Freedom and Safety

April 1995

A Colorado Center Cares for Alzheimer's Patients

Ms. Scandura is administrator, Namaste Alzheimer Center, Colorado Springs, CO.


Namaste Alzheimer Center, in Colorado Springs, CO, was founded in 1990 as a free-standing special care facility for persons suffering from Alzheimer's disease. We do not physically restrain our residents and make only minimal use of psychotropic drugs. We want our residents to be as free of restrictions as possible — and also as safe as possible. Sometimes these goals conflict.

As our census climbed, the number of resident falls seemed to be climbing as well. We responded to this by charting the falls. The graphs showed us which residents had the most falls, which building wings most falls occurred in, and the times of day falls were most likely to occur. Armed with this information, our staff deployed themselves in a way to help prevent falls. Namaste had 35 resident falls in October 1992. In February 1993 we had only nine.

We not only reduced the number of falls; by furnishing the wings with beanbag chairs and futons instead of the usual furniture, we made falls less dangerous. We are now in the process of sharing what we have learned with the three acute care facilities that, with Namaste, are owned and operated by Penrose-St. Francis Health Care System.

When we opened Namaste Alzheimer Center in Colorado Springs, CO, in May 1990, it was one of the first free-standing special care facilities in the nation for persons suffering from Alzheimer's disease.

Created as an environment especially suited for those with dementia, Namaste is "user friendly." It comprises four separate locked "pods," two large and two small, each housing up to 16 residents. Persons are assigned to a pod according to their stage of dementia. One of the large pods is home to residents who, though they have relatively high cognitive levels of functioning, would not be safe outside a locked environment. In the other large pod live residents who are aggressive, combative, or behaviorally inappropriate. The smaller pods house residents who have mixed symptoms.

The center, designed for openness, allows the staff to see residents easily. In each of the larger pods, for example, eight semiprivate rooms line one wall, leaving the remaining space, including areas for activities and dining, in full view of the center's staff. Each pod is staffed during the day and evening shifts by a registered nurse (RN), a licensed practical nurse (LPN) in charge of medication, two certified nursing assistants (CNAs), and an activity aide who is also a CNA. At night, the pod staff is reduced to an RN and a CNA. Namaste's nurses' stations are placed between each pair of pods.

Untying the Elderly
The federal Omnibus Budget Reconciliation Act (OBRA) of 1987 contained provisions for the reform of nursing homes. Among those provisions was one requiring that residents be given the services necessary for them "to attain and maintain the highest possible mental and physical function status...." OBRA, which was implemented in December 1990, clearly did not permit an indiscriminate use of physical restraints on residents. Long-term care facilities everywhere began to "untie the elderly."

We at Namaste did not physically restrain our residents, so we had no negative behaviors to unlearn. Maintaining residents' rights and dignity is at the core of our center's operational philosophy. Our mission is "to provide high-quality, compassionate care in a special, safe environment to those who have a diagnosis of dementia or are cognitively impaired but can nevertheless function within our philosophy of few restraints."

Restraints include psychotropic drugs. We were determined never to restrain a resident physically and to use psychotropic drugs only with the most combative. We have committed ourselves to a minimal use of such drugs for two reasons:

  • We want our residents to be as free of restrictions as possible.
  • We want our residents to be as safe as possible. The more psychotropic drugs a resident has taken, the more likely he or she is to have balance and perceptual problems and to fall and get hurt.

But these two goals — freedom and safety — can sometimes be in conflict. Because everyone admitted to Namaste has at least some degree of cognitive impairment, we decided that all residents would be characterized as at "high risk" for falls. Namaste is owned and operated by Penrose-St. Francis Health Care System, a three-hospital acute care system. It was a challenge to convince the system's senior managers and legal and risk management departments that we could not tie or sedate all Namaste residents simply because they were at high risk for falling. But persuade them we did.

Tracking Residents' Falls
Having convinced the system's leaders that Namaste should not employ physical restraints, we found ourselves facing an even bigger challenge. For if we were going to leave our residents free of restraints, we would of course increase their risk of falling. And by 1993, by which time our census had jumped from 48 to 61 residents, patient falls seemed to be increasing as well.

We knew we could not prevent all falls. But we did not know how many were "acceptable." Because Namaste is so unusual, we have been unable to "benchmark" our policies against those of similar institutions. We know of no other facility for persons with Alzheimer's disease that does not physically restrain at least some residents. We have searched journals for information, but the articles we have found focus on either acute care settings or on long-term facilities with heterogeneous populations. We have found no article describing an institution like ours, one specifically devoted to residents with dementia.

The Colorado Department of Health requires us to keep a record of falls on a monthly basis. To actually prevent falls, we decided, we needed to know more about them than the numbers. Early in 1993, we began to collect data on each patient fall. After tracking falls for three months, we began to graph these data. We came up with some interesting results.

On one graph we isolated falls according to the pods they occurred in. As expected, the highest percentage happened in the pods housing patients in mid stages of dementia. On another graph, we showed the time of day falls were most likely to occur. In still another diagram, we showed which residents had the most falls and which drugs they were taking.

Preventing Residents' Falls
We asked our staff members what might be done to reduce the number of falls. They responded at first by saying, "We need more staff." But once they were convinced that adding staff was impossible, they became creative in the way they covered the pods.

Our data showed that most falls happened on the evening shift, from 8 pm to midnight, though the staff members on that shift refused to believe it until we showed them the graph. Then they developed their own action plan to reduce falls during these "peak hours." They began to arrange baths for the majority of residents between 3 and 3:25 in the afternoon, waiting until later in the evening to bathe the combative minority, after most residents were in bed.

We also got permission from the State Department of Health to put mattresses on the pod floors for those residents at risk for falling out of a regular bed. We call this our "safe sleeping" policy. In addition, we have furnished the pod living areas with beanbag chairs and futons — furniture that is comfortable and unrestrictive but also safe, because it is close to the floor. Indeed, Namaste staff members have collaborated with a bed manufacturer in designing a foam futon that is ideal for our residents, for it reduces their fear of falling. We hope, in the near future, to offer the futons for sale.

The futons, incidentally, play a role in our discussions with those considering Namaste as a home for a family member. In describing the center, our social worker emphasizes Namaste's restraint-free philosophy, tells how the pods' open design allows staff to easily visualize all residents, and lists the center's safety features, including the futons. Families who visit Namaste see how practical the futons are.The futons, along with the other measures, have helped us make the environment safer for residents. In October 1992 we recorded 35 falls, an all-time high for Namaste. By February 1993 we were down to only nine falls, a significant improvement. We gave staff members a pizza party to celebrate their accomplishment and also asked them to meet or further reduce that number every month thereafter. So far, we must admit, that has happened only twice.

Sharing Our Methods
Because our residents occasionally need to be hospitalized, we find ourselves sharing Namaste's methods with colleagues at Penrose-St. Francis's acute care facilities. For example, we remind them that patients with Alzheimer's always feel cold because the disease damages the hypothalamus. We remind them not to put "wandering" patients near exits. Members of the system's risk management department visit our center weekly, and they see first-hand the ways we work to balance residents' freedom and safety.

We have also helped form a systemwide task force to help acute care personnel deal with the confused elderly in a more humane way. Many hospitals have "high-risk fall protocols" under which certain confused patients — those 65 or older, for example — are automatically placed in physical restraints. Our task force is working to make such protocols more flexible. Members of the Penrose-St. Francis task force include, besides representatives from Namaste, the system's director of nursing, the manager of the behavior health unit, and representatives of the department that formulates policy. I am confident that the system's acute care staff will eventually be able to treat patients without restraining them. But we in long-term care must take the initiative in helping our colleagues understand the patients' rights issues involved.

Persons interested in further discussing the care of persons with Alzheimer's disease should call Deborah Scandura, 719-776-8500.


Copyright © 1995 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Freedom and Safety

Copyright © 1995 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.