FALL PREVENTION PROCEDURE

(Customize this form by using your logo if desired and removing the instructions below) FALL PREVENTION PROCEDURE ASSESSMENT AND PREPARATION 1. There are many Fall Risk Assessment Tools available. Provide the details of the tool that has been selected by your organization. If one is not in use, discuss with the leadership team to select an appropriate fall risk assessment tool for your area. 2. Use the fall risk assessment tool to assess the patient's motor, sensory, balance, and cognitive status. Also note the patient's ability to follow directions and cooperate. Age over 65 years, confusion, impaired memory and cognition, incontinence or urinary frequency, decreased vision and/or hearing, cataracts or glaucoma, orthostatic hypotension, dizziness or vertigo, decreased balance, impaired gait, history of stroke or parkinsonism, decreased energy or fatigue, and decreased peripheral sensation should be scored at higher risk for falls. 3. As an additional part of the assessment, review the patient's medication history, always including over-the-counter medications and herbal products, for polypharmacy (use of multiple medications), and use of antidepressants, anticonvulsants, antihypertensives, antihistamines, antipsychotics, benzodiazepines, corticosteroids, diuretics, nonsteroidal antiinflammatory drugs, antidiabetics, antiparkinson drugs, and histamine receptors. These medication place patient's at a higher risk for falling that may not be scored in a fall risk assessment scale. 4. Assess the patient for fear of falling; consider patients who are older than 80 years, female, have poor perceived general health, and history of multiple falls at increased risk. Fear of falling places patients at higher risk for falls. 5. Assess risk factors within your facility that pose a threat to the patient's safety (e.g., attached equipment such as electrocardiogram leads, IV tubing or oxygen tubing, improperly lit room, obstructed walkway, clutter of supplies and equipment). 6. Perform the timed "Get Up and Go" test. a. Have the patient rise from sitting position without using arms for support. b. Instruct the patient to walk 3 m, turn around, and walk back to the chair. c. Have the patient return to chair and sit down without using arms for support. Look for unsteadiness in the patient's gait. 7. Determine if the patient has a history of falls or other injuries within the home. Consider polypharmacy (use of four or more medications), age-related Falls, other Medical Factors such as acute or chronic illnesses that cause gait disturbances, and environmental factors in the home. 8. Determine what the patient knows about his or her risks for falling and what prevention steps he or she usually takes. 9. After assessment, apply a color-coded wristband (yellow is the national color for fall risk) for patients at high risk for falling.

10. Gather equipment such as ambulation assistive devices and gait belt. PEDIATRIC CONSIDERATIONS A child's activity level and curiosity often create an increased risk for falls. JTry to eliminate places for the child to climb and consider the use of crib hoods. For children at risk for falls, maintain the bed in the lowest position with the side rails up. When caring for an infant, keep a hand on the infant when turning away from the bedside, even for a second. GERONTOLOGICAL CONSIDERATIONS Increasing lower body strength and improving dynamic balance through regular physical activity reduce the risk for falling. Tai chi is one type of exercise program that has been effective in accomplishing these goals. HOME CARE CONSIDERATIONS Family and caregivers benefit from learning how to assist the patient to ambulate or to transfer from bed to chair or wheelchair to chair safely. It is important to teach the patient and caregiver what to do in case the patient falls, including accessing emergency assistance and how to prevent further injury. PATIENT AND FAMILY EDUCATION Emphasize and reinforce during every encounter to patients at high risk for falls the need to ask for help before getting out of bed. Use signage in the room as a reminder. Also consider writing reminder messages on the whiteboard. Daily use of a patient education pamphlet on fall prevention at the bedside will help to reinforce the safety prevention strategies while the patient is in the hospital. If your facility does not have a patient education fall prevention brochure, discuss with leadership for the possibility of creating one. Emphasize to the patient the need to use good posture and look ahead when ambulating. Teach the patient how to use assistive devices, and ensure that he or she understands by using the teach back method. Encourage the patient to discuss any symptoms such as dizziness, lightheadedness, or syncope that might affect balance, vision, or proprioception. Encourage the patient and family to access the Centers for Disease Control and Prevention's (CDC) website, where they can find additional information regarding fall prevention. Information is available at http://www.cdc.gov/homeandrecreationalsafety/falls/index.html Encourage patients to have yearly vision and hearing examinations. Adaptive devices, such as hearing aids or glasses, are sometimes necessary or need modification.

PROCEDURE 1. Perform hand hygiene. 2. Identify the correct patient using two identifiers per institution policy. 3. Introduce yourself to the patient, including your name and your title or role. 4. Explain the plan of care. 5. Provide privacy. Assign the patient to a bed that allows exit using the patient's stronger side. Position and drape the patient as needed. Being able to exit using the stronger side enhances the patient's ability to move in bed and to get out of bed safely. 6. Adjust bed to proper height to allow the nurses to use proper body mechanics. However, lowering the bed allows ambulatory patients to get in and out of bed more easily and safely. 7. Teach the patient how to use the call bell and bed control system. a. Encourage the patient to wear hearing aid(s) and glasses if appropriate. Having maximum hearing and vision enables the patient to use the call system and to remain alert to conditions in the environment. b. Explain the best times for the patient and family to use the call bell or intercom (e.g., to get out of bed, go to bathroom, report pain). If the patient has a means to call for assistance, the nurse is more likely to be able to respond before the patient tries to get out of bed unassisted. c. Secure call bell and bed control system within the patient's reach every time you encounter the patient. 8. Minimize the use of side rails. a. Check institution policies regarding the use of side rails. The use of side rails can increase the patient's risk of falling and may be considered a restraint. b. Explain to the patient and family that the main purpose of the side rails is to assist the patient to move and turn in the bed. c. When not administering patient care, keep one side rail up in a two-rail system, and keep three of four rails up (one lower rail down) in a four-rail system, with bed in low position and wheels locked. Rails positioned in this manner allow the patient to maneuver and get out of bed safely. 9. Provide environmental interventions as needed. a. Place nonslip padded floor mat on exit side of bed. b. Position assistive devices (e.g., walking aids, bedside commodes) on the exit side of bed. Placing assistive devices on the exit side of the bed provides added safety and support when the patient is transferring out of bed. A bedside commode eliminates the patient's need to walk to the bathroom. c. Position the patient's bedside table, water, and personal care items (e.g., eyeglasses, dentures, telephone) within easy reach. 10. Assure the patient that the nurse will conduct hourly rounds to reassess for fall risks, provide toileting needs, and attend to symptom management. The practice of hourly rounds has been shown to reduce the incidence of falls by greater than 50%. 11. Provide clear instructions to the patient and family regarding mobility restrictions, ambulation, and transfer techniques. 12. When assisting a patient to ambulate, use a gait belt, and walk along beside the patient. A gait belt gives the nurse a secure hold on the patient during ambulation.

13. If the patient starts to fall while ambulating, do the following; a. Grasp the gait belt. b. Stand with feet apart to provide a broad base of support. c. Extend one leg forward, and let the patient slide against the leg to the floor. d. Bend knees and lower body as the patient slides to the floor. 14. Teach the patient specific safety measures to prevent falls (e.g., wearing well-fitting, flat footwear with nonskid soles, dangling feet for a few minutes before standing, walking slowly, and asking for help if dizzy or weak). Dangling provides adjustment to orthostatic hypotension, allowing blood pressure to stabilize before ambulating. 15. If available, offer a hip protector to patients who are fearful of falling. Hip protectors reduce the fear of falling in community-living older adults. 16. Ensure that the ambulatory patient's pathway to the bathroom facilities is clear. 17. If possible, provide adequate, non-glare lighting throughout the room. Have a nightlight in the room. Glare creates a major visual problem for older adults. Non-glare lighting reduces the likelihood of bumping into or falling over objects. 18. Remove unnecessary objects or equipment from the room. Eliminating unnecessary objects or equipment reduces trip hazards when the patient gets out of bed or ambulates. 19. If needed, consider consulting with a physical therapist about the possibility of gait training and muscle-strengthening exercise. Gait and exercise training improve balance and strength and are effective interventions among older adults at risk for falling. 20. As appropriate, discuss with the practitioner the possibility of adjusting the number of medications the patient is taking to reduce side effects and interactions. Sometimes the number of medications a patient receives can be safely reduced by balancing the benefits of the medications and risks for adverse events. 21. Ensure safe transport when the patient is in a wheelchair. a. During transfer, position the wheelchair on the same side of the bed as the patient's strong or unaffected side to assist in transferring to the chair. b. Place a wedge cushion in the chair to help prevent the patient from slipping out of the chair. c. Securely lock the brakes on both wheels when transferring the patient into or out of a wheelchair. d. Raise the foot plates before transfer; lower the foot plates and place the patient's feet on them after the patient is seated. e. Have the patient sit with buttocks well back in seat. Patient may benefit from a quick-release seat belt. f. Back the wheelchair into and out of elevators and doors, leading with large rear wheels first to prevent the smaller front wheels from catching in the crack between elevator and floor, causing the chair to tip. 22. Perform hand hygiene. 23. Document the procedure in the patient's record. MONITORING AND CARE 1. Conduct hourly rounds. Hourly rounds is a universal precaution against falls and other events and allows the nurse to monitor the patient for ongoing risks for falls. 2. Observe the patient's immediate environment for presence of hazards and resolve problems as necessary.

3. Evaluate the patient's ability to use assistive devices. 4. Ask the patient or family member to identify safety risks. Having the patient or family member verbalize perceived safety risks allows the nurse to assess the patient's or family member's understanding. 5. Reassess motor, sensory, and cognitive status. Determine the need for increased measures and interventions to prevent another fall. 6. Report the patient's specific safety risks to other health care personnel and measures taken to minimize these risks. DOCUMENTATION Risk assessment findings and specific interventions (including instructions) Specific information if the patient suffers a fall (i.e., what occurred, including description of the fall as given by the patient or a witness). Include: o Baseline assessment o Any injuries noted o Tests or treatments given o Follow-up care o Additional safety precautions taken after the fall Patient and family education Notification of practitioner should a fall occur Create a separate policy or institution-based incident report should a fall occur. Do not document the incident report in the patient's medical record. REFERENCES 1. Brown, T. (2011). Chapter 27: Pediatric variation of nursing interventions. In M.J. Hockenberry, D. Wilson (Eds.). Wong's nursing care of infants and children (9th ed., pp. 998-1051). St. Louis: Mosby. 2. Centers for Disease and Control and Prevention (CDC). (2012). Falls among older adults: An overview. Retrieved on February 29, 2012 from http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html (Level VII) 3. Centers for Disease and Control and Prevention (CDC). (2012). Falls older adults. Retrieved on February 23, 2012 from http://www.cdc.gov/homeandrecreationalsafety/falls/index.html (Level VII) 4. Digby, R., Bloomer, M., Howard, T. (2011). Improving call bell response times. Nursing Older People, 23(6), 22-27. (Level I) 5. Greenspan, A.I. and others. (2007). Tai chi and perceived health status in older adults who are transitionally frail: A randomized control trial. Physical Therapy, 87(5), 525-535. doi:10.2522/ptj.20050378 6. Healey, F. and others. (2008). The effect of bedrails on falls and injury: A systematic review of clinical studies. Age and Aging, 37(4), 368-378. doi:10.1093/ageing/afn112 (Level I) 7. Joint Commission, The. (2012). National Patient Safety Goals effective January 2, 2012. NPSG 09.02.01: Reduce the risk of falls. Retrieved on February 15, 2012 from http://www.jointcommission.org/assets/1/6/npsg_chapter_jan2012_lt2.pdf (Level VII)

8. Lake, E.T. and others. (2010). Patient falls: Association with hospital Magnet status and nursing unit status. Research in Nursing & Health, 33(5), 413-425. doi:10.1002/nur.20399 (Level II) 9. Maciaszek, J. and others. (2007). Effect of tai chi on body balance: Randomized controlled trial in men with osteopenia or osteoporosis. The American Journal of Chinese Medicine, 35(1), 1-9. doi:10.1142/s0192415x07004564 (Level II) 10. Mathias, S., Nayak, U.S., Isaacs, B. (1986). Balance in elderly patients: The "get-up and go" test. Archives of Physical Medicine and Rehabilitation, 67(6), 387-389. (classic reference)* 11. Orr, M.E., Travikoff, D. (2011). Implementing fall prevention plans. Retrieved on February 23, 2012 from http://web/ebscohost.com/nrc 12. Perry, A.G., Potter, P.A. (2010). Clinical nursing skills & techniques (7th ed.). St. Louis: Mosby. 13. Rutledge, D.N., Travikoff, D. (2011). Restraints: Minimizing use in skilled nursing facilities. Retrieved on February 23, 2012 from http://web/ebscohost.com/nrc 14. Studer Group. (2012). Hourly rounding. Retrieved on March 2, 2012 from http://www.studergroup.com/mh6 15. Tinetti, M.E. (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348(1), 42-49. doi:10.1056/nejmcp020719 (classic reference)* 16. U.S. Department of Veterans Affairs. (2009), VHA NCPS fall prevention and management. Morse fall scale. Retrieved on October 2, 2012 from http://www.patientsafety.gov/cogaids/fallprevention/index.html#page=page-4 17. Zijlstra, G.A. and others. (2007). Interventions to reduce fear of falling in communityliving older people: A systematic review. Journal of the American Geriatric Society, 55(4), 603-615. (Level I) doi:10.1111/j.1532-5415.2007.01148.x