What are the criteria for admitting a patient at high risk for falls to a rehabilitation or skilled nursing facility after emergency room evaluation?

Criteria for Admission to Rehabilitation or Skilled Nursing Facility for High Fall Risk Patients

A patient at high risk for falls who is not safe to return home without assistance should be admitted to rehabilitation or skilled nursing facility based on their fall risk assessment, functional status, and potential for improvement.

Fall Risk Assessment Criteria

The American Heart Association/American Stroke Association guidelines provide clear criteria for determining when a patient at high risk for falls requires admission to rehabilitation or skilled nursing facility 1:

1. Documented Fall Risk Factors:

   • History of recent falls or fear of falling
   • Residual neurological or functional impairments
   • Poor balance and postural instability
   • Gait abnormalities requiring assistance
   • Cognitive deficits (awareness issues, disinhibition, visual neglect)
   • Sensory impairments (visual field cuts, hemianesthesia)

2. Functional Assessment Results:

   • Inability to safely perform activities of daily living
   • Need for assistance with transfers and mobility
   • Decreased postural stability during standing
   • Asymmetrical weight bearing (favoring non-affected side)
   • Delayed and less coordinated responses to balance perturbations 2

Documentation Requirements for Admission

To successfully advocate for rehabilitation or skilled nursing facility admission, document the following:

For Inpatient Rehabilitation Facility (IRF):

• Patient requires intensive rehabilitation (minimum 3 hours/day)
• Evidence that significant functional improvement can be expected within a reasonable timeframe
• Patient can likely return to a community setting after discharge 1
• Medical necessity for physician involvement at least every 2-3 days
• Need for coordinated interdisciplinary team approach 1

For Skilled Nursing Facility (SNF):

• Patient requires daily skilled nursing or rehabilitation services that can only be provided on an inpatient basis
• Services require skills of qualified healthcare professionals (nurses, therapists)
• Even if full recovery isn't expected, skilled services are needed to maintain or prevent deterioration 1

Advocating for Admission

When the ER is attempting to discharge a high-fall-risk patient home without adequate support:

1. Document Fall Risk Assessment:

   • Use standardized fall risk assessment tools
   • Document specific functional deficits that make home discharge unsafe
   • Note any history of previous falls 1

2. Request Formal Rehabilitation Assessment:

   • All patients should undergo formal rehabilitation assessment by clinicians with expertise in rehabilitation before discharge 1
   • Assessment should evaluate activities of daily living, communication abilities, and functional mobility 1

3. Emphasize Safety Concerns:

   • Document that the patient cannot safely perform necessary activities of daily living
   • Note lack of adequate home support/supervision
   • Highlight that falls are associated with increased mortality, morbidity, and decreased quality of life 1

4. Reference Guidelines:

   • Cite AHA/ASA guidelines recommending that individuals with stroke at risk for falls receive formal fall prevention programs during hospitalization (Class I; Level of Evidence A) 1
   • Note that fall prevention requires a structured interdisciplinary approach to management 1

Important Considerations

• Falls are a common complication after stroke with incidence ranging from 7% in the first week to 73% in the first year 1
• Among stroke survivors, 22-48% experience at least one fall during hospital stay 1
• Falls lead to increased healthcare costs, longer length of stay, and have been independently associated with loss of function 1
• Patients with stroke are at higher risk for falls than the general population, with fall rates as high as 50% in community-dwelling stroke survivors 2

Common Pitfalls to Avoid

• Inadequate Documentation: Ensure thorough documentation of specific fall risk factors and functional limitations
• Focusing Only on Medical Issues: Emphasize functional limitations and safety concerns, not just medical diagnoses
• Accepting Pro Forma Assessments: Insist on meaningful interactive assessments rather than superficial evaluations 1
• Overlooking Cognitive Factors: Include assessment of cognitive deficits that may impact safety at home
• Failing to Include Family Input: Document family/caregiver concerns about home safety and ability to provide care

By following these guidelines and thoroughly documenting fall risk and functional limitations, you can effectively advocate for appropriate rehabilitation or skilled nursing facility placement for patients who are unsafe to return home without assistance.