Falls: prevention and intervention, adult - SCH



Original: 5/93 and 8/97 Revised: 12/05

Replaces: Falls: Prevention and Intervention 9/04, 9/05

Responsible Person: Ortho/Neuro Acute Care Director

Approving Committee: Clinical Nurse Practice Committee

Category: Patient Care

PURPOSE:

To provide guidelines for assessment criteria and interventions for prevention of falls in adults.

DEFINITION OF FALLS:

A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level from a standing, sitting or horizontal position (Agostini, Baker, Bogardus, 2001). In many instances, a person who has seemingly fallen may not remember the circumstances surrounding a fall, or alternatively, the fall may not have been witnessed. Evidence of a fall is based on the recollection of the person who fell and/or description of the fall form a witness (Ledford, 1996; Morse, Tylko & Dixon, 1987).

POLICY/STANDARD OF CARE:

St. Cloud Hospital Inpatient Specific:

All adult patients will be assessed for risk of falling by a registered nurse using the Falls Risk Assessment Tool and interventions (Addendum 2) will be implemented at the time of admission and throughout their hospitalization. Interventions to protect patients at risk for falling and harming self will be initiated using the least restrictive alternative available. Restraints are utilized only after other options are unsuccessful.

Intensive Care Unit and Cardiac Care Unit:

All patients in the Intensive and Cardiac Care units will be considered high fall risk and will have fall prevention measures in place. Therefore, these units are exempt from completing the Fall Risk Assessment Tool. Refer to Intensive Care Unit and Cardiac Care Unit Standards of Care for more detail. Fall prevention interventions will be documented on the daily flowsheet.

Adult Mental Health Unit, Family Birthing Unit and Women’s Health:

The Fall Risk Assessment Tool will be completed as part of the admission process. If the fall risk score is score is 9 or health care personnel judgment indicates that the patient is at risk will have appropriate Fall Prevention interventions initiated (see Addendum 2 – St. Cloud Hospital Specific or Addendum 1 – Ambulatory/Outpatient Specific).

IV. Documentation

A. For all patients, Fall Protection information will be given to patient/family and documented on Interdisciplinary Teaching Record (ITR). Outpatient/ambulatory areas will give patient/family fall information as appropriate, with documentation on the appropriate tool.

B. For patients with a Fall Risk score >9, educate patient/family regarding Fall Prevention interventions and document on ITR.

C. Interdisciplinary Care Plan will reflect if the patient is on Fall Protection or Fall Prevention.

V. If a Fall Occurs

Care of the patient who falls:

1. Assess for injuries and provide appropriate aid

2. Obtain and record vital signs

3. Assess for change in range of motion and level of consciousness

4. Notify physician

5. Notify family as appropriate

6. Continue to monitor patient as condition warrants

7. Document circumstances in medical record

8. Complete variance report

9. Assess physiologic and environmental factors that contributed to the fall

10. Notify all team members, including Charge Nurse/Department Director and Quality Resource nurse

11. Complete a Fall Reassessment

12. Assess interventions and modify Plan of Care as needed

REFERENCES:

▪ Agostini, J.V., Baker, D.I., & Bogardous, S.T., Jr. (2001). Prevention of falls in hospitalized and institutionalized older people. In A.J. Markowitz, K.G. Shojania, B.W. Duncan, K.M. McDonald, & R.M. Wachter (Eds.), Making Health Care Safer: A Critical Analysis of Patient Safety Practices, (#43, pp.281-299). Rockville, Maryland: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services

▪ Ledford, L. (1996). Prevention of Falls Research-Based Protocol. In M.G. Titler (Series Ed.), Series on Evidence-Based Practice for Older Adults. Iowa City, IA: The University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core. (R )

▪ Salsbury Lyons, Stacie (2004) “Evidence Based Protocol – Fall Prevention for Older Adults” University of Iowa Gerontological Nursing Intervention Research Center.

▪ In addition, reviewed other sources as a background for the revised policy.

St. Cloud Hospital Ambulatory/Outpatient Flowsheet

Fall Assessment Tool

|Date | | | | | | |

| Time | | | | | | |

|Age | | | | | | |

|History of Falls | | | | | | |

|Mental Status | | | | | | |

|Physical Mobility | | | | | | |

|Communication | | | | | | |

|Elimination | | | | | | |

|Vital Signs | | | | | | |

|Medications | | | | | | |

|Diagnosis | | | | | | |

|Total Score | | | | | | |

|Fall Protection | | | | | | |

|Fall Prevention | | | | | | |

|Mark the interventions| | | | | | |

|you use with the | | | | | | |

|letter assigned to | | | | | | |

|them on the grid on | | | | | | |

|the back of this form.| | | | | | |

|Indicate any | | | | | | |

|additional | | | | | | |

|interventions on the | | | | | | |

|ICP. | | | | | | |

|Initials | | | | | | |

• Score of 9 or greater or fall during admission = At Risk. Place on Fall Prevention Protocol and add to care plan.

|Variable |0 |1 |2 |3 |

|Age |18-30 |31-60 |61-75 |>75 |

|History of Falls |No history |> 6 months |1-6 months ago |Within 1 month |

|Mental Status |Alert & Oriented x 3, |Oriented to person/place |Oriented to person only, |Disoriented, unable to |

| |follows instructions | |Short Term Memory loss |follow instructions |

|Physical Mobility |No physical impair-ment,|Use assistive device and/or|Assist of 2 or more to |Unable to ambulate |

| |no assistive devices to |able to ambulate |ambulate | |

| |ambulate | | | |

|Communication/Sensory Impairment (vision, |No deficits |1 deficit with correction |1 deficit without |3 or more deficits or onset|

|hearing, speech, neuropathy, language | | |correction or 2 deficits |of 1 new problem |

|barrier) | | |with correction | |

|Elimination (nocturia, frequency, urgency, |No problem |1 problem and/or |2 problems or removal of |3 or more problems or onset|

|diarrhea, incontinence, retention, laxative,| |Foley/ostomy |Foley within 24 hours |of 1 new problem |

|bowel prep) | | | | |

|Vital signs |No problem |Asymptomatic bradycardia |Two or more of the |Symptomatic hypotension SBP|

| | |100; |following: *Asymptomatic |102 |tachycardia >100; |bradycardia 102 |Symptomatic tachycardia |

| | |Requires O2 to hold sats at|* Requires O2 to hold sats |>100; Unable to maintain O2|

| | |>90% |at >90% |sats >90% |

|Medications (CV: antihypertensive, |No CV or CNS meds |CV meds |CNS meds |>9 medications |

|diuretics, antiarrhythmics) | | | |(prescription, OTC, herbal,|

|(CNS: narcotics, psychotropics, | | | |street drugs) |

|anti-convulsants, benzodiazepine) | | | |OR |

|(Anesthesia: Within 24 hrs) | | | |CV and CNS meds |

|Diagnosis |N/A |N/A |N/A |Cognitive impairment |

St. Cloud Hospital Inpatient Flowsheet

Fall Assessment Tool

|Date | | | | | | |

| Time | | | | | | |

|Age | | | | | | |

|History of Falls | | | | | | |

|Mental Status | | | | | | |

|Physical Mobility | | | | | | |

|Communication | | | | | | |

|Elimination | | | | | | |

|Vital Signs | | | | | | |

|Medications | | | | | | |

|Diagnosis | | | | | | |

|Total Score | | | | | | |

|Fall Protection | | | | | | |

|Fall Prevention | | | | | | |

|Mark the interventions| | | | | | |

|you use with the | | | | | | |

|letter assigned to | | | | | | |

|them on the grid on | | | | | | |

|the back of this form.| | | | | | |

|Indicate any | | | | | | |

|additional | | | | | | |

|interventions on the | | | | | | |

|ICP. | | | | | | |

|Initials | | | | | | |

• Score of 9 or greater or fall during admission = At Risk. Place on Fall Prevention Protocol and add to care plan.

|Variable |0 |1 |2 |3 |

|Age |18-30 |31-60 |61-75 |>75 |

|History of Falls |No history |> 6 months |1-6 months ago |Within 1 month |

|Mental Status |Alert & Oriented x 3, |Oriented to person/place |Oriented to person only, |Disoriented, unable to |

| |follows instructions | |Short Term Memory loss |follow instructions |

|Physical Mobility |No physical impair-ment,|Use assistive device and/or|Assist of 2 or more to |Unable to ambulate |

| |no assistive devices to |able to ambulate |ambulate | |

| |ambulate | | | |

|Communication/Sensory Impairment (vision, |No deficits |1 deficit with correction |1 deficit without |3 or more deficits or onset|

|hearing, speech, neuropathy, language | | |correction or 2 deficits |of 1 new problem |

|barrier) | | |with correction | |

|Elimination (nocturia, frequency, urgency, |No problem |1 problem and/or |2 problems or removal of |3 or more problems or onset|

|diarrhea, incontinence, retention, laxative,| |Foley/ostomy |Foley within 24 hours |of 1 new problem |

|bowel prep) | | | | |

|Vital signs |No problem |Asymptomatic bradycardia |Two or more of the |Symptomatic hypotension SBP|

| | |100; |following: *Asymptomatic |102 |tachycardia >100; |bradycardia 102 |Symptomatic tachycardia |

| | |Requires O2 to hold sats at|* Requires O2 to hold sats |>100; Unable to maintain O2|

| | |>90% |at >90% |sats >90% |

|Medications (CV: antihypertensive, |No CV or CNS meds |CV meds |CNS meds |>9 medications |

|diuretics, antiarrhythmics) | | | |(prescription, OTC, herbal,|

|(CNS: narcotics, psychotropics, | | | |street drugs) |

|anti-convulsants, benzodiazepine) | | | |OR |

|(Anesthesia: Within 24 hrs) | | | |CV and CNS meds |

|Diagnosis |N/A |N/A |N/A |Cognitive impairment |

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Addendum 1

| Patient |Assessment |Re-Assessment |Interventions |

|Category | | | |

| All |Identified |After a fall, |Fall Protection: |

|Patients |patients will |as needed |Call light within reach or patient under direct |

| |be assessed for|post-procedure,|supervision |

| |falls upon |change in |Orientation to environment |

| |initial |clinical |Bed or chair in low position/brakes on |

| |assessment and |condition which|Appropriate footwear(non-skid) |

| |risk assigned |could increase |Personal items within reach |

| |according to |fall risk, or |2 top rails up or person in attendance |

| |the Fall |based on |Share with patient/family education regarding fall |

| |Assessment Tool|nursing |protection program and document ITR |

| | |judgment |Clear pathway |

| | | |Appropriate lighting |

| | | |Sit before standing |

| | | |Assistive devices will be used as appropriate |

| |Patients |After a fall, |Fall Protection (above) and |

| |Assessed with |as needed |Fall Prevention: |

| |Risk Score |post-procedure,|Identify fall prevention within medical record |

| |equal to or |change in |Communicate risk level |

| |greater than 9 |clinical |Identify fall risk on appropriate communication tool |

| | |condition which|based on outpatient area |

| | |could increase |Share with patient/family education regarding fall |

| | |fall risk, or |prevention program and document ITR |

| | |based on |Family present, 1:1 (requires MD order) |

| | |nursing |Relocate patient to highly visible area |

| | |judgment. |Toileting, offer food/drink prn |

| | | |Frequent re-orientation |

| | | |Ambulate with assist |

Addendum 2

|Patient |Assessment |Re-Assessment |Interventions |

|Category | | | |

| |Upon admission,|Once per 12 hr |Fall Protection: |

|All |all patients |shift, after |Call light within reach or patient under direct supervision |

|Patients |will be |any fall, post |Orientation to environment |

| |assessed for |procedure as |Bed or chair in low position/brakes on |

| |falls risk |needed, upon |Appropriate footwear(non-skid) |

| |according to |transfer to |Personal items within reach |

| |the Fall |another unit, |2 top rails up or person in attendance |

| |Assessment Tool|change in |Share with patient/family education regarding fall protection|

| | |clinical |program and document ITR |

| | |condition which|Clear pathway |

| | |could increase |Appropriate lighting |

| | |fall risk, or |Sit before standing |

| | |based on |Assistive devices will be used as appropriate |

| | |nursing |Identify Fall Protection on ICP and Kardex. |

| | |judgment | |

| |Patients |Once per 12 hr |Fall Protection (above) and |

| |Assessed with |shift, after |Fall Prevention: |

| |Risk Score |any fall, post |Identify Fall Prevention on front of chart, ICP and Kardex |

| |equal to or |procedure as |Communicate risk level |

| |greater than 9 |needed, upon |Place falling leaves magnet on patient room door frame. |

| | |transfer to |Share with patient/family education regarding fall prevention|

| | |another unit, |program and document ITR. |

| | |change in |Increased side rails |

| | |clinical |Family present, 1:1 (requires MD order) |

| | |condition which|Chirper |

| | |could increase |Bed alarm |

| | |fall risk, or |Restraints (requires MD order) |

| | |based on |Relocate patient to highly visible area |

| | |nursing |$)íöN X Z o j |

| | |judgment |ƒ |

| | | |ª |

| | | |c |

| | | |Π|

| | | |K&(ÀÂ[pic]ß?…!,k7“TOP” – toileting, offer food/drink, |

| | | |position change every 2 hours |

| | | |Frequent re-orientation |

| | | |Pharmacy consult for medication review |

| | | |PT/OT consult (requires MD order) |

| | | |Ambulate with assist |

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