Department(s): Patient Care Areas

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Effective Date:

Policy Title: Fall Reduction Program

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Review Dates:

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POLICY:

1.This protocol is a guideline outlining the responsibilities for the clinical management of all inpatients who may be at risk for falling. It is not to be used as a substitute or replacement for independent clinical assessment and judgment.

2.Interventions may be changed to meet individual patient needs based upon condition and assessment data.

3.Medications are not included as individual risk factors. The most common side effects of drug therapy that increase the risk of falls are reflected in the assessment criteria. These are considered to be a risk factor only if the patient exhibits side effects.

4.An environmental assessment is conducted to address those settings and patient populations that are at risk for fall. Those areas are outlined below. All other areas are determined to be minimal risk of harm from fall with individual patient fall assessment not required.

5.MANAGEMENT

5.1Fall Risk Criteria (Caution)

5.1.1Basic Risk

  • Age > 80
  • Dizziness
  • Generalized weakness / unsteady gait / use of an ambulatory assistive device.
  • Altered elimination – incontinence, diarrhea, bowel prep, nocturia, frequency.
  • Drowsiness / forgets limitations
  • Increased Risk (Alert)
  • * Fall within past 6 months
  • * Confusion /disorientation

5.2Risk Level determination will be as follows:

5.2.1.1CAUTION – Any one basic risk criteria

5.2.1.2ALERT – Two (2) or more basic risk criteria or one (1) increased risk criteria.

5.3Initial Assessment

5.3.1For those units where the nurse to patient ratio is one-to-one or two-to-one, where the physical layout of the patient care unit allows for high visibility of the patient and where the maximum described fall interventions are conducted for the patient population as a component of routine care provided, these units are not required to conduct fall assessments as each patient is treated as a high risk for fall. These units include <list units, typically ED, ICU, CCU, Pediatrics).

5.3.2At the time of admission to the <List names of units included in fall criteria assessment program> inpatient unit, an RN will complete an assessment to determine Fall Risk Level based upon the following criteria in 2.1.

5.4Reassessment

5.4.1Fall risk will be assessed by an RN or an LPN under the supervision of an RN as a component of routine daily assessment, and

5.4.1.1On transfer to another unit or change in level of care

5.4.1.2If the patient falls or is observed in a potential or near fall situation.

5.4.2Risk Level and interventions will be altered to reflect changes in patient risk status based upon nursing assessment and clinical judgment.

5.5Fall Reduction interventions(including those units where all patients are determined to be at risk for falls) will be as follows:

5.5.1CAUTION

  • Patient and family education about hospital safety
  • Anti slip footwear
  • At least 2 side rails up
  • Eliminate environmental hazards, floor clutter
  • Frequent orientation to surroundings
  • Assess need for additional lighting in room
  • Ensure that items for patient use are within easy reach, especially eyeglasses, hearing aids, personal ambulatory assistive devices.
  • Evaluate need for urinal or bedpan at bedside
  • Offer toileting / assistance frequently and at bedtime.
  • ALERT – All CAUTION Level interventions plus the following:
  • Relocate patient to room close to Nurses Station
  • Make hourly rounds on patient
  • Assist with/offer toileting every 2 hours based on patient cues
  • Provide close supervision with ambulation and transfers
  • Bed alarm turned on with volume turned up
  • Evaluate need for sitter. Physician order required every 24 hours.

5.6General Patient and Family Education

5.6.1Provide age appropriate explanation regarding the fall reduction interventions as outlined in 5.5 above.

5.6.2Emphasize patient and family/significant other’s responsibility in preventing falls

5.7If a fall occurs:

5.7.1Provide care as patient condition requires

5.7.2Notify the attending physician or designee on call.

5.7.3Document on the medical record:

5.7.3.1Circumstances surrounding the fall

5.7.3.2Assessment data

5.7.3.3Restraints (if in use)

5.7.3.4Notifications, who and time notified

5.7.3.5Care and treatment provided

5.7.4Complete Incident Report

6.DOCUMENTATION

6.1INITIAL ASSSESSMENT AND DATA BASE – Initial Fall Risk Assessment to be completed by the RN within 24 hours of admission.

6.2INTEGRATED PLAN OF CARE – Risk Level and Interventions to be reflected in plan of care.

7.EDUCATION

7.1.1Staff are educated in the fall reduction protocol at time of initial orientation and are assessed for competency <list time frame>

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