Post-Fall Huddle

A huddle is a quick gathering of teammates to strategize and brainstorm in an attempt to determine root-cause and develop appropriate interventions.

Who should be involved in this Huddle? The nurse on duty, the CNA assigned to the resident, other CNAs on duty who frequently care for this resident, any other staff who interacted with resident prior to fall, and other interested staff

Team Members:

When should the Huddle occur? The huddle should occur on the shift in which the resident sustained the fall and not to exceed one hour post-fall.

Resident Name: Room: Date/Time of fall:

Ask the team the following questions:

Was there anything different about the resident prior to the fall (change in transfer status, ambulation status, cognitive status)?

Was the resident’s call light on prior to the fall? If so, what do you think he/she needed?

What devices were in place for resident safety at the time of the fall (low bed, glasses, mat on floor, footwear, assistive devices)?

Were any devices not functioning at the time of the fall?

Last known toileting time, if applicable:

Why do you think the resident fell (bathroom, item out of reach)? Quickly brainstorm pertinent reasons for the fall.

We need to do something to help this resident so that he/she does not fall again. You know this resident more than most. What should we do to try to prevent another fall? Inform staff that the intervention chosen should be related to the reason the resident fell. The intervention must be able to be implemented at this time.

Note: The intervention will be reviewed by the interdisciplinary team, and may change. These changes will be reflected in the resident’s plan of care. This tool is not meant to replace the fall investigation.

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This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-WI-C2-15-169 091015