ABC’s of OT: how to assist with FALL PREVENTION in the SNF

Fall prevention is one of the most important things we focus on within the SNF setting. A fall for an older adult can be debilitating if not fatal, especially in instances where surgical intervention is required in adults who already have progressed dementia. This is why it is so important as the occupational therapist to assess risk for falls in order to ensure the safety of our residents.

When I assess fall risk, I consider four main areas: biomechanical, neurological, cognitive, and environmental.

Let’s start with biomechanical, or in other words strength and ROM. The questions I want to make sure I’m asking myself include: Can the patient achieve full ROM? Can the patient achieve at least a 3+/5 MMT in both lower extremities? Is there tone in the lower extremities? Does the patient have any persistent pain? What does the skin look like?

Something to keep in mind when it comes to range of motion (ROM); ankle range is particularly important. If the patient cannot achieve a normal range in both ankles (plantar flexion of 0-50 degrees, dorsiflexion of 0-20 degrees) then he or she has a higher chance of falling backwards because the feet cannot get flat to the floor in standing.

Then I think about neurological function, specifically proprioception (where is my body in space?) and vestibular function (where is my head in relation to my center of gravity?). There are various balance assessments that look at global function, including vestibular input and proprioception. These include the Berg, the Tinnetti, and the Functional Reach Test. In my facility, physical therapy is usually the one to perform these assessments, but there might be an instance in which a long-term care patient is referred to therapy due to increased fall risk and we as the OT department have more opening in caseload. Either way, I believe it is important for us as OT’s to understand how to administer these balance assessments and how they relate to overall functional performance.

It is incredibly important to consider cognitive function when assessing fall risk. Specifically, safety awareness. Can the patient effectively negotiate obstacles? Can the patient remember to appropriately square off his/her hips to the chair surface before attempting to sit? Can the patient remember his/her adaptive equipment during functional ambulation? Does the patient know how to use the call bell? Will the patient attempt to self-transfer without asking for help? This is where standardized assessments are incredibly helpful in eliminating gray areas and ensuring effective staff education/carryover of safety measures.

Lastly, I consider the patient’s environmental supports. Many of the questions I ask myself when assessing the environment will overlap with cognitive function. Are there multiple obstacles that could cause the patient to trip or stumble? Is the adaptive equipment appropriately sized to the patient? Is the patient’s room located close enough to the nurse’s station to ensure that the patient is frequently monitored? Does the patient actively participate in the environment during the day? How early does the patient get out of bed in the morning? Is the patient sleeping all night? Can the patient communicate his/her needs (including hunger, need to void, presence of pain, etc)?

Once I’ve determined what areas could use some intervention, I can confidently make a plan of care that will address the areas of concern and ultimately decrease fall risk.

Caregiver education is a major component of fall risk intervention. We as occupational therapists are uniquely taught to view patients from the above point of view (the same is true of physical therapists). We are taught to think about all of these areas of function in light of any and all tasks. Therefore, it is our role and responsibility to share what we know with our patients, their families, and the facility staff that provide care to ensure that effective carryover is maximized.


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