Fall Risk Assessment

Objectives

  1. Ensure that all patients are assessed for falls risk.
  2. Identify those at risk and institute prevention intervention to minimize falls.
  3. Carry out appropriate post fall care and learning measures.
  4. Ensure patient safety while under our care.

Definition,  Responsibilities, Assessment and Reassessment

A fall is defined as an unintended event that results in a person coming to rest on the ground or other object at a lower level (Kellogg International Work Group, 1987).

Reference

Kellogg International Work Group on Prevention of Falls in the Elderly. (1987). The prevention of falls in later life. Danish Medical Bulletin, 34(4), 1-24.

Responsibilities of RN, EN and NA

Fall Risk Assessment form

On admission staff shall perform a baseline falls risk assessment.

Assess the patients:

  1. Previous history of falls.
  2. Medical status or conditions that may lead to risks of falls.
  3. Functional status.
  4. Visual acuity.
  5. Cognitive and behavioural status.
  6. Current and past medical/surgical history.


Findings of assessment

Based on the findings, staff shall:

  1. Classify the patient's fall risk and assign them a fall scoring.
  2. Initiate a fall risk precaution alert sign matching the level of fall risk.
  3. Put alert sign "Fall Precaution" on the head board of the bed. 
  4. Inform care team members of the patient's risk for fall. 
  5. Documentation of falls risk on patient's Clinical notes and in Special Care  notes
  6. Handover on falls risk alert on every shift report.
  7. Institute appropriate interventions for patients with visual, balance and hearing problems.
  8. Refer to PT/OT for gait and balance assessment.

Reassessment

Daily (those high risk groups) and on every Monday and Thursday

Reassessment:

  1. When there is a change in the patient's condition.
  2. Where there is a change in the patient's medication regimen (could place patient at risk of falls).
  3. After the patient has sustained a fall.
  4. Upon transfer to and from another institution.
  5.  Document the findings in patient's clinical notes.

Fall risk assessment is the responsibilities of the EN and NA only?

  • Fall risk assessment is the responsibilities of EN and NA only.

When is a fall risk assessment done?

  • On admission.
  • Daily, every Monday and Tuesday.

When is a fall risk reassessment done?

  • Daily (those high risk group) and on every Monday and Friday.
  • Upon changes of patient's condition only.

The assessment of patient's with gait and balance problems should be done by

  • PT or OT.
  • Multidisciplinary team.

Fall Precaution alert sign include

  • Alert signage
    Visible location on the head of the bed
  • Handover on fall risk alert
    Every shift
  • Document risk alert
    Clinical and Special notes

Fall Risk Assessment form to assess patients

history of falls.

Medical status or conditions that may lead to  of falls.

Functional .

Visual .  

and Behavioural status.

 and past medical/surgical history.

Fall Prevention Strategies and Measures

General Fall Precautions

  1. Do not leave the patient's unattended in the toilet/shower area.
  2. Ensure the call bells is within patient's reach (call bells in working condition).
  3. Ambulating patients' are advised to wear comfortable non-slip footwear.
  4. Patient's clothes worn should be of appropriate size and length to avoid interference during mobilization.
  5. Advice the patients/families or caregivers to inform the nurse if symptoms of postural hypotension e.g. dizziness or light headaches are experienced.
  6. Assist patients in activities of daily living.
  7. Respond promptly to patient's call.
  8. Patient on Fall Precaution to check on them every 2 hourly.
  9. Restless and confused patients are to be nurse preferably in the Restless Cubicle (Bed 201 - 204).

Ensuring Safe Environment

  1. Call bells within patient's reach.
  2. Arrange patient's belongings within reach.
  3. Remove unnecessary clutter to provide clear passageway to toilet (avoid accidental tripping).
  4. Adjust bed to the lowest position.
  5. Locked the wheels of wheelchair, commodes, trolleys and recliners used to transport patients.
  6. Apply safety strap/seat belt when patient's are seated out on wheelchairs, commodes or recliners.
  7. Nurse to accompany patient when patient is seated on commode during voiding/defecation.
  8. Lift the bed side rails of patients e.g. immobile/totally bed bound, restless, confused and disorientated patients.
  9. Ensure adequate lighting, particularly at night to improve visibility.
  10. Ensure assistive devices such as wheelchair, commodes or recliners are serviced and maintained regularly.
  11. Prompt display of "wet floor" signboards in event of fluid spillage or during post floor cleaning.


Post Fall Analysis and Management

  1. In the event a patient's sustains a fall, an assessment for any serious injuries (head, spine, bony or bony injuries) are done.
  2. If no serious injuries are sustained, need to call for help and assist the patient's to his/her bed immediately.
  3. Inform the Doctor and Nurse Manager On-Call and the patient's families accordingly.
  4. If injuries are sustained, moved the patient to an appropriate safe location or position.
  5. Alert the Doctor immediately and ensure the patient's received the necessary attention and care.
  6. Dress any cuts, lacerations, abrasions or bruisers that the patient's may sustained.
  7. Inform the patient's families and Nurse Manager On-Call.
  8. Monitor the patient's vital sign e.g. O2 saturation, conscious level, mental status regardless with or without injuries.
  9. Provide appropriate follow-up care and monitoring.

Documentation, Analysis and Reporting of falls

  1. Document all incidences of falls in the patient's clinical notes.
  2. Report all incidences of falls.
  3. Conduct a post fall analysis to determine appropriate measures which should be taken to prevent recurrence.
  4. Highlight those resulting in adverse outcomes to Head of Nursing, Medical Director and Clinical Quality Aassurance Committee.

Ensuring Safe Environment

  • Call bells and patient's belongings
    Within patient's reach.
  • Remove clutters
    To provide clear passageway.
  • Apply safety strap/seat belt
    When patient's sits on wheelchair, commode or recliner.
  • Ensure adequate lighting
    To improve visibility.

General Fall Precaution

  • Check patient's on fall precaution 2 hourly.
  • The patient's in the shower room can be left unattended.

Post Fall Analysis and Management

  • If patient sustained injury, need to call Doctor, Nurse Manager On-Call and families.
  • If patient sustained injury, need to call Doctor On-Call and families.

Documentation and Reporting of fall

Document all incidences of falls in the patient's notes.

Conduct a  to determine appropriate measures which should be taken to prevent recurrence.