Fall Risk in California Assisted Living: What Homes Can and Cannot Do

Yes. A history of falls is not on California's lists of restricted or prohibited health conditions for assisted living communities and board and care homes, licensed in California as residential care facilities for the elderly (RCFEs). Many people move for this reason: someone is nearby when they get up at night.

It helps to be realistic about what a move changes. The Centers for Disease Control and Prevention (CDC) reports that more than one out of four older people falls each year, and that falling once doubles the chances of falling again. A care home lowers some risks. It does not remove them, and California law limits how far a home may go to keep a person from getting up.

The CDC says most falls are caused by a combination of risk factors, and that many of them can be changed. The National Institute on Aging (NIA) adds that conditions that cause rushed trips to the bathroom, such as incontinence, can raise the chance of falling, and that older adults with mild cognitive impairment or certain types of dementia are at higher risk. Risk factors on the CDC's list include:

• Lower body weakness.
• Difficulties with walking and balance.
• Use of medicines such as tranquilizers, sedatives or antidepressants.
• Vision problems.
• Foot pain or poor footwear.
• Hazards such as broken or uneven steps, throw rugs and clutter.

This is why a fall plan starts with the doctor and not with the building. The CDC's advice is to ask a doctor or health care provider to evaluate the risk of falling, and to ask a doctor or pharmacist to review all medicines, including over-the-counter ones, for any that cause dizziness or sleepiness.

Title 22 does not contain a fall prevention program by name. It sets building standards and duties of care that bear on falls.

The building: sections 87303 and 87307 require grab bars at each toilet, bathtub and shower residents use, slip-resistant surfaces in tubs and showers, nonslip material on rugs, night lights in hallways and passages to shared bathrooms, and sturdy hand railings and good lighting on stairways, inclines, ramps and open porches. Homes licensed for 16 or more residents, and homes with separate floors or buildings, must have a signal system that works from each resident's living unit.

The care: a home assesses walking and transfers before admission, must observe residents regularly for changes in physical and mental functioning, and must update its appraisal after a significant change in condition and bring it to the attention of a medical professional. See our guide to wheelchairs and transfers for the mobility rules and staffing requirements for who is on duty at night.

After a fall: section 87211 requires a written report to the licensing agency and to the person responsible for the resident, no later than seven days after any serious injury, as determined by the attending physician, that occurs while the resident is under the home's supervision.

This is where families are most often surprised. An RCFE works under Title 22, section 87608, which allows only what it calls postural supports: appliances or devices such as braces, spring release trays or soft ties, used to achieve proper body position and balance, to improve mobility and independent functioning, or to position a person, not to restrict movement. Positioning can include keeping a resident from falling out of a bed or chair.

Other parts of the law point the same way. Residents have the right to leave the home at any time and not to be locked into any room. The Resident's Bill of Rights, Health and Safety Code section 1569.269, lists the rights to be free from involuntary seclusion and punishment, to make choices about daily life, and to request, refuse or discontinue a service. The regulations name a breach of the postural support rules, which they describe as relating to restraints, among the examples of serious deficiencies.

Medication is the other form of restraint families ask about. Sedating drugs appear on the CDC's own list of fall risk factors, and our guide to dementia medications in care homes covers consent and the right to refuse.

The section's rules are:

The steps federal health agencies recommend are ordinary ones. Ask the doctor whether each applies to your parent:

• Strength and balance exercise. The CDC gives tai chi as an example.
• A medicine review with the doctor or pharmacist.
• An eye check at least once a year, and updated glasses, per the CDC. The NIA adds hearing tests.
• Footwear: the NIA suggests nonskid, rubber-soled, low-heeled shoes, and no walking in socks or smooth-soled slippers.
• Standing up slowly, because blood pressure can drop on rising, according to the NIA.
• A cane or walker that is the right size, with a therapist's help to choose it and learn to use it.
• Telling the doctor about every fall, even one that did not hurt.

The NIA notes that a physical or occupational therapist can help choose devices and teach safe use. Our guide to therapy and home health in assisted living explains how outside services come into a licensed home. Poor sight and hearing get their own page: vision and hearing loss.

The CDC warns that an older person who falls and hits their head should see a doctor right away, especially if they take blood thinners. In an emergency, call 911. If you believe a licensed home is restraining a resident or ignoring falls, raise it with the administrator, and know that the Long-Term Care Ombudsman and California's Community Care Licensing Division both take complaints about licensed homes.

Questions for a tour:

• What do you do in the first minutes after a resident falls, and who decides whether to call 911?
• How quickly do you tell the family and the doctor?
• Is the night caregiver awake? How do residents call for help from bed and from the bathroom?
• Do you use half bed rails, and how do you decide?
• How do you help someone who gets up at night to use the toilet?
• After a fall, what changes in the care plan, and is there a charge?

Hamssa Benrekia is a senior living placement specialist in Torrance who holds an RCFE Administrator Certificate and has a background in hospice and home health. She helps families in the South Bay and Harbor area compare licensed homes, goes on tours with them, and checks each home's public licensing record with Community Care Licensing. She cannot promise that a home will prevent falls, and no one can. To talk about assisted living placement, contact Hamssa. The California Assisted Living Placement Guide covers the rest of the decision.