Annual Costs and Nursing Care Interventions to Prevent Falls Over 1 Year in a Long Term Care Facility

Deanna Gray-Miceli ^1,*, Jeannette Rogowski ², Sarah J. Ratcliffe ³

1. Jefferson School of Nursing, Thomas Jefferson University, 901 Walnut Street, Suite 707, Philadelphia, PA 19107, USA

2. Department of Health Policy and Administration, The Pennsylvania State University, 504U Donald H. Ford Building, University Park, PA 16802, USA

3. Department of Public Health Sciences, University of Virginia, Po Box 800717, Charlottesville, VA 22908-0717, USA

* Correspondence: Deanna Gray-Miceli

Academic Editor: Pedro Morouco

Special Issue: Advances in Geropsychiatric Nursing

Received: March 11, 2025 | Accepted: September 08, 2025 | Published: September 16, 2025

OBM Geriatrics 2025, Volume 9, Issue 3, doi:10.21926/obm.geriatr.2503327

Recommended citation: Gray-Miceli D, Rogowski J, Ratcliffe SJ. Annual Costs and Nursing Care Interventions to Prevent Falls Over 1 Year in a Long Term Care Facility. OBM Geriatrics 2025; 9(3): 327; doi:10.21926/obm.geriatr.2503327.

© 2025 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

1.1 Falls Among Older Adults Are a Public Health Problem with Enormous Economic Impact

Falls among older adults within any healthcare setting are associated with extended hospital stays, higher readmission rates, and substantial increases in healthcare costs [1]. The economic burden to society for caring for older adults who fall, and do so repeatedly, is enormous. Falls are highest among older adults residing in long-term care (LTC) and residential nursing facilities, where over 60% of the 1.43 million United States residents fall each year [2]. Within LTC facilities in the United States, recurrent falls, estimated to be 2.3 falls per person per year, are particularly concerning [3]. Moreover, injuries from falls in LTC account for an estimated 40% of potentially preventable emergency department visits every year [4]. The attributable fraction of medical expenditures associated with deaths from falls is estimated at $754 million in 2015 and $49.5 billion for nonfatal falls [5] based on data from the Medicare Current Beneficiary Survey (MCBS). Falls in LTC nursing facilities are estimated to cost $6,200.00 per resident per year [6]. To understand how to prevent recurrent falls among older adults in LTC, we must first analyze the nursing care and health care interventions utilized and associated costs to prevent falls, especially if they are effective.

A systematic review of research studies examined the costs to LTC facilities from multiple countries for use of multifactorial interventions used by nursing staff to prevent the recurrence of falls [7]. Multifactorial interventions included medication reconciliation, orthostatic hypotension assessment, physical therapy, fall risk reduction activities, gait and balance training, exercise, and consultation with a physician. Results show that despite the high effectiveness of multifactorial interventions to prevent older adult falls, the cost of the interventions were high and were not cost-effective [7]. Unfortunately, nursing care interventions and/or use of durable medical equipment (DME) was not captured in this systematic review, so total costs for multifactorial interventions used is unknown [7]. Interventions which could be considered a nursing care intervention, and part of usual care, are those linked to patient assessment findings and nursing diagnoses. For instance, nursing assessment of the patient’s medications could reveal side effects leading to a nursing diagnosis of alteration in gastrointestinal motility, mobility or altered level of consciousness- thereby generating specific nursing care interventions in the patient plan of care, which could generate the use of DME interventions. Deficits in patient knowledge related to medication side effects, orthostatic hypotension, fall risk reduction activities, gait and balance training and exercise can also generate a nursing diagnosis of insufficient knowledge and thus prompt a nursing care intervention which may include use of a DME.

Knowing the component parts of the multifactorial intervention that are effective in reducing falls is vitally important to maintain patient safety in LTC nursing care facilities [8,9]. Since professional nurses assess patients and design the plan of care for older adult residents in nursing homes who fall [10], it is important to further describe the type of nursing care interventions they use during usual care to prevent recurrent falls, thereby closing the practice gap to determine which interventions are effective and their associated costs.

Caring for older adults in long term care nursing care settings in their remaining years requires nurses’ focused attention to patient safety for the prevention of recurrent falls among older adults. Evidence-based practice interventions for falls prevention among older residents include use of single, multiple and/or multifactorial interventions, all of which are found to have varying degrees of effectiveness in falls prevention [7]. In our prior work, we demonstrated that recurrent falls among vulnerable older long term care nursing facility residents can be reduced when the type of fall and its associated symptoms were identified and managed by trained nurses using a clinical decision support tool, called the Post Fall Index (PFI)™, which allowed them to individualize fall prevention interventions [11]. Among these interventions included the use of DME such as a wheel chair or cane for mobility or non-DME, which involved nursing care interventions such as assessing and managing residents for orthostatic hypotension, reviewing medications or assisting residents one on one with their mobility. The present study did not monetize the costs of the nurse's time for these interventions because it was part of their usual care. However, counts of the services they provided were included.

Given the economic burden of falls, it is vital to determine the healthcare costs of various interventions utilized by nurses to manage various types of falls, especially if these nursing care interventions prevent subsequent fall types. Moreover, those DME interventions used in falls management, i.e., such as a walker, which may be ineffective in falls or fall-related injury reduction [9,12], carry a cost to the facility. Expenditures for equipment or devices used to prevent a fall, but that fail in their prevention should prompt stakeholders to consider assessing: “what are the associated costs for falls prevention inclusive of the costs of nursing labor, number and type of interventions, and costs for DME?” It is important to note in this study we could not monetize nursing labor costs associated with various interventions used to manage falls, as they were part of usual care and therefore do not create an additional cost to the facility, unless additional staff is required.

1.2 Purpose of the Study

The purpose of this study is to describe the costs (except for nursing labor) for DME and non-DME nursing interventions used in the delivery of falls prevention care in one LTC nursing facility where all of the older LTC nursing facility residents who fell benefited from the nurse’s use of at least one evidence-based intervention to prevent a secondary fall.

1.3 Background and Significance of Prior Work

The data described in this present single site study is drawn from our prior work examining the effect of the Post-Fall Index (PFI)™ [11], as an intervention to prevent subsequent falls (Refer to Table 1). The PFI™ is a valid and reliable 30 item clinical decision support tool, designed for trained registered nurses to use in their post fall assessments of older adults who fall in LTC [11]. The PFI™ assists trained nurses to comprehensively assess the older adult’s fall so as to identify likely fall etiologies in order to develop a comprehensive plan of care of fall prevention interventions targeted to the older adult’s likely fall causes [11]. In prior research, when trained nurses who utilized the PFI™ to categorize falls according to perceived underlying likely causes and type [11] (Refer to Table 2), a 29.4% reduction in the fall rate (z = 3.89, p < 0.001), 27.6% decline in total falls experienced by all fallers (p < 0.001), and a 34.0% decline for recurrent fallers (p = 0.025) from pre-intervention to intervention year was observed [11]. It was demonstrated in this research, that once trained nurses critically examined each fall occurrence they would be able to align nursing care and health care interventions according to the type of fall and nursing diagnosis (Refer to Table 2), and by doing so, fall rates would decline. Thus, when trained nursing staff utilized the PFI™ in their post fall assessments, we found a significant reduction in the number of total and recurrent falls among residents [11].

Table 1 Falls and fall-related injuries among older adults during a 3 year cohort study [11].

Table 2 Interventions According to RNS Categorization of Causes to Fall during a 3 year cohort study [11].

This present study is the next step in understanding what type of nursing interventions were used which resulted in a statistically significant reduction in falls from pre-intervention to the intervention year in the LTC facility.

2. Methods

2.1 Design

Secondary analysis of interventions used to prevent falls during the intervention year of a three-year cohort study of all LTC nursing care facility older adult residents who fell during the 365-day intervention year. Data were collected from a 110-bed continuing care retirement community and LTC nursing facility located in the northeastern US, housing 59 skilled nursing, long term care beds and 51 assisted living beds from 2005 to 2007.

2.2 Sample

All residents over age 65, who had resided at the facility and fell during the intervention year regardless of death, discharge or transfer from the facility.

2.3 Procedures

Prior to the start of the study, the PI requested from the administrative Director of Nurses a listing of all equipment, devices and interventions used by nurse’s facility-wide to manage falls. We did not measure if the interventions and items used such as hip protectors or alarms were reused or replaced after each fall event, this listing was reviewed for accuracy by the Director of the Rehabilitation Program at the facility, who also provided the dollar cost of each item which was considered DME. Fall data including resident symptoms were obtained by trained registered nurses (RNs) who used the Post-Fall Index™, a comprehensive post fall assessment and clinical decision support tool [11] within 24 hours of a resident fall. The purpose of use of the PFI™ was to provide nurses at the point of care with a comprehensive set of questions and physical assessment parameters needed to identify the type of fall which occurred so they could intervene accordingly. Trained nurses used the PFI™ facility-wide with 100% adherence over the course of the one year-intervention period.

2.4 Data Sources

Insurance payers describe DME as any equipment that provides therapeutic benefit to a patient in need because of certain medical conditions or illnesses [13]. Items considered must be used to serve a medical purpose, prescribed by a physician, reusable, and further, be able to stand repeated use. DME interventions used by the nurses at the study site/LTC nursing facility are listed in Table 3 and Table 4, and include assistive devices, surveillance devices and injury protection devices. Assistive devices were utilized to aid in patient mobility or transferring the patient from bed to chair or vice versa, such as wheelchairs, walkers, bedside commode, specialized orthotic shoes; devices to assist with transferring to or from the toilet such as grab bars, and specialized chair lifts or recliners. Surveillance devices included bed or chair alarms and door way alarms such as a Wander Guard. Injury reducing devices included hip protectors, low rise bed and floor mats. Non-DME interventions used by nurses at the study site/facility are listed in Table 4 and Table 5 and include items such as wheelchair safety belts, physical and occupational therapy consultation, nursing assessment of daily orthostatic blood pressures, timed voiding and nighttime toileting regiments, patient instruction/education, assistance with activities of daily living such as arm in arm assistance with mobility, ongoing evaluation and re-evaluation of medication regimen, assessment for acute changes in mental status, monitoring laboratory values, and re-evaluation of the plan of care based on the resident’s changing health status.

Table 3 Interventions to Manage Falls (n = 286): Durable Medical Equipment and Non-DME Purchased and Costs to the NH Facility during the Pre-Intervention Year (2019 constant dollars).

Table 4 Interventions Utilized to Manage 207 Falls in the Intervention Year: Type of DME/Non-DME and Frequency and Costs (2019 constant dollars).

Table 5 Description and frequency of use of Non-durable medical equipment (non-DME) items and nursing care activities for management of 207 falls during the intervention year.

2.5 Determination of Type of Intervention and Costs

A listing of DME and non-durable medical equipment (non-DME) used by nurses in the LTC nursing facility and number of items purchased over the length of the study (pre intervention and intervention years) was generated along with the direct costs for either renting or purchasing the equipment for use on the nursing units (Refer to Table 3 and Table 4). The analysis of cost for interventions used by nurses in the pre-intervention year is based on an aggregate count of the number and type of DME and other interventions (non-DME) utilized in the pre-intervention year by older adult residents who had fallen at the long term care facility. For both pre-intervention and intervention years, the dollar cost value for each DME and non-DME intervention used were generated by the administrative Director of Nurses, who served as the Health Systems Director of Care. All costs were converted to 2019 constant dollars based on the medical component of the consumer price index (CPI).

2.6 Variables/Outcomes of Interest

DME devices and non-DME interventions, their frequency of usage and costs to the long term care facility for the entire years of study were the variables of interest in this study. Items such as specialized low mattresses, use of floor mats or wander guards were not billed to the individual patient for their use, although they did carry a one-time cost outlay by the long-term care facility. Data describing the intervention chosen by nurses to institute to prevent additional falls were obtained on a case by case basis following completion of the PFI™ after each fall occurrence. Many of the non-DME interventions used by nurses to prevent subsequent falls were non reimbursable to the facility, but are described in Table 4 and Table 5. Interventions such as nursing assessments and patient education are non-reimbursable costs to the facility, even though they carry a labor cost to the facility in terms of the nurse’s time.

2.7 Data Analysis

This analysis is limited to descriptive statistics. Descriptive frequencies and summary statistics including the count (percentages), confidence intervals were used to describe demographic patient characteristics, falls, fall rates, fall-related injuries, fall-related injury rates, type of DME and non-DME nursing care interventions. Data were not available to perform inferential statistics to test cost or outcome differences between the two years.

3. Results

During the pre-intervention year, 286 falls occurred by 91 unique older adults residing in the long-term care facility with a calculated annual fall rate of 6.7 (5.95-7.51 95% CI) and during the intervention year, 77 unique older adults experienced a total of 207 falls with a calculated annual fall rate of 4.73 (4.11-5.40 95% CI; refer to Table 1) [11]. The sample were mostly female (77%), and widowed (67%) with an average age of 89.1 years (SD = 6.6). For all of the 207 falls during the intervention year, nurses were able to categorize the fall type as those due to: chronic medical causes, acute medical causes, medications, environmental causes, behavioral causes, poor safety awareness, misjudgment during transfer and unknown causes (Refer to Table 2), suggest a DME or Non-DME intervention based on their knowledge of the fall type and working knowledge of the older long-term care resident, and then implement a DME or Non-DME intervention (Refer to Table 4 and Table 5). Nurses could choose one or more diagnoses and also could select one or more interventions. In each type of fall nurses categorized, the nurse independently selected and instituted an intervention more than 50% of the fall types (Refer to Table 2).

3.1 Cost Expenditures for the Pre Intervention Year (2019 Dollars)

To manage 286 falls, during the pre-intervention year, 26 assistive devices costing the LTC nursing facility $16,910 were used; 89 surveillance devices costing the facility $48,808 were used and 30 injury reducing devices costing the facility $2,538 were used. The total expenditure was $68,256 for use of these 145 single type of fall prevention interventions (Refer to Table 3 and Figure 1).

Figure 1 Estimated total costs (USD) for interventions utilized to manage 286 falls during the Pre-Intervention Year.

3.2 Cost Expenditures for the Intervention Year

Following the use of the PFI™ by trained nurses in the intervention year, 207 falls occurred (Refer to Table 4 and Figure 2) which were managed by 46 various types of surveillance devices, injury reducing devices or other type of interventions costing the facility $14,725. Some of these interventions were continuation of DME, while other interventions were non-reimbursable DME items used by nursing staff in falls prevention (Refer to Table 5 and Figure 3).

Figure 2 Estimated total costs (USD) for interventions utilized to manage 207 falls in the Intervention Year.

Figure 3 Frequency and types of Non-durable medical equipment (non-DME) items and nursing care activities for management of 207 falls during the intervention year.

As can be seen in Table 5, to manage these 207 falls, nurses performed 15 daily orthostatic blood pressure assessments, 16 timed voiding’s and nighttime toileting, 11 patient safety checks such as education and reinforced use of equipment, 14 assistances with activities of daily living, 32 on going evaluation of medication regiments, and 14 evaluations for acute changes in condition and re-evaluation of the plan of care. Of the 148 combined interventions instituted (drawn from Table 4 and Table 5), 68.9% (n = 102) were nursing care – centered activities and interventions (non-DME) which carried no additional outlay purchase cost to the facility, as they were subsumed during the routine delivery of care by staff nurses. Overall, these nursing care interventions added to the cost of fall care, but included non-reimbursable nursing activities/interventions. Additionally, about 49% of all the falls which occurred during the intervention year received an additional nursing care activity or intervention individually determined according to the fall type and the resident’s needs.

4. Discussion

This study fills an important gap as current evidence of fall costs have been limited to fatal versus non-fatal costs [5] or hospitalization and facility costs among residents of LTC institutions [6]. Moreover, DME and non-DME nursing care costs have not been included in these analyses. Additionally, findings from one systematic review study [7], failed to analyze nursing care interventions as was captured in the present study. This is the first study to show the cost outlay for nursing care interventions (non-DME) and DME usage in a long-term care nursing facility during the pre-intervention (standard care) year compared to the intervention year following use of the evidence-based practice assessment tool, the PFI™ [11], which was shown effective in reducing falls.

Several findings warrant discussion. First, findings illustrate a decreased utilization of standard equipment and devices used to manage falls in long term care, i.e. use of assistive devices, surveillance devices and injury reducing devices (145 devices versus 32 device types). Second, in the standard care or pre-intervention year, there is less usage of nursing centered interventions in favor of use of DME and non-DME type equipment for falls management. This is likely due to routine falls prevention education which focuses on general safety precautions in the environment as the main foci of assessment and intervention. Thus, it is possible that the high use of DME and surveillance devices predominated in the standard of care year because of the culture of care and knowledge dissemination reinforcing that falls are largely due to environmental factors. Additionally, during the pre-intervention or standard care year, there were no educational in services on the use of comprehensive post fall assessment tools containing national recommendations for falls prevention. Thus, the reduction of equipment usage seen in the intervention year is likely due to the nurses’ ability to utilize the PFI to learn about the resident fall type to further individualize and select appropriate nursing care interventions for fall management based on the likely underlying causal factors for the fall and fall type.

Fourth, the fall reduction of 79 falls following use of the PFI was accompanied by a reduced outlay purchase of DME and an increased utilization of nursing-centered interventions, i.e. non-DME type interventions. The time nurses spent doing the intervention was not monetized because it was part of usual care. The outlay of costs for nursing interventions can include the nurse’s amount of time to stay current with the evidence based literature recommendations for fall care, reading any additional educational materials, attending webinar or seeking added certification in falls prevention. Other nursing activities include further discussion of fall care plans with supervisors or mentors for additional support and guidance. Communication with family caregivers and physicians are also time intensive activities that contribute to the overall individualized plan of care for the resident who falls, and are considered usual care. Future studies might monetize these activities to inform staffing needs.

In the current practice standard, we have little knowledge of the type and cost of single or multiple types of devices used by nurses to prevent additional falls. We can infer that current practice interventions are not working, as the rate of falls and recurrent falls remain high in the long-term facility. One aim, which we have described here, is to examine new intervention options and their relative costs. New options are needed if we are to someday achieve the Triple Aim outlined by the Institute for Healthcare Improvement (IHI) which addresses the quality of care and economic value of care from the experience of the individual in a defined population [14].

Given economic constraints experienced by long-term care facilities, the cost for purchase of devices used by long-term care facility nurses in management of older long-term care facility residents who fall must be weighed against their effectiveness in preventing additional falls. Nurses who care for older long-term care facility residents who fall repeatedly need to select effective, person-centered interventions shown to reduce falls and to be cost saving. However, training is needed to do this effectively. This study found a reduced purchase of DME equipment and devices with increased utilization of nursing centered types of interventions from pre-intervention to intervention year when nurses were trained to use the PFI™. As noted by Sherman [15], nurses play an important role in reducing costs... and are expected to do more with less. It is conceivable that unnecessary costs for purchase of additional equipment or multiple types of DME and non-DME interventions can be avoided when nurses use effective nurse-centered care innovations which encourage clinical decision making and appropriate selection of person-centered interventions.

In summary, the PFI™ was effective in reducing falls, but the type of nursing care interventions instituted to achieve these results and how cost effective they were require additional study to fully understand.

4.1 Limitations

There are a few limitations to this study. First, we did not have a means to collect all of the possible nursing interventions that could have been implemented for fall care in the pre-intervention year, which are considered non-DME, such as daily orthostatic blood pressure assessment, timed voiding’s or medication reconciliation performed by the nursing staff. This would have required a secondary analysis of all 286 care plans of residents. The second limitation concerns the dual use of devices purchased in the care of the resident. For example, the PI was only informed of DME and non-DME used for fall care. It is possible that the DME and non-DME intervention served dual purposes. Meaning that it was purchased by the facility for use with a primary diagnosis other than a fall. An example would be care for a resident with Parkinson’s Disease who utilized a walker prior to the fall. Also of note, this study did not measure if the interventions and items used such as hip protectors were reused or replaced after each fall event, which would impact the total expenditure costs. The third limitation is that the researchers made no attempt to analyze each DME or non-DME intervention according to the CPC billing codes or type of chronic or acute illness occurring which may have generated utilization of the DME/non-DME.

Additional studies are needed to determine who is paying to properly care for older adults who fall in long term care facilities. Since reimbursements are fixed and center on DME reimbursable costs, and resources are constrained with nursing shortages for patient care, it is important to determine how resources through nursing care interventions can be leveraged to benefit the older adult resident who is falling repeatedly. Older LTC nursing care residents who fell during the intervention year clearly benefited from reduced falls because of the quality of nursing care interventions they received. The array of multifactorial interventions was targeted to their individualized needs and type of fall they encountered. This knowledge paves the way for additional national nursing research such as demonstration projects to quantify the costs, benefits, effectiveness and overall added value from the delivery of quality nursing care provided by trained nurses.

5. Conclusion

The number and type of interventions used and their costs are important factors in the overall plan of care for each resident and each type of fall. Many types of nursing interventions are used by nurses in LTC facilities to prevent falls. This includes interventions such as arm in arm or standby assistance with mobility, assessment of orthostatic hypotension and intervention, use of gait belts, and patient education, to name a few. This study provides detailed evidence of the number and costs of durable medical equipment and number and type of non- durable medical equipment, i.e., nursing care interventions, utilized to prevent falls. This study did not measure if the interventions and items used such as hip protectors were reused or replaced after each fall event. Noteworthy is the decline in usage of durable medical equipment over the course of this study along with an increase in usage of non-durable medical equipment such as nursing care interventions. Although nursing labor costs were not analyzed because they are part of usual care, they do represent a substantial part of non-DME expenditures which require further study. Nursing care interventions and their associated costs have a tremendous value and ethical implication in the prevention of falls in LTC. The shift in a reduction of use of non-DME and an increase in nursing care interventions means nursing care is more comprehensively focused at the type of fall and specific care needs of each resident. This equates to improved care quality through targeted person centered care interventions.

Author Contributions

DGM was responsible for project development, data collection and manuscript preparation. JR was responsible for data analysis and manuscript development. SJR was responsible for statistical analysis and manuscript development.

Competing Interests

The authors have declared that no competing interests exist.