 poststudy implementation. Pre-study implementation Medication Risk scores ranged from 0 to 10, identifying two residents with Medication Risk Scores greater than five. The median Medication Risk score was 5. Post-study implementation Medication Risk Scores ranged from 2 to 10. Two participants decreased their Medication Risk scores, while one resident increased the Score but remained in the low-medium risk category. The median Medication Risk Score post-study implementation was 5.

6.2 Intervention Effectiveness
It is difficult to determine if the intervention was effective in reducing falls. The small sample size (n=5) reduced the power of the study, increased the margin of error, and reduced the confidence level of the study, which made the results of correlating Morse Fall Scale scores higher than 45 and Medication Risk Scores of 6 or more with increased fall rates unreliable. Likewise, insufficient evidence was present to determine cause and effect. Fall Knowledge pre-tests were intended to identify baseline staff knowledge of falls. Post-tests were meant to measure the same knowledge following an educational intervention. However, the educational intervention did not occur, leaving the researcher to assume that staff Fall Knowledge Test scores increased due to chance or other factors.

6.3 Intervention Revision
Outcomes may have been substantiated with a larger sample size. Power, the margin of error, and the confidence level of the study could have improved, all of which would have made correlating Morse Fall Scale scores higher than 45 and Medication Risk Scores of 6 or more with decreased fall rates. More evidence may have been available to determine cause and effect.

6.4 Opportunities
The researcher identified many opportunities and recommendations following the study. Despite having had support from another community in February 2022, the organizational leadership ultimately chose not to authorize the implementation of the study in any of their communities. This information was relayed to the student in July 2022, leaving little time to align with another community. Because of the limited time remaining to implement the study, a decision was made to utilize a clinical site associated with the student researcher’s employer. Communication with the site was problematic from the outset. Despite multiple and continued efforts to communicate, the contacts at the ALC did not return telephone calls, texts, or email messages. Physical access to the community was limited due to a resurgence of COVID-19. The student researcher was allowed one on-site visit, during which staff and residents were educated about the study. It was agreed that the student researcher would utilize electronic means to educate and assess staff fall knowledge; however, this never came to fruition because a date and time for the training were not received. As a result, staff was left to interpret and complete the AHRQ Fall Knowledge Test without education or direction at both pre-and post-study implementation deadlines. Although post-study implementation test scores showed a moderate improvement, no conclusion can be drawn regarding the reason for the improvement. These results may be coincidental, or staff worked on their tests together, comparing answers to select their responses.
The nursing staff did not follow the study’s established protocols related to the use and timing of the assessment tools. One resident fell during the study, which should have triggered a reassess using the Morse Fall Scale and Medication Risk Score. No documentation of such a reassessment was acknowledged or received from the facility, leaving the researcher to assume that the reassessment was not completed. Resident and staff demographic forms were incomplete, leaving potentially important information about the cohorts unavailable and replication by other researchers difficult.

7. Conclusions
Evidence-based practice is crucial for fall risk assessment and reduction in ALCs. The researcher’s inquiry may ultimately affect systems, organizations, communities, and individuals. Existing evidence demonstrates a need for a national movement to create regulations requiring ALCs to implement fall risk assessment and reduction programs. However, because most ALCs operate on a business model instead of a medical model, such a change may be considered financially impractical and meet resistance.
However, a benefit/cost ratio analysis found that for every $1 spent on fall reduction, a community could benefit by $2.05. Inflating the 2014 $70,000,00 New Mexico Medicaid shareof-cost for non-fatal falls to the 2021 rate of $80,122,584 and conducting a benefit/cost, the result revealed that for every dollar spent on fall reduction, The State of New Mexico Medicaid program could benefit by $4.05. The long-term effects of a successful fall reduction study should reduce falls in ALCs, reduce individuals entering the healthcare system through emergency departments, emergency department and hospital overcrowding, and costs associated with fall injuries to third-party payors. In addition, reducing falls would improve morbidity and mortality rates, improve the safety and quality of life of adults 65 and older, and preserve the dignity of our aging population.

8. Further Study of Intervention
The scarcity of research on falls in ALCs demonstrates the need for ongoing fall reduction research in this setting. It is essential to establish how falls are viewed in ALCs, what fall risk assessment and reduction practices are in current use, how many falls occur in ALCs, and if other fall reduction programs have outcomes other than those in the current study. In addition, evaluating programs developed and implemented in the acute- and post-acute settings would help determine their adaptability and effectiveness in the AL setting.

34. IMPROVING FALL RISK ASSESSMENT

Executive Summary Evidence demonstrates that one-third of adults aged 65 and older fall annually [7], resulting in more than 2.8 million emergency room visits and over 800,000 hospital admissions for fall-related injuries [5]. In 2014, the costs of fall-related emergency room visits in New Mexico were $257,000,000 [4]. Inflated to 2023 dollars, that figure rose to $317,705,524, an increase of $60,705,524. Assuming falls could be reduced by 10%, a savings of $6,070,552 exists. That savings could be applied to other healthcare or benefits programs to benefit the older adults of New Mexico. Changing how falls are assessed in assisted living communities has been shown to reduce falls.

A literature review retrieved 943 articles. Following two rounds of review, 36 articles were synthesized for content. Four themes were revealed in the synthesis: assessment tools, fall risk factors, consequences of falls, and fall-reduction strategies. The research question that grew from the review asked if using the Morse Fall Scale, the Medication Risk Score, and universal or individualized fall reduction strategies, compared to using the Morse Fall Scale alone, reduced falls in assisted living residentsaged 65 and older.to using the Morse Fall Scale alone, reduced falls in assisted living residents aged 65 and older.

The researcher anticipated that using the Morse Fall Scale in combination with the Medication Risk Score and universal or individualized fall reduction strategies would reduce falls by 20% throughout the study compared to the same timeframe from the previous year. Total community falls were higher during the study period (34 falls) than in the comparison group (29 falls) for the same timeframe from the previous year. The calculated fall rate per 1000 days for the study period was 7.7 falls. Compared to the fall rate per 1000 days in the comparison group of 5.5 falls, an increase of 2.2 falls per 1000 days was evident during the study period.

Staff fall knowledge improved slightly from 41.8% pre-study implementation to 55% post-study implementation. Fall Knowledge pre-study tests were intended to identify baseline staff knowledge of falls, while post-study tests were designed to measure the same knowledge following an educational intervention. However, the educational intervention did not occur, leaving the researcher to assume that staff Fall Knowledge Test scores increased due to chance or other factors. The researcher did not anticipate any changes in pre- and post-study intervention Morse Fall Scale or Medication Risk Scores. However, both these measures also improved in the project. Mean Morse Fall Risk Scores decreased from 66.25 pre-study implementation to 61 post-study implementation. Mean Medication Risk Scores also improved from 7.5 pre-study implementation to 5.8 post-study implementation

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