Geriatric Nursing
Volume 28, Issue 6 , Pages 349-357, November 2007

Fall Prevention in Assisted Living: Assessment and Strategies

Ethel Mitty and Sandi Flores

Article Outline

Residents in assisted living residences have similar risk factors for falls as do community-residing older adults and, as such, can benefit from the research findings on falls prevention conducted with that population. Some risk factors can be managed, such as, medication side effects, and muscle weakness; others such as degenerative neurological changes, cannot. Knowing a resident’s falls history and conducting a full risk assessment, in combination with appropriate interventions, can reduce the probability of a future fall. Exercise appears to be the most effective factor in reducing the risk of falls and injuries from falls. The fear of falling, whether or not associated with a previous fall, is more common among older women and can seriously restrict their quality of life. This article describes evidence-based falls risk assessment instruments and interventions to reduce falls risk. T’ai chi, for example, can reduce falls risk by improving balance. The article describes a standard fall prevention program for older adults that can be part of a resident’s care or service plan, criteria for an occurrence report, quality improvement monitoring, and a formula to calculate the residence’s monthly falls rate.

 

What is the likelihood of a future fall? The best predictor is a previous fall. Although the fall rate in assisted living (AL) communities is unknown, the fact that more than one third of community-dwelling older adults1 and slightly over half of residents in continuing-care retirement communities and retirement homes fall annually2, 3 and that more AL residents than skilled nursing facility residents sustain a fall-related injury1 is more than sufficient evidence that AL residents are at risk for falls. It is sobering to note that falls are the leading cause of injury-related death among older adults (i.e., those aged over 65 years).4 This article describes the etiology of falls, risk factors, instruments to assess fall risk, postfall assessment, and fall prevention strategies. A continuing quality improvement monitoring plan for a fall management program and a simple formula to compute falls rate are suggested.

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Etiology and Risk Factors of Falls 

The epidemiology of falls can be is categorized as intrinsic and extrinsic risk factors.5 Intrinsic factors include normal age-related changes; concurrent diseases; impairment in the neurological, musculoskeletal, sensory, and cardiovascular systems; and cognitive changes such that a person is unable to recognize or evaluate a risk in the environment or changes in the body’s homeostatic and adaptive mechanisms. Age-related changes in visual function predispose the older adult to fall risk because the reduction in depth and spatial perception lead to reduced ability to differentiate solids and shadows and greater sensitivity to glare. Falls are associated with lower-extremity weakness, poor balance, poor grip strength, and polypharmacy. Extrinsic factors include poor lighting, slippery floors, lack of handrails (especially in toilet and shower/tub areas), poor signage, and certain classes of medications. There is a significantly increased risk of falls associated with psychotropic, antiarrhythmic, digoxin, and diuretic medications.5 The combination of balance instability, taking 4 or more medications, and hip joint weakness is 100% predictive of falls risk.4 This speaks clearly to the need for specific kinds of assessment, many of which can be done by a nurse; for example, the Tinetti Gait and Balance Scale (discussed later in this article) and medication reviews.

People with Alzheimer’s disease and related dementias are at greater risk of falling and have more falls than older adults who are not suffering from a dementing illness.6 Approximately 25% of the falls result in hip fracture for which prognosis and recovery is less satisfactory than for those residents without dementia.6 Impairment of cognitive function, an intrinsic risk factor, interacts with the environment (an extrinsic risk factor) such that people with dementia might fail to comprehend a clear or potential danger, denies their frailty, are unable to ask for help because of impaired communication, overestimates their capability to maneuver an environmental hazard (e.g., puddle, corridor barrier), or forgets that they need assistance in ambulating.6 The combination of visual changes with reduced recognition of familiar places, changes in attentiveness to cues and details, and other at-risk behavior (e.g., sundowning, wandering, agitation), are significant risk factors.6 Unfortunately, there are no published studies that describe the relationship between severity of dementia and falls risk. Clearly, this research is needed and could be initiated in an AL community where persons with dementia are still mobile and interactive.

An analysis of 16 studies found the following risk factors associated with falls, in descending order of importance: muscle weakness, history of falls, gait deficit, balance deficit, use of assistive device, visual deficit, arthritis, depression, cognitive impairment, and age over 80 years.4 Some risk factors can be attenuated, such as medication side effects, muscle weakness, and low blood pressure; others, such as degenerative neurological changes, cannot. The driving principle for the American Geriatrics Society Panel on Fall Prevention was that knowledge of a person’s history of falls and administering a full assessment could likely reduce the probability of a future fall in combination with an appropriate intervention.5 Anticoagulant therapy is a risk factor because it increases risk of bleeding after a fall. Osteoporosis (and osteopenia) increases fracture risk, most commonly at the wrist, hip, and spine.7

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“Near Falls” 

In constructing a resident’s falls history, it is important to ask about “near falls” (just as it is important to document and report “near-miss” medication errors). These events are sometimes characterized as “almost falling” or “incomplete falls.” Being “found on the floor” may have been a near-fall. The AL facility policy should define this kind of event; it has clinical implications with regard to how to protect the resident from significant injury and legal implications with regard to a facility’s responsibility to protect a resident from harm. It is recommended that “stumbles” or near falls should be treated with equal concern as an actual fall.8 Residents can be helped to think about these near misses and asked if they almost fell, grabbed on to something nearby, or lowered themselves to the floor.

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The Occurrence Report 

Some nursing homes differentiate kinds of events or occurrences: an “incident” is an event in which there is no evidence of injury (immediately or after several hours/days); an “accident” is an event with an injury that is immediately visible or noted relatively soon thereafter (ie, within 24 hours). At the very least, an occurrence report should include a description of the time, location, and environment of the event; how the resident was found; and what the resident said about the incident. Information for an occurrence report that is useful for continuing quality improvement as well as informing the resident’s care or service plan to prevent recurrence is shown in Table 1.9 Some states require that nursing homes provide a copy of the resident’s account of the occurrence to the resident or family.

Table 1. Occurrence Report

•Resident’s account of the occurrence

•Staff account of the occurrence (if observed)

•Etiology: self-ambulation, self-transfer, self-toileting

•Location and time

•Where and when resident was observed before the occurrence or finding

•Type and site of injury (if evident)

•Vital signs taken when resident was found; resident’s baseline vital signs

•Optional to include range of motion, level of consciousness, neuro status (ie, pupils)

•Witness(es)

•Environment: floor, lighting, handrail, corridor obstacles (eg, cleaning equipment)

•High-risk factors in the situation: resident is a new admission, room change

•High-risk factors, resident characteristics: sensory impairments, pain, physical limitations, known gait and balance difficulties, cognitive impairment (eg, poor judgment), concurrent medical diagnoses that influence health and require oversight, medications

•Mobility devices in use

•Pattern of occurrences

Data from Mitty.9

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Fear of Falling 

Some older adults, after having fallen once, whether or not they experienced a significant injury such as a fractured hip, may develop a fear of falling such that it prevents them from enjoying activities from which they may have previously derived pleasure, such as going to a movie, attending a family event, or strolling in a park. Research suggests that even those without a personal experience of a fall can be fearful of falling.8 This syndrome appears to be associated more with women and advancing age, and it can affect gait and balance. It has significant consequences on quality of life and willingness to participate in certain activities, in addition to its cumulative effect on mobility and dependency.

Several instruments address fear of falling from the perspective of efficacy or self-confidence in one’s ability to do something.8 Questions must be sensitively phrased and can be as simple as “How afraid are you of falling?” Avoid asking a yes-no question: “Are you afraid of falling?” The question can be specific: “How afraid are you of falling when taking a bath or shower? When you go shopping? When you get up from a chair or your bed?” “How has your gait and balance affected your social life?” Questions can be phrased as: “How confident are you that you can do X without falling?”8 (p. 228). Questions can be asked about the person’s confidence getting in or out of a car, walking down a ramp, reaching for something on an upper shelf, bending down to fix one’s shoe, and so on.10, 11 A variation on ascertaining a person’s fear of falling could be to ask the extent to which he or she avoids certain activities because of anxiety about falling or not wanting to be embarrassed by a fall in public8 (p. 230).

Multifactorial interventions are more effective than single interventions for fear of falling. The combination of t’ai chi, exercise, and the use of hip protectors either directly or indirectly reduced fear of falling among community-residing older adults.12 A nursing approach for people who are afraid of falling is to encourage them to express their fear and show them that they really can transfer and ambulate safely.7 This approach draws on the concept of self-efficacy—confidence in one’s ability.

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Assessment for Fall Risk 

It is recommended that older adults who have not fallen or who have fallen only once should be asked at the time of their annual physical about any falls that occurred in the past year.5 Those individuals who report a single fall should be tested with the “Get Up and Go Test,” and if no unsteadiness or difficulty is observed, there is no need for further testing.5 Older adults who have difficulty with the Get Up and Go Test or who have experienced several falls in the past year require more intensive assessment including cardiovascular, neurological, and medication assessment.5

Assessment for falls risk is multifaceted and includes the history and details of a previous fall(s), intrinsic and extrinsic risk factor, other medical conditions (ie, comorbidity), and mobility status.5 Medications should not be considered in isolation; for example, an older person receiving a psychotropic medication is not necessarily at high risk unless comorbid conditions exist that predispose the individual to balance or gait impairment. Medical conditions must be considered with regard to their acuity and interactive effect on mobility. The risk assessment tools discussed in this section include these factors. Each tool is based on observation of 1 or more gait and balance tasks, and none require special equipment. The health care team of the AL residence should decide which instrument best captures at-risk information for the current resident population. (Note: instruments are accessible via the Internet; see the Resources section).

Get Up and Go Test 

The person sits in a chair with his or her back against the chair, arms on the chair arms, and any mobility aid in position. Upon the command “go,” the person is observed getting up from the chair, walking 10 feet, and returning to sit down in the chair. Observation consists of whether the person used his or her arms to push off from the chair, ease of getting up, and balance during the walk and when turning around to return to the chair. In one version of this test, each task is scored on a scale from 1 to 5 (normal to very abnormal). The average time to complete this test is 7–10 seconds.13

A variation of this measure, the timed Get Up and Go Test, observes the time it takes to complete the full maneuver. Independently mobile older adults completed it in less than 20 seconds, whereas mobility-dependent older adults required more than 30 seconds.8 This test can be used as a baseline measure for subsequent assessment and as an indication that the person could be at risk for a fall.

Time Up and Go Test 

This test assigns a score for the average completion time of each segment. If the mobility segment (ie, getting up from a chair and walking 8 feet and back from a set point and turning back) required 8.5 or fewer seconds, then the individual is “freely mobile” (or “independently mobile”), is low (to moderate) risk for falls, and no additional assessment is needed.14 A multifactor fall assessment should be undertaken and specialist referral should be made if the activity requires more time. The person can be given the opportunity to practice this test activity and is then timed doing it 3 times.

Performance-Oriented Mobility Assessment 

Also known as the Tinetti Gait and Balance Test, this is a widely used, scaled test that assesses stationary (ie, static) and dynamic sitting and standing balance and ambulation.15 It is considered more reliable and predictive than the Get Up and Go Test and takes approximately 15 minutes to do. The 9-item balance component includes observation of individuals’ sitting balance, their ability to get up from a chair (including use of arms and the number of attempts it takes to rise), standing balance with feet at least 4 inches apart with eyes open and with eyes closed, ability to maintain balance while feet are together and a slight “nudge” is applied to the chest, and ability to turn around and return to the chair. The maximum score is 16. The 7-item gait assessment directs individuals to walk down a hallway at their usual pace and then at a faster (but safe) pace using any mobility device they customarily use. Observation includes right and left foot step length and height, step length symmetry (are they equal?), stopping or lack of continuity between each step, remaining on the path (ie, not veering to the left or right), trunk sway, and walk posture. The maximum score is 12. Interpretation of the score in context with other high-risk characteristics is necessary.

The Functional Reach Test 

This measure of balance defines functional reach as the maximum distance individuals can reach forward with their arm fully extended and their hand in a fist while standing up and without moving foot position.16 A yardstick or a “band” is horizontally mounted on the wall at the level of the person’s shoulder. Inability to reach 6 inches or less, and, interestingly, ability to reach forward 6 to 10 inches, is associated with increased falls risk.8 This test should not be performed with a person known to have imbalance problems, and it is recommended that, if administered, a second person should be standing close by.

The Performance-Oriented Mobility Screen8 

This 10-item gait and balance test is adapted from several mobility assessment instruments; it reportedly requires less than 5 minutes to conduct. Each task is judged as performed either normally or abnormally. It includes the Romberg maneuver: while standing with feet 3 inches apart, with eyes closed and arms at sides, the ability to maintain balance is observed. Imbalance is noted as postural sway or reaching out to hold on to something. As with the Functional Reach Test, it is advisable to have a second staff person standing close by. The tasks include sitting down and standing up from a chair, standing with eyes closed, receiving a chest “nudge” while standing, standing on tiptoes and reaching down as if to retrieve an object from the floor, a 15-foot walk and turn around, lying down on the floor, and the ability to get up. Any abnormal finding is indicative of falls risk, and some (eg, being unable to rise without using armrests) might indicate the need for environmental modifications, such as toilet grab bars. Inability or refusal to perform a balance test could be a sign of fear of falling.8

The Hendrich Fall Risk Model 

This test consists of 8 assessment domains for high-risk fall identification.17 It is widely used in acute care and has acceptable reliability and validity. A “risk point” (see number in brackets) is assigned to each of 8 items: confusion or disorientation (or Mini-Mental State Examination score of less than 17) [4], depression (as identified by a valid depression measure) [2], toileting and elimination assistance need [1], dizziness or vertigo (documented in the record) [1], gender [1], receiving antiepileptic medication [1], receiving a benzodiazepine [1], and the Get Up and Go score for ability to rise from the chair [range: 0–4 (able-unable to get up)]. An individual is high risk with 5 or more risk points and placed on “fall precautions.” This evidence-based tool has acceptable reliability and validity and can avoid the possibility of failing to identify an at-risk resident or overidentifying a resident who is not at risk. Hendrich and colleagues noted that males may be less inclined to ask for assistance and more likely to take risks. Medications, in their view, are not a fall risk factor on their own but, rather, in terms of their potential side effects on ambulation, cognition, and so on.

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Postfall Assessment 

The postfall evaluation seeks to elicit the person’s awareness and understanding of his or her fall, gathers information about the environment and context of the fall (eg, activity at the time of the occurrence), and any symptoms experienced just before falling (eg, dizziness, being short of breath, sudden pain or weakness, unsteadiness, urgent need to use the bathroom, feeling anxious).18 After physical examination and review of systems, identification of the etiology of the fall proceeds by a series of steps that take into account all the information obtained. Sometimes constructing a “case vignette” synthesizes the information into a meaningful pattern from which preventative measures can be designed.

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Fall Prevention Strategies 

Interventions to prevent falls include staff and resident education, gait training and appropriate use of ambulation devices, medication review, particularly of psychotropics (i.e., benzodiazepines, neuroleptics, antidepressants), exercise, and environmental modification.5 Having an adequate scientific or evidence base to justify a particular intervention is not always possible. It is therefore important to describe the link between a specific risk factor (or cause) and a specific intervention.5 Environmental assessment and strategies to reduce fall risk are beyond the scope of this article. However, environmental safety includes attention to lighting and signage, floor surfaces (eg, glare) and textures (eg, scatter rugs), bed height, armchair and couch height and armrest placement, stairways and step edges, grab bars in toileting and bathing areas, and absence of clutter.

The influence of education on falls risk and reduction is greater on staff in long-term care settings than on adults in community settings, such as senior centers.5 In isolation, education alone does not reduce falls risk for the older adult. An AL provider in several states required that all nurses attend a 4-week falls risk program held via webinars and conference calls. The executive directors of each residence were also required to attend, thereby hoping to spread falls awareness and responsibility beyond the nursing department. Nurses involved in the conference calls shared their concerns, successful interventions, and failed approaches. With input from consultant pharmacists, the program reduced injuries from falls by 11% (personal correspondence, S. Flores, August 28, 2007).

Exercise that includes balance training appears to have the strongest positive effect on falls reduction; resistance and aerobic training lack sufficient evidence as to their usefulness. Given the varied length and intensity of the exercise programs reported in the literature, there are not as yet any standardized guidelines for exercise programs. A 12-month study of a group exercise program for older adults living in retirement villages (age range: 62–95; N = 551 men and women) randomly assigned the study participants to 3 classes: exercise; flexibility and relaxation; no class. Despite some differences in group characteristics (eg, age range, gender, number of classes attended), there were fewer falls among the exercise group during and 6 months after the program ended.19 A multifactorial intervention of 3 fall-prevention modalities (environmental assessment and modification, education about strengthening exercises, and exercise training that included stretching, balance training, and muscle strengthening) for community-dwelling Taiwanese older adults (aged >65 years) found greater improvement in functional reach, gait, and balance, as well as reduced fear of falling, among the exercise intervention group compared with the education-only group.20 Quality-of-life measures (e.g., depression and fear of falling scores) also improved among those who received exercise training.

Another multifactorial fall prevention program that included these modalities but also provided free hip protectors, conducted postfall conferences, and supplied and repaired assistive devices was effective in reducing both falls and femoral fractures among residents aged 65 years and older in residential care facilities in Sweden.21 Led by an interdisciplinary team (physicians, nurses, physical and occupational therapists), medication review removed or lowered the dosage of high-risk medications (noted earlier). Interestingly, some medications were started because of medical conditions that placed the resident at high risk for falls, such as anemia, infection, and pain. In contrast, a fall prevention program that included systematic individualized falls risk assessment and intervention failed to show any reduction in falls or injuries from falls.3

T’ai chi that includes balance training designed for individuals’ personal characteristics is associated with fall reduction.22 T’ai chi provided in 20 congregate living facilities for 48 weeks to women (n = 291) and men (n = 20), aged 70 to 90 years, did not reduce the risk of fall among those receiving t’ai chi instruction (i.e., the intervention or treatment group) compared with the control group who received wellness education alone.23 Although not statistically significant, those receiving t’ai chi had fewer falls and a lowered fear of falling score than the control group. Another t’ai chi randomized controlled study with community-residing inactive older adults that provided stretching classes 3 times a week for 24 weeks reported reduced falls and fear of falling, decreased risk of falling, and improved physical function.24

Strength or resistance training programs are based on the presumption that lower-extremity strength, walking endurance, and improved cardiac status influence fall reduction. The Osteofit Program—exercises performed in twice weekly classes with community-residing older women with osteoporosis—reported that the exercise intervention group had improved balance compared with the control group.25 A 1-year long, twice weekly, weight-bearing exercise program with 551 high-risk AL and independent-living residents was associated with 22% fewer falls, improved gait, and improved walking endurance in the intervention group compared with the control (ie, no intervention) group.19

Rehabilitative strategies include proper footwear, hip protectors, and mobility assistance devices. Older adults with muscle and fat malnutrition might benefit by wearing hip protectors to reduce the impact of a fall.7 Risk reduction of 4% is reported with the use of hip protectors.4 Use of hip protectors can extend quality-adjusted life-years (QALYs) for men starting at age 85 and women starting at age 75.26 For younger men and women, use of hip protectors has no effect on QALYs or health care system costs. Education regarding proper footwear can reduce the risk of falls, but there are no rigorously controlled studies to support the observations made from small trial studies. Among the findings are that women ambulate more safely when wearing low-heeled shoes than when walking barefoot, and men walk with better balance when wearing shoes with high midsole hardness and low thickness.5 Those using a cane or walker paid greater attention to their ambulation than those who did not use assistive devices; this is true even for those experienced with using the assistive device.27 This raises an interesting concern about increased falls risk with use of mobility assistive devices.

A fall prevention plan of care for all older adults, not just those with a history of falls, includes proper footwear, the environmental contingencies described earlier, an individualized toileting plan, appropriate bed height for transfer safety, having a night light and important objects placed within reach, monitoring, education, and exercise at individuals’ highest attainable level to maintain safe physical functioning.7

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Continuing Quality Improvement 

A successful falls management program relies on policies and procedures for responsibility and accountability in fall management practices; communication to all relevant staff of interventions and care plan changes; and teamwork that supports formal and informal education.28 A quality improvement “monitor” that lists the criteria applicable to a specific resident’s fall prevention regimen could be placed in the resident’s record and used to track desirable fall prevention outcomes.29 The monitor or checklist should include items relevant to a recent fall: identification of falls risk factors and measures taken to prevent recurrence of falls and related injuries. This last section can be particularly instructive by including medication review, a specific exercise program, any environmental modifications, use of glasses, wearing of proper footwear, any protective devices used, and the resident’s toileting program.

The continuing quality improvement plan should require a monthly (and annual) report of occurrences.9 The monthly report should include the number of occurrences (as defined in policy, ie, incident or accident) with regard to location and time of day, giving particular attention to change of shift and staff break time. Data from the preceding month should be included to judge the effectiveness of the falls prevention program. Drawing on the occurrence report categories, the report should enumerate the number of occurrences related to self-ambulation, transfer, toileting, high-risk factors, type of injury, and so on (see Table 1).

Residents who are “repeat fallers” should be identified in a separate report that details their risk assessment score, mental status, major diagnoses, and the team’s recommendations to manage the resident’s high risk for falls. A resident and family conference might be called to discuss what the AL residence can and cannot do to protect the resident from injury. Whether this is included in a service plan or “risk contract” will vary by state regulations and facility policy. All conversations about risk potential and steps to reduce risk should be documented.

Falls Rate Calculation 

An AL residence should calculate and track falls rate on a monthly basis. The fall rate reflects risk by indicating the number of falls that can be anticipated for every 1000 bed days of care (BDOC). BDOC is the census across a period of time; for example, a census of 60 for 30 days is 1800 BDOC. The formula is simply the number of resident falls divided by the number of resident BDOC, multiplied by 1000.30 For example, if 4 residents fell during the previous month, during which there were 1800 BDOC, the fall rate would be 4 divided by 1800, times 1000, or 2.2%. This means that for every 1800 BDOC, at least 2 falls are likely.

You Can Lead a Horse to Water… 

…but some assisted living residents will choose not to attend an exercise class. It might be that these residents fear inducing pain associated with the exercise, being injured by the exercise motions, or that the exercise will sap their strength, leaving them unable to enjoy their other pursuits.1 This is all rational and real and is compounded by the residents’ feeling that exercise is for the young and healthy or that it is not beneficial unless it is strenuous (which is something they cannot do). Men and women reportedly have totally different attitudes toward exercise. For men, the best predictor of intention to exercise is attitude toward exercise, whereas for women, the intention to exercise is influenced by a combination of attitude toward exercise—perception of benefits, locus of control, and the feeling of self-confidence (ie, efficacy) in the activity.1

Motivation to exercise can be affected by not wanting to do it alone and the fact that the person finds it, quite simply, boring and not too much fun. According to the Centers for Disease Control and Prevention, physicians do not as a matter of course ask their patients about their exercise routine and nutrition. This could lead to older adults’ conclusion that exercise is unimportant for their well-being.1 Talking with reluctant residents to identify a satisfying personal goal with exercise and perhaps using a diary to record their progress toward that goal might be motivating, as can helping the person find a “buddy” with whom they can exercise.1 It is important to treat any persistent (ie, chronic) pain that interferes with the activity—and the enjoyment of it. Exercise “prescriptions” should be used with caution to avoid a one-size-fits-all program that is the antithesis to a person-specific exercise and falls reduction program.

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Resources 

Assessment Instruments 


•Get Up and Go Test: www.americangeriatrics.org/education/02-get-up-go-test.pdf

•Get Up and Go Test, timed: www.fallprevention.ri.gov/Module3.htm

•Up and Go Test: www.va.gov/NCPS/SafetyTopics/fallstoolkit/media/timed_up_and_go_test-07-15-04.pdf

•Tinetti Gait and Balance Test: www.sgim.org/Tinetti Tool.PDF

•Functional Reach Test: www.ohcponline.com/tools/functionalreach.html or http://web.missouri.edu/∼proste/tool/Functional-Reach.rtf

•National Center for Patient Safety, 2004 Falls Toolkit: www.va.gov/NCPS/SafetyTopics/fallstoolkit/index.html

•For a list of assessment tools, including the Tinetti Gait and Balance Assessment, visit www.anodynetherapy.com (click on “Care Center Program Resource Area”)

•Hartford Center for Geriatric Nursing Web site: www.hartfordign.org. Click on “Try This” for links to many assessment tools including Fall Risk Assessment; Beers’ Criteria for Potentially Inappropriate Medication Use in the Elderly.

Web Sites 

www.stopfalls.org

www.cdc.gov.ncipc/duip/FallsPreventionActivity.htm

www.americangeriatrics.org Guidelines and Position statements.

www.amda.com American Medical Directors Association

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References 

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  30. VA National Center for patient Safety. www.va.gov/NCPS/SafetyTopics/fallstoolkit/index.htmlCited August 29, 2007

ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, and consultant in long term care at the Hartford Institute for Geriatric Nursing, College of Nursing, New York University.

SANDI FLORES, RN, C, is executive director of the American Assisted Living Nurses Association and education director of Community Education LLC (www.communityed.com).

PII: S0197-4572(07)00306-0

doi:10.1016/j.gerinurse.2007.10.005

Geriatric Nursing
Volume 28, Issue 6 , Pages 349-357, November 2007

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