Visitor and Ambulatory and Community-Based Falls

A fall may be defined as an inadvertent event which results in a person coming to rest on the ground or floor or other lower level (World Health Organization, 2021). Injuries sustained by visitor and client slips, trips, and falls can result in significant personal harm and financial losses. As a result of provincial and territorial occupiers liability legislation (i.e., legislation regulating the duty of care owed by persons who own or lease property to those who visit or trespass on such property), healthcare organizations may be held liable for injuries if they fail to provide a reasonable standard of care in keeping the premises free from hazards. Criteria used to assess occupiers liability include (but is not limited to): whether a hazard was foreseeable, the existence of an adequate system of inspection and maintenance, and whether the occupier was complying with its own safety program. Claims arising from visitor and client slips, trips, and falls can be difficult to defend as the courts view such events as being largely preventable with reasonable adherence to proper risk management and preventive maintenance practices.

Expected Outcomes

Adopt standardized grounds, facility, and workplace maintenance, inspection, and environmental hazards response protocols / programs. 

Implement a standardized post-incident management and investigation protocol for reported and witnessed visitor and client slips, trips, and falls.

Implement formal processes to ensure a valid service agreement is in place whenever snow and ice removal is outsourced to a third party.

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• Healthcare organizations - organizations engaged in providing, financing, improving, supervising, evaluating, or other activity related to healthcare

Common Claim Themes and Contributing Factors

Organizational

• Common hazards:
  • Uncleared ice and snow;
  • Uneven and deteriorated walking surfaces;
  • Wet and slick surfaces;
  • Curled entrance mats or inappropriate type of mat for the purpose;
  • Missing and loose stair rails;
  • Inadequate lighting;
  • Unsecured construction sites;
  • Lack of appropriate signage for work in progress;
  • Lack of visual cues for uneven surfaces or changes in elevation.
• Frequently involve persons with mobility challenges.
• Inconsistent or inadequate incident reporting and investigation procedures.
• Limited security camera coverage.
• Infrequent and undocumented grounds, facility, and workplace patrols, maintenance, and inspections.
• Delayed and inadequate response to preventable hazards once identified or reported.
• Role and responsibility confusion surrounding inspections, maintenance, and repairs, including rented and leased premises.
• Inconsistent use of wet floor signage during floor cleaning.

Mitigation Strategies

Procurement and Contract Management

• Implement formal process to ensure a valid service agreement is in place whenever snow and ice removal is outsourced to a third party (Rogers Partners LLP, 2021). 

Additional Considerations

Examples of elements to address in service agreements for snow and ice removal:

• Specific start and end dates;
• Adequate insurance and indemnity provisions;
• Minimum snow or ice accumulation volumes which will trigger the vendor’s obligation to perform snow and ice removal, and response time;
• Scope of work and areas where snow and ice removal will occur, including a map of the healthcare organization;
• Vendor’s 24-hour contact information including alternate emergency contact;
• Requirement that all work performed is recorded on snow and ice removal dedicated maintenance logs, including pictorial evidence where possible.

Grounds, Facility and Workplace Maintenance and Inspection    

• Adopt a standardized facility maintenance and inspection program or policy that meets industry standards (Kolos & Fishman, 2022) (curi, 2022).

Additional Considerations

Examples of elements to consider in a facility maintenance and inspection program / policy:

• Frequency of maintenance and inspections;
• How the maintenance and inspections are to be carried out;
• Who is responsible for performing the maintenance and inspections;
• How the maintenance and inspections records are to be documented and retained;
• Remedial steps to be followed if the standards are not met.

• Implement scheduled grounds, facility, and workplace inspections including (but not limited to) daily or per shift rounds as well as scheduled biannual or annual interdisciplinary team facility reviews.
• Adopt a standardized grounds, facility, and workplace inspection log / form / checklist (Canadian Centre for Occupational Health and Safety, 2021) (Victoria University in the University of Toronto, n.d.).

Additional Considerations

Examples of elements to consider in standardized inspection log and / or forms:

• Inspection times;
• Specific hazards identified; 
• Current weather conditions such as, precipitation / temperature and extreme conditions;
• Snow and ice removal times and locations;
• Application of salt and / or sand times and locations, amount and type of de-icing product used;
• Pictures of areas inspected;
• Interviews and discussions with staff.

• Install video surveillance near entrances, stairwells, common and high traffic areas; post clear and understandable notices about the use of video surveillance on premises to individuals whose images might be captured by them, before these individuals enter the premises (Office of the Privacy Commissioner of Canada, 2008) (Dewhirst, 2019) (Information and Privacy Commissioner of Ontario, 2016) (College of Physicains and Surgeons of Alberta, 2020).
• Retain video surveillance records for a period that aligns with industry best practices (Ontario Hopsital Association, 2022) (Alberta Health Services, 2022).
• Adopt a standardized floor mat program that meets current industry standards (U.S. Department of Veterans Affairs, 2014) (National Safety Council, 2016). 

Additional Considerations

Examples of elements to consider in the floor mat program:

• Types of mats based on intended use (e.g., industry certified or standard grade high quality rubber- backed high traction mats; beveled-edge, flat, and continuous mats);
• Location of mats;
• Application and installation of season-appropriate mats;
• Care, maintenance and disposal of matting.

• Adopt a standardized housekeeping program that meets current industry standards (Canadian Centre for Occupational Health and Safety, 2018a) (CSA Group, 2020).

Additional Considerations

Examples of elements to address within the standardized housekeeping program:

• Where and how cleaning products are safely stored;
• How to  contact the housekeeping program for immediate response;
• When to use wet floor signs;
• Frequency for cleaning  various areas of the facility with regard to volume of traffic and proximity to specific hazards, such as, food service areas;
• Documentation of the cleaning performed and timing;
• Method for cleaning different surfaces and areas.

• Adopt a formal strategy to reduce falls on exterior grounds and parking lots (including owned and leased parking lots) (Canadian Centre for Occupational Health and Safety, 2018b). 

Additional Considerations

Examples of elements to reduce falls on exterior grounds and parking lots:

• Posting warning signs and / or barriers where indicated;
• Marking and repairing damage, spills, and oily spots immediately;
• Keeping lighting and speedbumps (where used) in good repair;
• Marking tire stops with contrasting or highly visible colour;
• Marking any hazardous changes in elevation such as, between sidewalks and roadways, with contrasting or highly visible colour.

• Adopt a standardized spills response program or plan (i.e., response plans for any incident involving the spill / release of water, sewage, hazardous chemicals, mixtures of such chemicals, or hazardous waste – also known as code brown) that meets current industry standards (Winnipeg Regional Health Authority, 2009).

Additional Considerations

Examples of elements to address in a standardized spill response program / plan:

• A centralized reporting contact number;
• Documentation of the call request, responses, causes, clean-up, and / or maintenance work;
• Two person response where available (e.g., one to guard the spill, second to obtain the cleaning equipment).

Incident / Emergency Response

• Implement a standardized incident management and investigation protocol for reported and witnessed visitor and client slips, trips, and falls (Rogers Partners LLP, 2021) (ECRI, 2016). 

Additional Considerations

Examples of elements to address within the visitor / client fall management and investigation protocol:

• Assisting the injured visitor or client in finding medical treatment;
• Adoption of a standardized incident reporting form that captures key information;
• Photographing the scene, ground and / or hazard capturing e.g., photographs of floor cones, seasonal mats, warning signs, footwear, and mobility equipment of the visitor prior to clean-up, sanding or salting, etc.;
• Securing and retaining video surveillance in line with the organization’s retention guidelines (where possible, include the 30 minutes leading up to the event);
• Securing and retaining all incident-related documentation;
• Interviews and discussions with staff and / or witnesses;
• Reporting the incident to the insurer in a timely manner;
• A follow-up process with visitors and clients who have slipped, tripped, or fallen to invite them to participate or provide feedback into the review.

References

• Alberta Health Services. (2022, 3). Records Retention Schedule (1133-01). Retrieved from Alberta Health Services.
• Canadian Centre for Occupational Health and Safety. (2018a). Workplace Housekeeping. Retrieved from Canadian Centre for Occupational Health and Safety: https://www.ccohs.ca/oshanswers/hsprograms/housekeeping/house.html
• Canadian Centre for Occupational Health and Safety. (2018b). Safety Hazards - Parking Lots - Fall Prevention. Retrieved from Canadian Centre for Occupational Health and Safety: https://www.ccohs.ca/oshanswers/safety_haz/parking_lots.html
• Canadian Centre for Occupational Health and Safety. (2021, 12). Inspetion Checklist - Sample Checklist for Outdoor Areas. Retrieved from Government of Canada: https://www.ccohs.ca/oshanswers/hsprograms/checklist/list_outdoors.html
• College of Physicains and Surgeons of Alberta. (2020, 10). Surveilllance camera usage in community clinics: is it appropriate? Retrieved from College of Physicains and Surgeons of Alberta: https://cpsa.ca/news/surveillance-camera-usage-in-community-clinics-is-it-appropriate/
• CSA Group. (2020). CSA Z317.12:20 - Cleaning and disinfection for health care facilities. Retrieved from CSA Group: https://www.csagroup.org/store/product/CSA%20Z317.12:20/
• curi. (2022, 1). Preventing Falls in Medical Office Setting. Retrieved from curi: https://curi.com/news/slips-trips-and-falls-in-the-outpatient-setting-key-strategies-to-prevent-and-address-patient-injury-at-medical-offices/
• Dewhirst, K. (2019, 1). Health Privacy Update: Do you have a video surveillance camera on your property? Retrieved from Kate Dewhirst: https://katedewhirst.com/blog/2019/01/15/health-privacy-update-do-you-have-a-video-surveillance-camera-on-your-property/
• ECRI. (2016). Steos to Follow After a Fall. Retrieved from ECRI: https://www.ecri.org/components/HRC/Documents/SPT/SafSec/SafSecPol97.pdf
• Information and Privacy Commissioner of Ontario. (2016, 11). Video Surveillance. Retrieved from Information and Privacy Commissioner of Ontario: https://www.ipc.on.ca/wp-content/uploads/2016/11/2016-00-09-video-surveillance.pdf
• Kolos, N. D., & Fishman, A. (2022, 5). Court emphasizes system of maintenance in occupiers' liability claims. Retrieved from Borden Ladner Gervais LLP: https://www.blg.com/en/insights/2022/05/court-emphasizes-systems-of-maintenance-in-occupiers-liability-claims
• National Safety Council. (2016, 4). Floor mats and runners. Retrieved from National Safety Council: https://www.nsc.org/getmedia/42c5c438-37c3-4e0c-8c94-c555f40c90e3/floor-marts-and-runners.pdf.aspx
• Office of the Privacy Commissioner of Canada. (2008, 3). Guidelines for Overt Video Surveillance in the Private Sector. Retrieved from Office of the Privacy Commissioner of Canada: https://www.priv.gc.ca/en/privacy-topics/surveillance/video-surveillance-by-businesses/gl_vs_080306/
• Ontario Hopsital Association. (2022, 9). Records Retention Toolkit. Retrieved from Ontaro Hospital Association: https://www.oha.com/Legislative%20and%20Legal%20Issues%20Documents1/Records%20Retention%20Toolkit,%20September%202022.pdf
• Rogers Partners LLP. (2021, 2). The Occupiers' Liability Handbook. Retrieved from Rogers Partners LLP: https://www.rogerspartners.com/wp-content/uploads/2021/02/Occupiers-Liability-Handbook-Feb-2021.pdf
• U.S. Department of Veterans Affairs. (2014, 4). Floor Mat Resource and Implementation Guide. Retrieved from U.S. Department of Veterans Affairs: https://www.patientsafety.va.gov/docs/fallstoolkit14/floor_mat_guide_042114v2.pdf
• Victoria University in the University of Toronto. (n.d.). Grounds - Workplace Inspection Checklist. Retrieved from Victoria University in the University of Toronto: https://www.vicu.utoronto.ca/assets/PDFs/HR/Grounds-Inspection.pdf
• Winnipeg Regional Health Authority. (2009, 5). Occupational and Environmental Safety and Health Operational Procedure. Retrieved from Winnipeg Regional Health Authority: https://professionals.wrha.mb.ca/old/professionals/safety/files/OP_CodeBrown.pdf
• World Health Organization. (2021). Falls. Retrieved from https://www.who.int/news-room/fact-sheets/detail/falls