TITLE: FALL PREVENTION PROTOCOL POLICY # F 01.5 MANUAL: CLINICAL PROCEDURE MANUAL Page 1 of 11

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1 TITLE: FALL PREVENTION PROTOCOL POLICY # F 01.5 MANUAL: CLINICAL PROCEDURE MANUAL Page 1 of 11 Effective Date: 10/00 Reviewed/Revised: 5/02; 6/02, 11/05, 11/06, 2/07, 12/09, 11/10, 4/11, 7/12, 8/13, 8/14 Approval /s/tiffany Oliver Tiffany Oliver RN, MSN, MBA, CNO I. VALUES CONTEXT Our value of service assures that we respond to the needs of the whole person. II. PURPOSE\EXPECTED OUTCOME (S) The purpose of this policy is to reduce the incidence of patient falls at Santa Rosa Memorial Hospital including identification of patient at risk for falls, implementing action to prevent harm, and providing a safe therapeutic environment across the continuum of care. III. Personnel: Direct health care providers based on scope of practice. In addition all SRMH employees have a role in fall prevention by being aware of fall risk patients within the work environment, and working to maintain an environment free from hazards. Also, the patients have a responsibility to comply with fall prevention interventions within the scope of their abilities. IV. POLICY Santa Rosa Memorial Hospital believes that patients are at greater risk for falls when hospitalized. Therefore all hospitalized patients are considered a fall risk, and will be assessed to minimize their risk of falling. SRMH staff will work to actively reduce the risk of falls across the continuum of care by ensuring a safe physical environment and appropriate identification of fall risk patients. A. Background 1. A fall is defined as an unintentional event in which a patient comes to rest on the floor and can involve assistance by another (Morse, JM 1987) Evidence-based tools will be used in assisting the nurse to assess each patient for the risk of falls. The Fall Risk Assessment Tool by Morse (1997) has been chosen for adults at SRMH. G:Shared/patcare p&ps

2 FALL PREVENTION PROTOCOL Page 2 of There are three types of falls: A. Accidental Falls- includes patient slipping, tripping or have some mishap that results in a fall. They may have not been identified as a fall risk utilizing the Morse tool. Environmental factors and errors in patient judgment cause these types of falls. Prevention of these types of falls is geared at keeping the environment free from hazards and proper education for the patient/family regarding the environment and use of various devices. B. Unanticipated Physiological Falls-includes falls that are attributed to physiological causes that cannot be identified or predicted by any prior assessment, such as a seizure. There is not real way to prevent this type of fall the first time, but if it does occur, then the interventions are implemented to prevent injury if the event should happen again. C. Anticipated Physiological Falls-includes falls identified by using a fall risk assessment tool. Fall Prevention programs are geared to decrease the number and severity of these types of falls. Predictable factors include: more than one diagnosis, a previous fall, a weak or impaired gait, the lack of a realistic assessment of his or her own abilities to go to the bathroom unassisted, an IV or saline lock; polypharmacy and an ambulatory aid. Anticipated physiological falls constitute 78% of all falls. V. PROCEDURE A. ENVIRONMENTAL AND HOSPITAL SAFETY All hospital staff are responsible for reducing fall risks and ensuring a safe environment free from hazards. All clinical and non clinical staff are aware of high fall risk patients, and will work within their scope of practice to prevent patient falls. Staff work as a cohesive team to eliminate hazards, by involving Environmental Services and Engineering as appropriate. This includes, however is not limited to: a. Monitor cords, equipment, and uneven surfaces to eliminate trip hazards. b. Clean up spills and place caution signs if floors are wet. c. Ensure patients immediate physical safety while notifying appropriate clinical staff if unsafe patient activity is observed. B. INPATIENT ASSESSMENT using Morse Fall Scale (Appendix A) 1. All inpatients will be assessed for fall risk using the Morse Fall Scale by the nurse as follows: a) Upon admission

3 FALL PREVENTION PROTOCOL Page 3 of 11 b) Every shift c) Post fall during hospitalization d) Anytime based on the nurse s discretion where changes in the patient s assessment including medication changes warrant re-evaluation of fall risk. 2. Morse Fall Scale (See Appendix A for description) A. Scoring a. Low Risk 0-23 b. Moderate Risk c. High Risk 44 or above Factor Points History of falling Yes = 25 Presence of Secondary diagnosis Yes = 15 IV therapy or peripheral IV lock Yes = 20 Type of gait Weak = 10 Impaired = 20 Use of walking aids Normal/bedrest/wheelchair = 0 Cane/crutches/walker = 15 Uses furniture = 30 Mental status Overestimates/forgets own limitations = 15 3.The following criteria are suggested to identify patients who are also considered at increased risk of harm from falls: a. AGE - Patients age 85 and older b. BONES-Patients who have a history of osteoporosis, previous fractures, or prolonged steroid use. c. COAGULATION-Patients who are taking anti-coagulation medication due to the increased risk of bleeding as a result of trauma caused by a fall. d. SURGERY- Patients who have recently undergone surgical procedure. e. This information does not alter the patient s Morse Fall Scale Score, but provides increased awareness for staff regarding patient s risk of harm from falls.

4 FALL PREVENTION PROTOCOL Page 4 of 11 C. FALL RISK REDUCTION INTERVENTIONS 1. Low Fall Risk Intervention The following interventions will be initiated for ALL inpatients. a. Orient patient/family to environment and routines. b. Place call light within reach and remind patient to call for assistance. c. Ensure that patient bed is in low position, the brake is on, and upper side rails are up. d. Bed Alarm is activated for all inpatients when patient is in bed, (with the exception of the Maternal Child unit) unless patient refuses. e. Place patient s necessary items within reach. f. Provide non-skid footwear for patient as needed. g. Minimize environmental trip/slip hazards h. Round frequently (approximately every hour) and assess for safety and comfort. 2.Moderate /High Fall Risk Interventions: In addition to the Low Fall Risk interventions listed above, more intensive interventions by the health care team are warranted for all those inpatients scoring Moderate/ High on the Morse Fall Scale. a. Visually identifying the patient as by placing YELLOW armband on patient wrist. Yellow skid proof socks are strongly encouraged but not mandatory. b. Consider placement in a room or area of high visibility near nursing station. c. Monitoring patient and environment for safety approximately every 1 hour. Place call light and frequently used items within reach. d. Initiate Fall Risk Care Plan - A plan of care is developed with appropriate interventions individualized to patient needs. e. Activate bed alarm at all times when patient is in bed. Assure bed is connected to call light system. Also, implement chair alarm as appropriate. f. Supervise patient directly (within visual observation) or while on commode or in bathroom. g. Assist with or supervise all transfers and ambulation using gait belt and other assistive devices as needed. h. If patient is impulsive, is Moderate/High Fall Risk, and/or has experienced a previous fall, a specialty low bed with mat is advised to reduce harm secondary to a fall. Specialty low beds may also be implemented based on nursing clinical judgment to provide a safer environment for the patient.a physician order is not required for a specialty low bed.

5 FALL PREVENTION PROTOCOL Page 5 of 11 i. Provide and review Fall Prevention patient education materials with patient and family. j. If patient is on a specialty low volume air mattress, it is recommended to have all four side rails are up for patient safety, and consider placing protective seizure pads on the bed to prevent the patient from sliding through the side rails. This is not considered a restraint. k. If patient is on a specialty low volume air mattress, and the head of the bed is raised 45 degrees or higher, it is recommended that the foot of the bed is elevated to prevent patient from sliding off of the bed. 3. Communicating Fall Risk Status- The following interventions are strongly suggested to communicate the patient s fall risk status and appropriate interventions to nursing and other licensed ancillary staff: a. High Fall Risk is identified on Status Board in the EMR. b. Communicate High Fall Risk status at shift report and confirm that Bed Alarm is on. c. Utilizing Ticket to Ride to communicate fall risk status when patient is going off the floor for a procedure. d. Safety issues will be discussed at unit huddles.. e. Review patient s Fall Risk status at all handoffs for transfers between units and utilize this information for safe patient placement 4. Increasing frequency of observation and assistance to the patient for care needs and ambulation is strongly encouraged. a. Patients identified, as Moderate/High Fall Risk should be prompted for toileting approximately every 2 hours while awake and PRN overnight. Offer bedpan, urinal, or assistance to bathroom at mealtime, at bedtime, and upon awakening. b. Closely monitor patients for change in fall status following the administration of medications. c. Be alert to and investigate noises from patient rooms. 5. Implementing actions to prevent falls or to reduce the severity of a fall. a. Using gait belt to transfer patients to a commode, chair or when ambulating. Keep a gait belt at bedside for patients identified as Moderate/High Fall Risk. b. Maintaining bed in low position when occupied by a patient with brakes on and upper side rails in the up position. c. Making sure floor is dry and removing any environmental obstacles from the patient s walking area.

6 FALL PREVENTION PROTOCOL Page 6 of 11 d. Reorienting to surroundings and environment as needed. 6. Educating patient and family regarding the risk of falling. a. Reminding patient to call for help before getting out of bed. b. Patients benefit from having family at the bedside to provide comfort & reassurance. Discuss high fall risk status with patient and/or family upon initial assessment of Moderate or High Fall Risk. Discussing benefits of continuous supervision with family as appropriate. 7. Environmental Factors c. Utilizing night light in patient room if indicated d. Beds that have split rails-keep the bottom side rail in the lowered position unless the patient is on a specialty low volume air mattress. e. Floors are uncluttered and trip hazards mitigated. f. There are skid proof surfaces in tubs, showers and bathroom floors. g. Wheeled furniture is locked to prevent slippage when leaned on for support. h. Slip resistant footwear is provided for patient use. i. Side rails on gurneys will be in the upright position at all times. j. Obtaining walker, cane or wheelchair from home if patient has need of assistive devices prior to admission. Assist with/supervise transfers and ambulation. k. If patient is on a specialty low air volume mattress, be alert to the risk of patient sliding. Do not use the mattress as a mechanism to transfer the patient. D. DOCUMENTATION 1. Fall risk score upon admission, each shift assessment and repeated as reassessed must be documented in the patient health record. 2. Notification of moderate/high fall risk status to patient, and family upon initial assessment of Moderate /High Fall Risk. Teaching to patient and/or family regarding risk of patient fall and prevention measures. 3. Document risk for injury related to fall risk on care plan. E. POST FALL FOLLOW UP 1. An RN or physician is required to assess the patient prior to moving the patient following a fall. Any observable injuries must be documented.

7 FALL PREVENTION PROTOCOL Page 7 of If there is concern regarding possible spinal cord injury, call Rapid Response Team and provide spinal immobilization before moving patient. 3. If there is no anticipated risk of spinal injury, the patient s nurse must assist with returning the patient to bed or chair using proper body mechanics and appropriate patient lift equipment 4. Assess patient (vital signs and patient response to fall) and document circumstances of the fall and the patient assessment in the patient health record. 5. Notify the physician of the fall and document in patient health record. 6. If patient is on anticoagulants, or there was evidence of head injury, ask the physician for instructions regarding ongoing neurological assessment. 7. Notify the Nurse Manager/Administrative Coordinator of the fall. 8. Notify the family or designee of the fall. 9. Review fall risk precautions and add additional precautions if indicated. 10. If a patient has fallen, consider implementing a low bed for the patient, and discuss with physician the need for a sitter or additional safety measures. 11. Care plan updated as indicated. F. REPORTING PATIENT FALLS Patient Falls must be reported through the standard incident reporting process which is available to throughout the facility. G. EDUCATION AND COMPETENCY OF THE STAFF 1. Patient Care Providers (licensed and unlicensed) are educated on the Fall Risk Program at new hire orientation and at annual competencies 2. Education for Fall Risk Program includes how to identify patients at risk for falls, how to communicate the risk level to the patient, family and other members of the health care team, and the use of fall precautions and interventions. H. ANALYSIS AND REVIEW OF PATIENT FALLS DATA The SRMH Falls and Restraint Committee is responsible for analysis and review of patient fall data, and reports to the SRMH Board Quality Committee. I. PEDIATRICS (SEE APPENDIX B) J. OUTPATIENT SERVICES FALL RISK SCREENING (SEE APPENDIX C)

8 FALL PREVENTION PROTOCOL Page 8 of 11 Authoring Department: Patient Care Services References: CALNOC, 2012 Codebook, Part 1 Collaborative Alliance for Nursing Outcomes Viney, Mary, et al, American Society for Healthcare Risk Management, Sharing Practices that Prevent Falls, Pressure Ulcers and Infections. February 2009 Audio Conference, IHI Miake-Lye, Isomi et. al. Inpatient Fall Prevention Programs as a Patient Safety Strategy Annals of Internal Medicine March 2013 Vol. 158 No. 5 Joint Commission Standards: National Patient Safety Goal 9- Reduce the Risk of Patient Harm Resulting from Falls Hourly Rounding AJN Oct Shorr, R, et al. Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients Annals of Internal Medicine Nov Vol. 157 No. 10 Waters, T. When is it safe to Manually Lift a Patient? AJN August 2007 Vol. 107 No. 8 1) Morse, J.M. (1993). Nursing research on patient falls in health care institutions. Annual Review of Nursing Research, Reviewed/Revised by: Falls & Restraint Committee,, Eileen Jensen RN MSN FNP Approvals: Clinical Practice Council (5/14) Distribution: All Patient Care Departments Restraint/Falls Task Force (3/14) MEC (8/14)

9 FALL PREVENTION PROTOCOL Page 9 of 11 APPENDIX A Morse Fall Scale The Fall Risk Score is assessed on admission and reassessed daily and for any change in orientation or level of consciousness. Factor Points Description History of falling Yes = 25 During present Hospitalization or Immediately prior to admit Ask Patient, Check admit assessment or H & P Presence of Secondary diagnosis Yes = 15 IV therapy or peripheral IV lock Type of gait Yes = 20 Weak = 10 Impaired = 20 Use of walking aids Normal/bedrest/wheelchair = 0 Mental status Cane/crutches/walker = 15 Uses furniture = 30 Overestimates/forgets own limitations = 15 Does the patient have 2 or more medical diagnoses? - Examples: diabetes, HTN, seizures, ostomy, sleep apnea, deaf/blind, arthritis, chronic pain, COPD, ostomy, Check admit assessment or H & P Consider the effect of multiple medications when scoring Normal = head erect, arms swing freely, striding unhesitantly. Weak = stooped but able to lift head without loosing balance. If support from furniture needed only featherweight touch for reassurance. Short steps or shuffle. Impaired = difficulty rising, pushes off on chair arms. Head down or watches ground. Poor balance, grasps on furniture white knuckle Review patient health care record. Consider the effect of multiple medications when scoring Normal = no walking aids (even if assisted by a nurse), uses wheelchair, is on bedrest or doesn t get up at all Uses furniture = Clutches onto furniture for support Review patient health care record. Check patients own self-assessment of his or her own ability to ambulate. Are you able to go to the bathroom alone or do you need assistance? or Do you feel safe getting up by yourself? If patient s reply is not consistent with MD or RN ambulation orders or if patient s assessment is unrealistic score as 15. Consider the effect of multiple medications when scoring.

10 FALL PREVENTION PROTOCOL Page 10 of 11 APPENDIX B Pediatric Patients 1. Neonates and infants are by definition at risk for falls due to their developmental age. Such patients are maintained in bassinets for their safety. No assessment/reassessment of fall risk is required for these patients. APPENDIX C 1. According to the National Safe Kids Campaign, falls are the leading cause of unintentional injury for children. Half of these injuries occur in children younger than 5 years old. Children under 10 have the greatest risk for fall related death and injury. At SRMH, the Humpty Dumpty Pediatric Fall Assessment Scale is utilized in the Pediatric Unit. Specific details regarding Low, Moderate, and High Fall Risk interventions are available in the Pediatric Department. Outpatient Services Fall Risk Screening The Fall Risk Reduction program in the out patient settings will consist of risk screening of the populations served, the services provided, and the environment of care. The outpatient fall reduction program may include risk screening and periodic evaluation of individual patients and/or the environment of care.. Periodic safety inspections will be conducted to comply with the Joint Commission Environment of Care Standards (EC 1.20) Outpatient Departments will screen patients based upon the following Fall Prevention strategies. 1. If a patient presents with obvious risk criteria such as unsteady gait, use of assistive devices, or other obvious need, then staff will take appropriate action to assure patient s safety during the provision of care, treatment and service. 2. Observe the patient s coordination and balance and assist with transfer and mobility activities as needed. 3. Use non skid footwear if indicated. 4. Transfer patient toward stronger side. 5. Actively engage and educate patients and family regarding fall prevention strategies. 6. Instruct patients: a) in all activities prior to initiation b) in medication time/dose, side effects and interactions with food/medications c) to call for help before getting out of bed (Demonstrate call system) 7. Orient the patient to the environment especially to the bathroom 8. Lock all moveable equipment before transferring patients. 9. Individualize equipment specific to patient needs. 10. Place patient care articles within reach

11 FALL PREVENTION PROTOCOL Page 11 of Provide a physically safe environment (eliminate spills, clutter, electrical cords and unnecessary equipment) Communicate Fall Risk Status: The patient s fall risk status and appropriate interventions are communicated with Nursing and other licensed and ancillary staff at the following times: Post Fall Procedures: 1. During staff report, shift to shift within the department at time of hand off. 2. Before transfer/discharge to another level of care at time of handoff report. 3. Prior to movement to another department for diagnostic test/procedure, or surgery utilizing Ticket to Ride. Outpatient services will follow the post fall procedure outlined in the Fall Prevention Policy, except the Morse Fall Scale will not be used. Emergency Department In the Emergency Department, it is recommended that the fall risk assessment will be completed and documented utilizing the Morse Fall Scale.