Inpatient Falls Risk Assessment Tool and Care Plan

Inpatient Falls Risk Assessment Tool and Care Plan

Complete for all patients aged 65 years and over

Guidance:

Complete pages 1-4 ON ADMISSION
Complete AMTS and CAM assessments only following positive response to prompts in section 6 of the Falls Risk Assessment
Complete daily review using the checklist to identify any changes. For any changes document further details on the communication sheet

Initial assessments

Action / Completed Yes/No / Comments
Educate on use of call bell
Check and advise on appropriate footwear
Complete manual handling assessment and check/ provide appropriate walking aid
AVOID introduction of new hypnotics/sedatives
Staff
Signature / NMC / DATE/TIME

Urinalysis and Observations

These assessments are to be completed on admission, if unable document reason e.g. post-surgery.

Urinalysis. Date…./…./…… / If positive urinalysis, send for culture and sensitivity and request a medical review.
Result:
Completed By:

Lying and Standing Blood Pressure

Guidance: Ensure that the patient has laid down for five to ten minutes prior to obtaining lying B.P, explain the procedure and gain consent, ensure that arm is supported at the level of the heart (for example on a pillow). Select appropriate cuff, ensure patient is aware to refrain from talking whilst completing procedure (can result in higher reading). Complete the recording using a blood pressure machine / manual cuff completing all of the below recordings (document if all standing blood pressures not charted).Please remember to record on VitalPac. Significant drop in blood pressure is >20mmhg drop in systolic or a >10mmhg drop in diastolic.

Position / Date / Blood pressure / Pulse rate / Pulse rhythm / Comments
Lying (for ten minutes) / /
Standing immediately / /
Standing after one minute / /
Standing after two minutes / /
Completed By:

Risk Assessment for Bed Rails

The purpose of this tool is to support staff in making assessments of the appropriate use of bed rails and low beds. It is not intended to be used as a prescriptive tool but as a support to reaching an informed decision having considered the benefits and risks as part of an individual patient care plan.If a patient is well enough to understand the risks and benefits, they should decide if they want bed rails. If patients are too ill to decide, the nurse responsible for their care should decide, in the patient’s best interests

Use of bedrails should be reviewed frequently; whenever a patient’s condition or wishes change but as a minimumevery 7Days.
Review use as indicated on risk assessment scale, inform patient/carer accordingly and record outcome.

Tick box relevant to patient at time of assessment

IMMOBILE / LIMITED MOBILITY / INDEPENDENT
MOOD / TOLERANCE
Patient is confused and disorientated / Use bed rails with care. Consider high low bed / Bed rails not recommended Consider high low bed / Bed rails not recommended

Patient is drowsy / Bed rails recommended / Use bed rails with care Consider high low bed / Bed rails not recommended

Patient is orientated and alert / Bed rails can be recommended with patients informed choice / Bed rails can be recommended with patients informed choice / Bed rails not recommended

Patient is unconscious / Bed rails recommended / N/A / N/A
2. Safety Measures Following Risk Assessment Outcome / Yes / No
Bed rails recommended
Patient requests bed rails
Ensure bed rails are compatible with the bed and mattress.
Ensure they do not cause a hazard by protruding from the bed end.
Ensure they do not cause the patient to be trapped.
The bed rails are fitted with a bumper if risk of limbs striking bedrails/limbs trapped in bedrails.
HIGH/LOW BED
Ensure no risk of entrapment
Ensure cables/air tube from airflow mattress cannot be trapped underneath bed
Ensure patient not able to get up from bed at its lowest height
Crash mat must not be a trip hazard for other patients
Patient must not be independently mobile as high low bed would be a restraint
BED RAILS OR HIGH/LOW BED NOT RECOMMENDED
Consider the use of technological aids i.e. sensor pads where available.
Increase frequency of Intentional rounding checks
Bed should be left at lowest height
Staff
Signature / NMC / Date/Time
Falls Risk Assessment
Risk factor / Yes/No / Suggested actions / Actions taken/Comments
1. History of falls in the past year?
Fear of falls?
Loss of consciousness or blackouts? / Review incident(s): Date, location, time, activity, frequency / Information leaflet given 
Request medical review
Provide verbal and written advice
2. Medications (see guide)
Taking 4 or more medications per day?
Taking drugs that can contribute falls? E.g. antidepressants, sleeping tablets, sedatives / Request doctor to review medications.
Provide information on medications
3. Dizziness/postural hypotension
Symptoms of dizziness or significant drop in blood pressure on standing (20mmHg drop in systolic or 10mmHg in diastolic) / Inform doctor of symptoms of dizziness/ drop in blood pressure
Provide advice on stabilising self after change in position and before walking
Advise request assistance when mobilising
Provide advice on adequate hydration
4. Balance, Transfers and Walking
Has difficulty moving from bed to chair?
Unsteady on their feet, shuffles or takes uneven steps?
Difficulty with foot care affecting mobility? / Provision/ check of appropriate walking aid / Complete Mobility care plan
Advise maintaining safety whilst mobilising e.g. asking for assistance
Refer to physiotherapy or Occupational therapy as appropriate
Consider foot care

5. Continence

Suffers from urgency, frequency, incontinence, suspected UTI/ positive urinalysis / Complete Continence care plan
Complete UTI care plan
6. Agitation / Confusion
ASK PATIENT OR CARER:
Have you (has the patient) been more forgetful in the past 12 months to the extent that it has significantly affected your/their daily life?
Does patient have a confirmed diagnosis of Dementia?
Has the patient experienced an increase in confusion recently?
/ Complete AMTS for patients without a definite diagnosis of dementia, who have been more forgetful in the past 12 months / Complete Confusion care plan
Complete 4ATS for all patients who have had an increase in confusion recently. If score 1 or above request a medical review.

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Risk factor / Yes/No / Suggested actions / Actions taken/Comments
7. Vision
Unable to recognise a key/pen held a bed length away (with glasses if worn)?
Unable to see print clearly (with glasses if worn)?
Wears bifocals/varifocals?
Reduced visual field? / Orientate to surroundings
Ensure spectacles are clean and within reach.
Advise caution with bi / varifocal glasses (increased risk of falls on steps and stairs)
Advise annual eyesight test
Provide appropriate support when mobilising
Ensure all necessary items are within reach whilst area remains clutter free
8. Hearing
Difficulty hearing conversational speech (with hearing aid if worn)? / Check hearing aid is working and worn correctly.
Request medical review if hearing impairment significant and untreated
9. Osteoporosis Risk Factors:
Does the person have any history of the following:
Fracture (broken bone) after a minor bump or fall >age 50yrs e.g. wrist, hip, spine.
Oral corticosteroid e.g. Prednisolone (for > 3 months) / Highlight risk factors to doctor for further assessment/investigations
Ensure patient is taking any current medication for osteoporosis e.g. bisphosphonate, calcium and vitamin D according to drugs guidance.
Highlight to doctor issues with medication compliance
Dietary and lifestyle advice, e.g. smoking cessation, safe alcohol limits
Staff
Signature / NMC / Date/Time

On Discharge

Consider community referral options for any remaining risks on discharge e.g. community physiotherapy, community nurse. Falls Team are available for advice and support for complex patients who require further input.

Falls Team details:

Middlesbrough, Redcar and Cleveland: Fax no: 01642 217204and Telephone: 01642 944070

Hambleton and Richmondshire: Fax no:01609 767510 and Telephone: 01609 767522

Cognitive and delirium assessments

Abbreviated Mental Test Score (AMTS) Score one for each correct answer, zero for an incorrect answer, and no half marks for answers.

Remember: Not valid if there is a language or communication barrier (e.g. deafness, dysphasia)
Some questions are UK-centric – if patient is a non UK national, consider if they could reasonably be expected to know the answer?
Any score of less than 8 requires medical review.
NON ELECTIVE PATIENTS AGED 75 YEARS AND OVER – COMPLETE CQUIN CODING FORM

Question / Score (1/0)

How old are you? (score one point if correct or if plus or minus one year only)

What is the time (to nearest hour)?

(If they spontaneously look at their watch or clock before answering that is ok, but don’t point watch or clock out to them)

I want you to try to remember this address for me ‘42, West Street’. Can you repeat the address for me so I know you heard it correctly?

What is the year?

What is the name of this building/place?

(accept the name it is publicly known by e.g. ‘City hospital’ is ok instead of ‘City hospital NHS foundation trust’)

Identify two people

(e.g. ‘Can you tell me who that lady is?’ Accept role where patient would not reasonably be expected to know the person’s name e.g. ‘that is the lady who cleans this ward’)

When is your birthday?

(date and month only needed for one point, year of birth not required)

What year did either World War One OR World War Two begin ? (1914 or 1939)

Can you tell me the name of the king or the queen we have at the moment?

Count backwards from 20 to one

(if need be say ‘like this: 25,24,23,22,21 – now you carry on’)
3. Recall address given above
Total
Staff Signature / NMC / Date/Time
4AT Delirium Assessment

ALERTNESS

/ CIRCLE
This includes patients who may be markedly drowsy (difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient, if asleep attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating. / -Normal (fully alert, but not agitated, throughout assessment)
-Mild sleepiness for <10 seconds after waking, then normal
-Clearly abnormal / 0
0
4

AMT4

Age, date of birth, place (name of the hospital or building), current year. / -No mistakes
-1 mistake
-2 or more mistakes/untestable / 0
1
2

ATTENTION

Ask the patient “Please tell me the months of the year in backwards order, starting at December”
To assist initial understanding one prompt of “what is the month before December” is permitted. / -Achieves 7 months or more correctly
-Starts but scores <7 months/refuses to start
-Untestable (cannot start because unwell, drowsy / 0
1
2

ACUTE CHANGE OR FLUCTUATING COURSE

Evidence of significant change or fluctuating in: alertness, cognition, other metal function (paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs / -No
-Yes / 0
4
4 OR ABOVE: Possible delirium +/- cognitive impairment / 1-3: Possible cognitive impairment / 0: Delirium or severe cognitive impairment unlikely
Staff Signature / NMC / Date

Daily review

Complete daily or on transfer to ensure all actions/ assessments still up to date with either Y or N. For any Y document variations/ new actions required overleaf

Week:

Review: any changes in the following: / Date
/ / Date
/ / / Date
/ / / Date
/ / / Date
/ / / Date
/ / / Date
/ /
Use of call bell
Appropriate footwear in situ
Manual handling assessment
Bed rails risk assessment
Bed rails safety measures
Assessments e.g. urinalysis/ blood pressure
Medications?
Dizziness?
Balance, transfers & walking?
Continence?
Agitation/confusion?
Vision?
Hearing?
Staff initials

Week:

Document any changes/new actions below following daily review.

Date/
time / Risk factor number / Review comments / Signature/ NMC no.

SUMMARY OF DEMENTIA SCREENING

FOR CQUIN CODING PURPOSES

(To be completed by nursing staff undertaking falls risk assessment).

AMTS SCORE .../10 Date Completed…./…./………. / PLEASE CIRCLE THE RELEVANT BOXES and GIVE TO WARD CLERK
STEP 1: CHECK DIAGNOSIS / CODE / ACTION REQUIRED
Does the patient have a confirmed diagnosis of dementia? / YES
Code DDXX / Proceed no further
NO / Proceed to next step: screening question
STEP 2: PATIENT SCREEN
When asking the patient or carer “Have you (has the patient) been more forgetful in the past 12 months to the extent that it has significantly affected your/their daily life?”, how did they respond?
Circle Response. / UNABLE
TO ASK
Code DQXX / State reason
NO
Code DQYN / Proceed no further
YES
Code DQYY / Proceed to next step:
Complete AMTS
STEP 3: FOLLOW-UP AMTS
Was the AMTS score less than 8 (indicative of dementia) / NO
Code DAYN / Proceed no further
YES
Code DAYY / Dementia Team to review.

FALLS ASSESSOR:

Name:______Date: ______

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