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Vanderbilt Psychiatric Hospital

Policy Title/Number:Falls Prevention Program06-517

Manual:Clinical Policy Manual

Review Responsibility:Clinical Practice Committee

Effective Date:July 1997

Last Revised Date:January 2010

Team Members Performing:

_____ All faculty and staff

X All faculty and staff providing direct patient care or contact

_____ MD

__X__ RN

_____ LPN

_____ VUSN/VUSM students

_____ Other licensed staff (specify):

_____ Other non-licensed staff (specify): Mental Health Specialists

_____ Not applicable

Specific Education Requirements:___X___ Yes ______No ______Not Applicable

Physician Order Requirements:______Yes ___X_ No______Not Applicable

  1. Outcome Goal:

To effectively enhance patient safety by identification of inpatients who are at risk for falls, to prevent patient falls and to protect patients from injury.

  1. Policy:
  1. All patients are assessed within 8 hours of admission and every 24 hours thereafter and with any change in patient condition or transfer using a standardized fall risk assessment tool. Interventions are implemented based on the assessment.
  1. All patients receive Standard Risk Intervention. Patients determined to be at High Risk for falls receive both Standard and High Risk interventions.
  1. Patients who are totally immobile and incapable of moving the body to change their position receive Standard Fall Interventions.
  1. All faculty and staff providing direct patient care or contact may use his/her judgment to assess any patient as High Fall Risk and implement High Risk interventions.
  1. Definitions:
  1. Fall: A sudden, uncontrolled, unintentional, downward displacement of the body to the ground or against another object.
  1. Near fall: A sudden loss of balance that does not result in a fall or other injury. This can include a person who slips stumbles or trips but is able to regain balance rather than falling, or an “assisted fall” where the patient is physically supported by another person.
  1. Assistive Device: Any tool used to assist with mobility and provide support to patients who are unable to ambulate independently (e.g., standard walker, rolling walker, crutches, standard cane, quad cane, wheelchair).
  1. Equipment/Supplies:
  1. Required for High Falls Risk:
  1. Yellow identification armbands on patient;
  2. Yellow non-skid footwear.
  1. Protocol:
  1. Complete and document the Falls Risk Assessment:
  1. Within 8 hours of admission, and every 24 hours thereafter;
  2. With any change in patient condition;
  3. With any change in level of care;
  4. Following actual fall or near fall.
  1. Initiate interventions based on the Fall Risk Assessment: Standard or High. All patients have Standard Risk Interventions; High Risk patients have Standard plus High Risk interventions.
  1. Patients qualify for high risk when the following criteria are met:
  1. Fall within the last 3 months;
  2. Meeting 2 of the following criteria:
  1. 70 years or more
  2. Impaired mobility
  3. Dizzy/vertigo
  4. Orthostatic hypotension
  5. Impaired elimination
  6. Impaired vision
  7. Anticoagulant medication
  8. Increased PT/PTT/INR
  9. Increased sedation
  1. Patients receiving 5 of the “risk meds” plus 1 item from C2 above:
  1. Opiates
  2. Hypnotics/sedatives
  3. Antihypertensive
  4. Diuretics
  5. Anticonvulsant
  6. Antidepressants
  7. Antipsychotics
  1. Document prevention interventions:

Standard Risk Prevention:

Bed low position with wheels locked

Orient patient to room and unit

Educate patient/family patient safety

High Risk Prevention:

Maintain Standard Risk and below;

Yellow footwear

Yellow armband

  1. Staff member(s) who identify unsafe environmental conditions take action to either correct it or notify the appropriate staff.
  1. Instruct and ensure that all patients wear foot covering when out of bed.
  1. Procedure:
  1. Use the Falls Risk Assessment as directed in Section V for all patients.
  1. Document the Falls Risk Assessment in the medical record as directed in Section V. A.
  1. Implement the appropriate Fall Risk interventions based upon the Fall Risk Assessment.
  1. Patient/Family Education:

Involve and educate the patient/family at the level of their understanding of the following:

  1. The purpose of recommended fall prevention measures.
  1. Measures taken to decrease environmental fall risks.
  1. The need to ask for assistance before exiting bed.
  1. Other Considerations:

None

  1. Attachments:

None

  1. Submitted By:

______

Lori Harris, RN, BSN Date

Interim Nursing Leader

  1. Approval:

______

Stephan Heckers, MD, Medical Director Date

______

William Parsons, CEO Date