Pointing out hazards in the physical environment plays a very limited role in fall prevention with severe cognitive disabilities because the person's ability to be careful is limited. Hazards below the knees can be pointed out, but the person's attention to the hazard and the necessary neuromuscular adjustments to be careful are rarely implemented by the person. Most fall preventions with hazards below the knees are done by another person who provides physical assistance.
Real life pictures of hazards are presented to stimulate thinking about each person's situation. The one size fits all approach to fall prevention tends to unnecessarily remove or install safety features and miss glaring hazards.
Stairs
Dogs are common in many homes and a procedure to keep the dog out of the way when negotiating steps needs to be established.
These five steps might be negotiated with assistance on the right and using the hand rail on the left, moving slowly in ACL 3.0.
These stairs were darker than the picture shows and slippery. The slipperiness was not detected by most people and certainly none below ACL 5.2, when surface properties enter the ACL scale. The hand rail on the right prevented a lot of falls. People tend to assume that glossy finishes are slippery and matt finishes are not, which can be incorrect and was with these stairs.
Flat Walking Surfaces
All water on all floor surfaces is not equal. This water can be seen easily.
The real questions are:
- Do they understand that water can be slippery?
- Do they think that they might fall?
- Can they make the neuromuscular adjustments to prevent a fall?
The answer to all of those questions is probably no until at least ACL 5.0, when they can make neuromuscular adjustments. Saying "Be careful" is like saying "Lock your brakes" when people have no idea what you are talking about. The reason for the direction does not compute.
The risk of falling is either a non-conceptual reaction to fear or an abstract concept. Primal fears enter the ACL scale in level one; abstract concepts enter the scale in level six. In between, fall risks require physical assistance from other people. Verbal cues are useless.
This is an ideal surface for taking a walk because it's flat, and the curbs are even slanted. The ideal surface is a luxury in many places and should not be assumed.
Dog bones and their toys, as well as children's toys, are more of a hazard than the rug, which stays put in the corner on a non-skid mat. Common sense and on-site visits at different times of the day should not be so uncommon when fall safety is in question.
Rugs
A rug that needed to be removed, is shown in this picture: it slides and wrinkles on bathroom tiles that have a shiny, slippery glaze that rarely gets wet because this shower is used.
Another hazard has been staged in the same photo by placing a newspaper on the edge of the bathtub. If the person is in the habit of using the bathtub rim to assist with standing, the newspaper must be moved before grabbing the rim to stand. We would not expect a person to anticipate the hazard with a spatial property until ACL 5.8.
Below is a personal account from Claudia Allen regarding rugs.
When our Aunt Tiny came to visit, she was functioning within ACL 3.4. I was not about to roll up the rugs for a few days, so I taped them down with clear packaging tape. At the time, I wondered if I was nuts. The tape is long gone now.
Aunt Tiny got in and out of this chair without incident. I taped the length and the split in between the two rugs. I was not nuts and the taping worked fine.
I have told this story for years and learned more about taping rugs.
Synthetic carpets tend to curl, making re-taping necessary to keep the curls down. Some synthetics simply will not stay uncurled. The curls are what people tend to trip over.
Cotton, jute and wool rugs rarely curl. The rugs I taped were cotton, which is probably why the taping worked.
Thick rugs and shag rugs are hard to tape down and hold in place. Even when taped, they tend to slide around. The thickness can be a cause of tripping and hard to move a wheelchair up and over.
The hazard here does not photograph well, but the hazard is a single step down. Superficially and traditionally, health care workers would focus on the rug, which was no problem for Aunt Tiny. The hazard was the one step down.
The fact that the step did not photograph well was included for educational purposes. Now that taking pictures is so easy with smart phones, hazards that do not show up in pictures are often the real hazards in various situations. Pictures showing how a hazard is hard to see in a photo may help caregivers understand how hazards are hard to see in their own homes.