I. VALUES CONTEXT We work together to be effective and efficient in the use of resources and to provide a safe environment.

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1 TITLE: FALL PREVENTION AND IDENTIFICATION OF PATIENTS AT RISK FOR FALLING MANUAL: ADMINISTRATIVE POLICY & PROCEDURE MANUAL (Previously Nursing Division Policy and Procedure) Effective Date: 4/98, 8/07 Reviewed/Revised: 6/99; 11/01; 12/02; 1/03; 9/05, 8/07; 3/09; 2/11; 6/14 Approval David Ziolkowski, Chief Operating Officer I. VALUES CONTEXT We work together to be effective and efficient in the use of resources and to provide a safe environment. II. III. PURPOSE/EXPECTED OUTCOME(S) To identify the patient at risk for falls, implement action to prevent injury, establish documentation guidelines, and to provide a safe therapeutic environment. POLICY A. Supportive Data 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 PVH. 2. ALL hospitalized patients are assessed by the RN for their risk of falling on admission, every shift, upon change in condition, post falls and when transferred. These assessments will be documented in the Patient Health Care Record. 3. 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.

2 Page 2 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. 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 and when transferred between levels of care. 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 1. Low Risk Moderate Risk High Risk 44 or Above Morse Fall Scale Factor Points History of falling Yes = 25 No = 0 Presence of Secondary diagnosis Yes = 15 No = 0 IV therapy or peripheral IV lock Yes = 20 No = 0 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 Page 3 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. III. PROCEDURE A. ENVIRONMENTAL AND HOSPITAL SAFETY All hospital staff is responsible for reducing fall risks and ensuring a safe environment free from hazards. All clinical and non-clinical staff is aware of high fall risk patients, and will work within their scope of practice to prevent patient falls. Staff works 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. d. Consider additional lighting. B. FALL RISK REDUCTION INTERVENTIONS 1. Low Fall Risk Intervention a. The following interventions will be initiated for ALL inpatients. b. Orient patient/family to environment and routines. c. Place call light within reach and remind patient to call for assistance. d. Ensure that patient bed is in low position and the brake is on. e. Bed Alarm is activated for all inpatients when patient is in bed, (with the exception of the Birthing Center unit) unless patient refuses. f. Place patient s necessary items within reach. g. Provide non-skid footwear for patient as needed. h. Minimize environmental trip/slip hazards i. Round frequently (approximately every hour) and assess for safety and comfort. j. Consider additional lighting.

4 Page 4 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 or higher 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, has a Fall Risk of Moderate/High 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 as a result of nursing clinical judgment to provide a safer environment for the patient. A physician order is not required for a specialty low bed. i. Provide and reveiw 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. Document required person assistance on whiteboard, i.e., Max assist 3 person d. Communicate fall risk status to transporter when patient is going off the floor for a procedure. e. Safety issues will be discussed at patient care conferences. f. Review patient s Fall Risk status at all handoffs for transfers between units and utilize this information for safe patient placement

5 Page 5 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. It is strongly recommended to 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. Place patient in a specialty low bed with matt if patient is impulsive, moderate/high fall risk. d. Making sure floor is dry and removing any environmental obstacles from the patient s walking area. e. Reorienting to surroundings and environment as needed. f. Consider a sitter at bedside or video monitoring. g. Consult with physician to obtain a Physical Therapy screen for possible inpatient/outpatient strengthening exercise if patient overestimates abilities, has impaired gait, or is unable to bear weight. h. Consider obtaining order from the physician for home safety evaluation and treatment on discharge. C. DIAGNOSTIC AREAS 1. Get report from the transferring nurse including Fall Risk.The Ticket to Ride communication tool is recommended. 2. Evaluate environment for tripping, hazards, and spills for all patients. 3. Ensure all patients have non-skid footwear for ambulation during ambulatory types of diagnostic procedures. 4. Provide proper lighting as appropriate. 5. Ensure that all wheelchairs and gurneys are in locked position. 6. Assess patient for elimination needs and support patient with toileting. 7. Assist in transferring and ambulation of patients identified as a high risk for falls or as needed.

6 Page 6 8. Consider use of Vera Lift or VanderLift for all transfers. Is use is warranted, ensure that the device is positioned outside patient s room with appropriate slings or belts. 9. Instruct patients: a. in all activities prior to initiation b. in medication time/dose, side effects, and interactions with food/medications as necessary for any medications given in department. c. to call for help before getting out of gurney/wheelchair. 10. Verbally discuss any changes in patient status to the assigned nurse when transferring patient back to the department. If patient has no changes, complete and return the Ticket To Ride indicating the condition has remained the same. 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 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 An RN or physician is required to assess the patient prior to moving the patient following a fall. Any observable injuries must be documented. 1. If there is concern regarding possible spinal cord injury, call Rapid Response Team and provide spinal immobilization before moving patient. 2. 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. Assess for the need to use a lifting device such as the Trans-Aid lift or Vanderlift, such as Hover Jack, Trans-Aid Lift or Vanderlift. The Hover Jack is required when lifting from the floor, any patient with cervical or spinal precautions 3. Assess patient (vital signs and patient response to fall) and document circumstances of the fall in the patient health record. 4. Notify the physician of the fall and document in patient health record. 5. If patient is on anticoagulants, or there was evidence of head injury, ask the physician for instructions regarding ongoing neurological assessment. 6. Notify the Nurse Manager/Administrative Coordinator of the fall. 7. Notify the family or designee of the fall.

7 Page 7 8. Review fall risk precautions and add additional precautions if indicated. 9. 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. 10. Care plan updated as indicated. 11. Report the fall through the standard event reporting system. F. REPORTING PATIENT FALLS Patient Falls must be reported through the standard incident reporting process which is available 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 annually. 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 PVH Falls Committee is responsible for analysis and review of patient fall data, and reports to the PVH Board Quality Committee. Author/Department: P. Ramer, RN 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, References: Joint Commission National Patient Safety Goals; VA National Center for Patient Safety Reviewed/Revised by: Eileen Jensen RN MSN FNP Approvals: Distribution: All Hospital Departments Administrative Policy Review Committee (3/11)

8 Page 8 Safety Committee (5/11/11) Coordinating Council 6/18/14 Addendum A: Instructions: Morse Fall Score Addendum B: Morse Fall Score Addendum C: Outpatient Services Fall Risk Screening Addendum D: Pediatrics

9 Page 9 Addendum A Instructions: Morse Fall Score The items in the scale are scored as follows: History of falling: This is scored as 25 if the patient has fallen during the present hospital admission, within the past 6 months or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the patient has not fallen, this is scored 0. Note: If a patient falls for the first time, then his or her score immediately increases by 25. Secondary diagnosis: This is scored as 15 if more than one medical diagnosis is listed on the patient s chart; if not, score 0. Ambulatory aids: This is scored as 0 if the patient walks without a walking aid (even if assisted by a nurse), uses a wheelchair, or is on a bed rest and does not or cannot get out of bed at all. If the patient uses crutches, a cane, or a walker, this item scores 15; if the patient ambulates clutching onto the furniture for support, score this item 30. Intravenous therapy: This is scored as 20 if the patient has an intravenous apparatus or a heparin lock inserted; if not, score 0. Gait: A normal gait is characterized by the patient walking with head erect, arms swinging freely at the side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the patient is stooped but is able to lift the head while walking without losing balance. Steps are short and the patient may shuffle. With an impaired gait (score 20), the patient may have difficulty rising from the chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by using several attempts to rise). The patient s head is down, and he or she watches the ground. Because the patient s balance is poor, the patient grasps onto the furniture, a support person, or a walking aid for support and cannot walk without this assistance. Mental status: When using this Scale, mental status is measured by checking the patient s own self-assessment of his or her own ability to ambulate. Ask the patient, Are you able to go the bathroom alone or do you need assistance? If the patient s reply judging his or her own ability is consistent with the ambulatory order on the kardex, the patient is rated as normal and scored 0. If the patient s response is not consistent with the nursing orders or if the patient s response is unrealistic, then the patient is considered to overestimate his or her own abilities and to be forgetful of limitations and scored as 15. Scoring and Risk Level: The score is then tallied and recorded on the patient s chart. Any patient with a score of 45 or less will need standard/universal fall precaution. Scores above 50 will require implementing the High Fall Risk strategies.

10 TITLE: PROTOCOL FOR THE MANAGEMENT OF PATIENTS AT RISK FOR FALLING Page 10 Addendum B: Morse Fall Score 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 No = 0 During present Hospitalization or Immediately prior to admit Ask Patient, Check admit assessment or H & P Presence of Secondary diagnosis Yes = 15 No = 0 IV therapy or peripheral IV lock Type of gait Yes = 20 No = 0 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.

11 Page 11 Addendum C: Outpatient Services Fall Risk Screening The Fall Risk Reduction program in the outpatient 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. No specific assessment/reassessment of fall risk is required of patients seen in the outpatient setting. However, 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. a. Use non skid footwear if indicated. b. Transfer patient toward stronger side. c. Actively engage and educate patients and family regarding fall prevention strategies. d. Instruct patients: 1. in all activities prior to initiation 2. in medication time/dose, side effects and interactions with food/medications 3. to call for help before getting out of bed (Demonstrate call system) e. Orient the patient to the environment especially to the bathroom f. Lock all moveable equipment before transferring patients. g. Individualize equipment specific to patient needs. h. Place patient care articles within reach i. Provide a physically safe environment (eliminate spills, clutter, electrical cords and unnecessary equipment) 3. 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: a. During staff report, shift to shift within the department at time of hand off. b. Before transfer/discharge to another level of care at time of handoff report. c. Prior to movement to another department for diagnostic test/procedure, or surgery utilizing Ticket to Ride.

12 Page Post Fall Procedures: a. Outpatient services will follow the post fall procedure outlined in the Fall Prevention Policy, except the Morse Fall Scale will not be used. b. In the Emergency Department, the fall risk assessment will be completed and documented utilizing the Morse Fall Scale for predetermined diagnosis.

13 Page 13 Addendum D: 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. 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.