Fall Prevention

Provide bathmats or towels

Patients showering or sponge bathing at the sink to absorb water and prevent water collection on the floor

Bedside Commode

• Alert, oriented, continent or newly incontinent patient who is non-compliant with calling for assistance for bathroom toileting • Patients receiving bowel preps, laxatives

Patients Identified As a Risk to Fall

1. Explain the Fall Risk Program to the patient and/or family. 2. Place the orange fall prevention bracelet on the patient's wrist (do not use in place of the ID Bracelet). 3. Place the Universal Bed sign on the wall above the patient's bed. 4. Fall Prevention Program pamphlet is given to either the patient or family members as appropriate. 5. If positive for risk factors and fall risk, initiate referrals for interdisciplinary team members relative to the type of risk factor (e.g. Pharmacy, PT, OT, Dietary). 6. Communicate fall risk status and fall prevention 7. interventions as part of the hand-off procedure 8. between units, level of care, providers, caregivers, 9. and shifts. 10. Place the blue none skip sleepers on the patient. 11. Documentation regarding falls and falls risk assessments will be included as appropriate in the patient's care plan, progress notes, and Fall Variance Report if the patient should fall.

Additional Interventions for High Risk patients to prevent falls

1. Reorienting the confused patient to time and place. 2. Checking the patient hourly. 3. Reviewing current plan of care as to effectiveness and making adjustments as necessary. 4. Including fall prevention in patient and family education efforts. 5. Initiating AM/PM Safety Huddles at shift change to alert staff of all patients on unit who are at risk for falls. 6. Use low beds for those at risk for falls. 7. Place hip protectors to all patients high risk to fall. 8. Use another protective equipment as helmets or bed alarms as established in the Fall prevention policy.

Locked wheelchair facing commode in bathroom when patient on stationary commode

Continent patients who cannot ambulate to the restroom to guard them from falling forward

Non-slip footwear

Patients who are able to stand-transfer, ambulate, stand, and sit/dangle on side of bed

Standby assist (audible distance) for Toileting

Patients who are continent, frequency, urgency, and who have attempted to transfer or ambulate without assistance to BSC or bathroom

Sitter ,attendant or Family companion

Patients who are extremely agitated, confused, other interventions unsuccessful, prior falls have occurred

Monitor lying/sitting/standing BP, blood sugars, and fluid intake

Patients who have high blood pressure, diabetics, dehydrated, <48 hours post-op

Unwitnessed Fall

a patient found on the floor or other object but no one knows how he/she got there

Near Fall

sudden loss of balance that does not result in a fall or other injury

Fall

sudden, uncontrolled, unintentional downward displacement of the body to the ground or other object

Intrinsic Patient Factors for Fall Risks

• Acute and Chronic illnesses • Metabolic Abnormalities • Arrhythmias • Orthostatic Hypotension • Fainting Episodes (vasovagal) • Sensory deficits/ problems with corrective devices: visual/hearing/ vertigo & dizziness • Dementia with altered judgment • Incontinence • Medications: anesthetics,antipsychotics, antihistamines, anticonvulsants, benzodiazapines, cardiac drugs (diuretics, antihypertensives, calcium channel blockers), hypoglycemics, narcotics and polypharmacy • Musculoskeletal: bone degeneration, osteoporosis, decreased bone density and muscle mass, decreased strength... • Degenerative joint diseases • Foot problems • Neurologic: Delayed reaction times, decreased sensation in lower extremities, changes in gait • TlA's/ Stroke • Seizures • Parkinson's Disease • Peripheral Neuropathies • Other degenerative diseases

When a Patient Falls

• Assess the patient for injury before moving! • Use a mechanical lift whenever possible to get patient off the floor. • Notify MD to see patient. • Document assessment, vital signs and other pertinent information in the progress notes. • Complete Patient Falls Variance Report and Fact Findings • Place complete information on your 24 hour report; • Notify your supervisor • Notify patient's family

Lock and remove leg rests from wheelchairs when not in use

• Avoid trip hazards in WC bound patients • Locked wheelchair frame may provide support during fall

Physical Therapy

• Gait and balance assessment and training • Patients who need assistive devices such as shower chair, patients with cane/WC/walker, raised toilet seat, gait belt • Patients who need transferring for toileting or WC

What is not a fall

• Incidents resulting from a major acute event i.e. stroke/ violence/ car crash. • Controlled or intentional movement to bed or floor. • Interruption of fall, e.g. when a patient is caught before hitting the ground, known as a "near fall" • Incidents caused by external forces i.e. when a person is pushed or knocked down

Involving Family/Significant Other in Falls Prevention

• Patient who may have a family member who would consider staying with patient if they are at a high risk for falling or confused. • Instruct family/SO to notify the nurse before leaving a confused or disoriented patient so appropriate safety measures can be taken.

Leave lights on in room or bathroom

• Patient's with visual and cognitive impairment. Leaving lights on increases orientation to surroundings • Patients who are continent, independent, may ambulate without assistance

Medication Evaluation by Pharmacy

• Patients with more than 5 medications or have been prescribed sleep aids, narcotics, anti-emetics, anti-hypertensives, and anti-coagulants • Substance abuse, nicotine addiction

Universal Fall Precautions

• Place orange wristband on patient to alert all personnel of fall risk. • Orient patient to surroundings. • Ensure patient wears eyeglasses, if applicable. • Ensure patient's footwear is adequate; if no footwear is available provide treaded socks. • Keep bed in low position. • Assure supervision and assistance are provided with elimination, transfers and ambulation. • Place the ID patient tag with the falling star logo. • Lock wheels on all wheelchairs, beds, commodes and stretchers. • Clean up spills immediately. • Ensure adequate lighting at night. • Assure nurse call system/ telephone and personal items are accessible at all times. • Medication review by pharmacy. • Recommend referral to PM&R for safe ambulation and transfer techniques.

Environmental/ Situational Fall Risk Factors

• Poorly maintained or improperly used assistive devices. • Unfamiliar environment. • Performing unusual activities. • Slippery or wet floors, scatter rugs, loose carpeting, exposed cords, wires, etc. • Surface irregularities, clutter, absence of railings. • Unstable furniture, low furniture and furniture without armrests and backrests. • Poor lighting including dim lighting, glare and absence of night lights. • Bathrooms: Low toilets absence of secure grab bars and tubs without bars or non skid strips. Inappropriate piacement of grab bars and assistive devices. • Ill fitting clothing • Improper shoes • Presence of tubes, catheters, etc.

Patient Teaching

• Wear non-slip foot wear if out of bed. • Call for help if you are unsteady when moving from bed to chair or chair to bed, walking, getting to the toilet or retrieving hard to reach items. • Make sure your wheelchair is locked and that the foot pedals are up before moving in or out of it! • Pause for a few seconds when changing positions, such as lying to sitting or sitting to standing. This allows your body to adjust to the change. • Avoid bending to pick up items. Ask for help. • Tell your doctor or nurse of any episodes of dizziness or lightheadedness.