Organizational factors of fall injuries among residents within German nursing homes: secondary analyses of cross-sectional data

  • Jaroslava ZimmermannEmail author
  • Michael Swora
  • Holger Pfaff
  • Susanne Zank
Original Investigation


The present study explored risk factors for fall injuries among nursing home residents, with a specific focus on the influence of organizational structure within facilities and their environment, which have been insufficiently investigated in the European context. For the analyses, secondary data collected in 2016 from 220 nursing homes across Germany were used. As a risk adjustment, two separate models were calculated for fall injuries among residents without (N = 7320) and with cognitive impairment (N = 8633). Results showed that residents without cognitive impairment had a decreased risk of fall injuries by 40.1% (P < 0.01), while those with cognitive impairment were at an increased risk of 23.8% (P < 0.05) when living in facilities that had dementia care units. However, disparities were found between federal states for both groups of residents (P < 0.05 vs. P < 0.01, respectively). Similarly, a higher proportion of registered nurses were associated with decreased risk of fall injuries among cognitively impaired residents (45.6%), which differed between federal states (P < 0.01). Facilities with homelike environments had a 16.7% (P < 0.05) lower risk of fall injuries among cognitively impaired residents than did traditionally organized facilities. Further research is needed to explain the disparities between German federal states using representative samples.


Adverse care outcome Fall injury Older adult Long-term care 



This work is a part of a dissertation project conducted within the scope of the Graduate School GROW – Gerontological Research on Well-Being, which is supported by the North Rhine-Westphalian Ministry of Culture and Science. The Diocesan Caritas Association in Cologne graciously provided the results of the Project EQisA, which were used in the study analyses.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.


  1. Ambrose AF, Paul G, Hausdorff JM (2013) Risk factors for falls among older adults: a review of the literature. Maturitas 75(1):51–61. Google Scholar
  2. Andersson Å, Frank C, Willman AML, Sandman P-O, Hansebo G (2018) Factors contributing to serious adverse events in nursing homes. J Clin Nurs 27(1–2):e354–e362. Google Scholar
  3. Auer S, Kienberger U, Pascher P, Geck M, Hofmann B, Viereckl Carmen, Span Edith (2017) Wohngemeinschaft versus traditionelles Pflegeheim für Personen mit Demenz. Eine Vergleichende Beobachtungsstudie (Small-scale group living versus traditional nursing home for persons with dementia: an observational comparison study). Pflegewissenschaft 19(3/4):156–165. Google Scholar
  4. Backhaus R, Verbeek H, van Rossum E, Capezuti E, Hamers JPH (2014) Nurse staffing impact on quality of care in nursing homes: a systematic review of longitudinal studies. J Am Med Dir Assoc 15(6):383–393. Google Scholar
  5. Becker C, Kron M, Lindemann U, Sturm E, Eichner B, Walter-Jung B, Nikolaus T (2003) Effectiveness of a multifaceted intervention on falls in nursing home residents. J Am Geriatr Soc 51(3):306–313. Google Scholar
  6. Berta W, Laporte A, Perreira T, Ginsburg L, Dass AR, Deber R, Baumann A, Cranley L, Bourgeault I, Lum J, Gamble B, Pilkington K, Haroun V, Neves P (2018) Relationships between work outcomes, work attitudes and work environments of health support workers in Ontario long-term care and home and community care settings. Hum Resour Health 16(1):15. Google Scholar
  7. Bloch F, Thibaud M, Tournoux-Facon C, Breque C, Riqaud AS, Duque B, Kemoun G (2013) Estimation of the risk factors for falls in the elderly: can meta-analysis provide a valid answer? Geriatr Gerontol Int 13(2):250–263. Google Scholar
  8. Boelens C, Hekman EEG, Verkerke GJ (2013) Risk factors for falls of older citizens. Technol Health Care 21(5):521–533. Google Scholar
  9. Bor A, Matuz M, Csatordai M, Szalai G, Bálint A, Benkő R, Soós G, Doró P (2017) Medication use and risk of falls among nursing home residents. A retrospective cohort study. Int J Clin Pharm Net 39(2):408–415. Google Scholar
  10. Botwinick I, Johnson JH, Safadjou S, Cohen-Levy W, Reddy SH, McNelis J, Teperman SH, Stone ME (2016) Geriatric nursing home falls. A single institution cross-sectional study. Arch Gerontol Geriatr 63:43–48. Google Scholar
  11. Büchele G, Becker C, Cameron ID, König H-H, Robinovitch S, Rapp K (2014) Predictors of serious consequences of falls in residential aged care: analysis of more than 70,000 falls from residents of Bavarian nursing homes. J Am Med Dir Assoc 15(8):559–563. Google Scholar
  12. Bystedt M, Eriksson M, Wilde-Larsson B (2011) Delegation within municipal health care. J Nurs Manag 19(4):534–541. Google Scholar
  13. Castle NG, Engberg J (2008) Further examination of the influence of caregiver staffing levels on nursing home quality. Gerontologist 48(4):464–476. Google Scholar
  14. Comondore VR, Devereaux PJ, Zhou Q, Stone SB, Busse JW, Ravindran NC, Burns KE, Haines T, Stringer B, Cook DJ, Walter SD, Sullivan T, Berwanger O, Bhandari M, Banglawala S, Lavis JN, Petrisor B, Schünemann H, Walsh K, Bhatnagar N, Guyatt GH (2009) Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis. BMJ 339:b2732. Google Scholar
  15. de Rooij AHPM, Luijkx KG, Schaafsma J, Declercq AG, Emmerink PMJ, Schols JMGA (2012) Quality of life of residents with dementia in traditional versus small-scale long-term care settings. A quasi-experimental study. Int J Nurs Stud 49(8):931–940. Google Scholar
  16. Dellefield ME, Castle NG, McGilton KS, Spilsbury K (2015) The relationship between registered nurses and nursing home quality: an integrative review (2008–2014). Nurs Econ 33(2):95–116Google Scholar
  17. Galet C, Zhou Y, Eyck PT, Romanowski KS (2018) Fall injuries, associated deaths, and 30-day readmission for subsequent falls are increasing in the elderly US population. A query of the WHO mortality database and National Readmission Database from 2010 to 2014. Clin Epidemiol 10:1627–1637. Google Scholar
  18. Grabowski DC, Angelelli JJ, Mor V (2004) Medicaid payment and risk-adjusted nursing home quality measures. Health Affair 23(5):243–252. Google Scholar
  19. Hamers J (2017) The prevention and reduction of physical restraint use in long-term care. In: Schüssler S, Lohrmann C (eds) Dementia in nursing homes. Springer, Cham, pp 219–228Google Scholar
  20. Hanlon JT, Zhao X, Naples JG, Aspinall SL, Perera S, Nace DA, Castle NG, Greenspan SL, Thorpe CT (2017) Central nervous system medication burden and serious falls in older nursing home residents. J Am Geriatr Soc 65(6):1183–1189. Google Scholar
  21. Hartholt KA, van Beeck EF, Polinder S, van der Velde N, van Lieshout EMM, Panneman MJM, van der Cammen TJM, Patka P (2011) Societal consequences of falls in the older population. Injuries, healthcare costs, and long-term reduced quality of life. J Trauma 71(3):748–753.
  22. Horn SD, Hudak SL, Barrett RS, Cohen LW, Reed DA, Zimmerman S (2016) Interpersonal care processes, falls, and hospitalizations in Green House and other nursing homes. Sr Hous Care J 24(1):31–46Google Scholar
  23. Iglesias CP, Manca A, Torgerson DJ (2009) The health-related quality of life and cost implications of falls in elderly women. Osteoporos Int 20(6):869–878. Google Scholar
  24. Kalisch BJ, Tschannen D, Lee KH (2012) Missed nursing care, staffing, and patient falls. J Nurs Care Qual 27(1):6–12. Google Scholar
  25. Kelleter H (2017) Outcome zur evidenzbasierten Steuerung in der Langzeitpflege. Wirkungen im Projekt EQisA (Outcome on evidence-based controlling in long-term care: impacts of the Project EQisA). Z Eval 16(1):173–183Google Scholar
  26. Kim H, Kovner C, Harrington C, Greene W, Mezey M (2009) A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiencies. J Gerontol Ser B Psychol Sci Soc Sci 64(2):269–278. Google Scholar
  27. Kimmey LD, Stearns SC (2015) Improving nursing home resident outcomes: time to focus on more than staffing? J Nurs Home Res 1:89–95. Google Scholar
  28. Kok JS, Berg IJ, Scherder EJA (2013) Special care units and traditional care in dementia: relationship with behavior, cognition, functional status and quality of life - a review. Dement Geriatr Cognit Disord Extra 3(1):360–375. Google Scholar
  29. Kropelin TF, Neyens JCL, Halfens RJG, Kempen GIJM, Hamers JPH (2013) Fall determinants in older long-term care residents with dementia: a systematic review. Int Psychogeriatr 25(4):549–563. Google Scholar
  30. Lannering C, Ernsth Bravell M, Midlöv P, Östgren C-J, Mölstad S (2016) Factors related to falls, weight-loss and pressure ulcers–more insight in risk assessment among nursing home residents. J Clin Nurs 25(7–8):940–950. Google Scholar
  31. Long JS (1997) Regression models for categorical and limited dependent variables. SAGE, Thousand OaksGoogle Scholar
  32. Luhmann N (1995) Social systems. Translated by John Bednarz, Jr. with Dirk Backer. Foreword by Eva Knodt. Stanford University Press, StanfordGoogle Scholar
  33. Luo H, Lin M, Castle N (2011) Physical restraint use and falls in nursing homes. A comparison between residents with and without dementia. Am J Alzheimers Dis 26(1):44–50. Google Scholar
  34. Mackenzie LA, Byles JE (2018) Circumstances of falls with fractured femur in residents of Australian nursing homes. An analysis of falls reports. J Aging Health 30(5):738–757. Google Scholar
  35. Meyer G, Köpke S, Haastert B, Mühlhauser I (2009) Restraint use among nursing home residents. Cross-sectional study and prospective cohort study. J Clin Nurs 18(7):981–990. Google Scholar
  36. Mor V, Zinn J, Angelelli J, Teno JM, Miller SC (2004) Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care. Milbank Q 82(2):227–256. Google Scholar
  37. Nobili A, Piana I, Balossi L, Pasina L, Matucci M, Tarantola M, Trevisan S, Riva E, Lucca U, Tettamanti M (2008) Alzheimer special care units compared with traditional nursing home for dementia care: are there differences at admission and in clinical outcomes? Alzheimer Dis Assoc Disord 22(4):352–361. Google Scholar
  38. Oppikofer S, Lienhard A, Nussbaumer R (2005) Demenzpflege-Evaluation. Bewohnerinnen und Bewohner mit Demenz im Pflegeheim. Darstellung und Vergleich spezialisierter versus integrierter Betreuungsformen (Evaluation of dementia care. Residents with dementia in nursing home. Description and comparison of specialized versus integrated forms of care). Zürcher Schriften zur Gerontologie, vol 2. Universität Zürich, Zentrum für GerontologieGoogle Scholar
  39. Rapp K, Lamb SE, Klenk J, Kleiner A, Heinrich S, König H-H, Nikolaus T, Becker C (2009) Fractures after nursing home admission. Incidence and potential consequences. Osteoporos Int 20(10):1775–1783. Google Scholar
  40. Rapp K, Becker C, Cameron ID, König H-H, Büchele G (2012) Epidemiology of falls in residential aged care: analysis of more than 70,000 falls from residents of Bavarian nursing homes. J Am Med Dir Assoc 13(2):187.e1–187.e6. Google Scholar
  41. Robison J, Pillemer K (2007) Job satisfaction and intention to quit among nursing home nursing staff. Do special care units make a difference? J Appl Gerontol 26(1):95–112. Google Scholar
  42. Schrappe M, Pfaff H (2016) Versorgungsforschung vor neuen Herausforderungen. Konsequenzen für Definition und Konzept (Health services research faces new challenges: consequences for definition and concept). Gesundheitswesen 78(11):689–694. Google Scholar
  43. Schulz C, Lindlbauer I, Rapp K, Becker C, König H-H (2017) Long-term effectiveness of a multifactorial fall and fracture prevention program in Bavarian nursing homes. An analysis based on health insurance claims data. J Am Med Dir Assoc 18(6):552.e7–552.e17. Google Scholar
  44. Seijo-Martinez M, Cancela JM, Ayán C, Varela S, Vila H (2016) Influence of cognitive impairment on fall risk among elderly nursing home residents. Int Psychogeriatr 28(12):1975–1987. Google Scholar
  45. Selbaek G, Kirkevold Ø, Engedal K (2008) Psychiatric and behavioural symptoms and the use of psychotropic medication in special care units and regular units in Norwegian nursing homes. Scand J Caring Sci 22(4):568–573. Google Scholar
  46. Spector W, Shaffer T, Potter DEB, Correa-de-Araujo R, Rhona Limcangco M (2007) Risk factors associated with the occurrence of fractures in U.S. nursing homes: resident and facility characteristics and prescription medications. J Am Geriatr Soc 55(3):327–333. Google Scholar
  47. Spilsbury K, Hewitt C, Stirk L, Bowman C (2011) The relationship between nurse staffing and quality of care in nursing homes: a systematic review. Int J Nurs Stud 48(6):732–750. Google Scholar
  48. Statistisches Bundesamt (2016) Pflegestatistik - Pflege im Rahmen der Pflegeversicherung - Ländervergleich - Pflegeheime 2013 (Nursing statistics - Nursing care in the context of nursing insurance - Comparison of the federal states - Nursing homes 2013), WiesbadenGoogle Scholar
  49. Statistisches Bundesamt (2017) Pflegestatistik 2015. Pflege im Rahmen der Pflegeversicherung - Ländervergleich - Pflegeheime (Nursing statistics 2015 - Nursing care in the context of nursing insurance - Comparison of the federal states - Nursing homes), WiesbadenGoogle Scholar
  50. Towne JR SD, Cho J, Smith ML, Ory MG (2017) Factors associated with injurious falls in residential care facilities. J Aging Health 29(4):669–687. Google Scholar
  51. Vandenberg AE, van Beijnum B-J, Overdevest VGP, Capezuti E, Johnson TM (2017) US and Dutch nurse experiences with fall prevention technology within nursing home environment and workflow. A qualitative study. Geriatr Nurs 38(4):276–282. Google Scholar
  52. Verbeek H, van Rossum E, Zwakhalen SMG, Kempen GIJM, Hamers JPH (2009) Small, homelike care environments for older people with dementia: a literature review. Int Psychogeriatr 21(2):252–264. Google Scholar
  53. Verbeek H, Zwakhalen SMG, van Rossum E, Ambergen T, Kempen GIJM, Hamers JPH (2010) Dementia care redesigned. Effects of small-scale living facilities on residents, their family caregivers, and staff. J Am Med Dir Assoc 11(9):662–670. Google Scholar
  54. Weyerer S, Schäufele M, Hendlmeier I (2010) Evaluation of special and traditional dementia care in nursing homes. Results from a cross-sectional study in Germany. Int J Geriatr Psychiatry 25(11):1159–1167. Google Scholar
  55. Wingenfeld K, Büscher A, Gansweid B (2008) Das neue Begutachtungsassessment zur Feststellung von Pflegebedürftigkeit. Modellprogramm zur Weiterentwicklung der Pflegeversicherung (The new assessment tool for determining the care dependency. Pilot program for further development of long-term care insurance), Bielefeld, MünsterGoogle Scholar
  56. Wingenfeld K, Kleina T, Franz S, Engels D, Mehlan S, Engel H (2011) Entwicklung und Erprobung von Instrumenten zur Beurteilung der Ergebnisqualität in der stationären Altenhilfe (Development and testing of the instrument for the evaluation of quality outcomes in inpatient elderly care). Abschlussbericht, BielefeldGoogle Scholar
  57. World Health Organization (2007) Global report on falls prevention in older age, GenevaGoogle Scholar
  58. Zimmermann J, Pfaff H (2018) Influence of nurse staffing levels on resident weight loss within German nursing homes. Res Gerontol Nurs 11(1):48–56. Google Scholar
  59. Zúñiga F, Ausserhofer D, Hamers J, Engberg S, Simon M, Schwendimann R (2015) Are staffing, work environment, work stressors, and rationing of care related to care workers’ perception of quality of care? A cross-sectional study. J Am Med Dir Assoc 16:860–866. Google Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Jaroslava Zimmermann
    • 1
    Email author
  • Michael Swora
    • 2
  • Holger Pfaff
    • 2
  • Susanne Zank
    • 3
  1. 1.Graduate School GROW - Gerontological Research on Well-BeingUniversity of CologneCologneGermany
  2. 2.Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences & Faculty of MedicineUniversity of CologneCologneGermany
  3. 3.Rehabilitative Gerontology, Faculty of Human SciencesUniversity of CologneCologneGermany

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