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5.17 – Fall Prevention and Procedures

Fall assessment and prevention are an integral part of the care process.  A fall is usually an interaction between an extrinsic (environmental) factor such as a slippery floor and an intrinsic (individual-related) factor, such as poor vision or gait problems.  Managing the risk of falling requires identifying both types of factors that contribute to fall risks in order to eliminate or minimize the risks while maximizing each individual’s independence and quality of life.

Falls may result in serious physical injuries such as fractures and head trauma.  Even though most individual falls do not result in serious physical injuries, falls can have serious consequences such as:  a loss of confidence in independent mobility, loss of self-esteem, depression, helplessness, social isolation, functional decline and increased risk of subsequent falls.   

The goal of this program is to enhance each individual’s mobility and encourage independence by removing the risk of falls where possible and reducing both the incidence of falls and the injuries that may accompany falls.

Policy

It is the policy of this facility to provide the highest quality care in the safest environment for the individuals residing in the facility.  The program identifies the factors that place individuals at risk for falls, promotes proactive healthcare practices for individual care planning using the least restrictive method possible to keep the individual safe and identifies the main components of an effective fall prevention program.  These components include fall risk assessment, identifying risk factors, implementing interventions, documentation, evaluation, regular reassessment and re-evaluation.

Interdisciplinary Team Policy

This facility has formed and will maintain an Interdisciplinary Team that actively meets to ensure there is an ongoing process to assess, monitor, identify outcomes, plan, implement and evaluate the fall prevention process. 

The Interdisciplinary Team will be notified of all falls and will be responsible for:

  • Review record of each individual who has fallen.
  • Review interventions based on identified reason for the fall.
  • Review effectiveness of interventions and individual response.
  • Review assessments of new individuals who have been identified as at risk for a fall.  Review care plan for appropriateness.
  • Complete fall assessments at least quarterly and develop action plans as needed.
  • Identify training needs of the staff.
  • The Fall Prevention Program is based upon a multidisciplinary team approach to fall prevention.  Success in reducing falls depends upon the expertise and cooperation from staff in administration, nursing, rehabilitation, and maintenance.

The Fall Prevention Program is based upon a multidisciplinary team approach to fall prevention.  Success in reducing falls depends upon the expertise and cooperation from staff in administration, nursing, rehabilitation, and maintenance.

Definition

A fall is a sudden unanticipated change in body position in a downward motion that may or may not result in a physical injury. 

For the purpose of evaluating fall risks and need for assessment and interventions or modification of the plan of care, the following constitutes a “fall”.

  • Found on the floor
  • States they fell
  • Witnessed fall, slip, or trip
  • Slides to the floor assisted or unassisted
  • Eased to floor assisted or unassisted
  • Rolls or slides off bed or chair onto the floor
  • Falls off or out of any equipment (including an apparatus used for therapy or transfer)
Assessment

All individuals will be assessed for falls.  Use the Fall Risk Assessment Form:

  • On admission within 24 hours
  • At least quarterly after admission
  • After pattern/trend of more than three falls identified by SRSR meeting
  • When team recommends

Individuals identified “at risk” for falls

  • Will be added to an “at risk” list when the:
    • Individual’s score on the Fall Risk Assessment Form is 10 or greater.
    • Individual experiences a fall with injury or more than three falls within a quarter time frame
  • Any individual “at risk” will have fall interventions placed on the individual care plan.  Document individual’s response to the interventions and alter interventions if not successful.  Possible risk factors and interventions include but are not limited to those listed below.
Intrinsic or Internal Risk Factors

Related to the individual; may be chronic or transient; may include cognitive impairment, age-related physiologic changes, medical conditions, certain medications, etc. Factors include:

  • Individual’s state of mind:
    • Confusion, distraction, agitation, lack of awareness, impaired judgment
    • Dementia
    • Fear, anxiety, depression
    • Unwillingness to accept physical limitations and assistance with certain tasks
  • Normal Aging
  • Auditory-Vestibular: Decreased peripheral vestibular excitability that affect spatial orientation at rest and during movement
  • Balance: Decreased sensory proprioception
  • Cardiovascular:
    • Decreased cerebral blood flow
    • Change in volume and sodium regulation that control blood pressure
  • Gait: Walk slower with reduced stride, decreased toe-floor clearance, and decreased arm swing and hip and knee rotation
  • Musculoskeletal:
    • Decreased lower extremity strength
    • Postural changes – kyphosis
    • Deterioration of cartilage of hips and knees
  • Nervous System:
    • Slower reaction time
    • Increased postural sway
    • Impaired righting reflexes
  • Vision:
    • Decreased visual acuity
    • Decreased depth perception
    • Decreased contrast sensitivity
    • Decreased color sensitivity
    • Decreased visual field
    • Decreased light sensitivity
    • Decreased adaptation to darkness
    • Decreased peripheral vision
    • Decreased glare tolerance
  • Medical Conditions
    • Cardiovascular conditions:
      • Orthostatic hypotension
      • Fluid volume depletion
      • Syncope
      • Dysrhythmia
    • Metabolic conditions:
      • Hypothyroidism
      • Hypoglycemia
      • Electrolyte imbalances
      • Diabetes Mellitus
    • Muscular skeletal diseases:
      • Arthritic conditions
      • Osteoporosis
      • Foot deformities
      • Recent fractures
    • Neurological diseases:
      • Stroke with hemiparesis
      • Parkinson’s disease
      • Dementia
      • Peripheral neuropathies
    • Miscellaneous
      • Vertigo or Dizziness
      • Incontinence, nocturia
      • Urinary tract infections
  • Medications:
    • Types
      • Sedatives, antidepressants, antianxiety medications, long-acting psychotropic
      • Diuretics and antihypertensive agents
      • Anticoagulants, Antiepileptics, Anti-Parkinsonian agents, Narcotic analgesics, Non-steroidal anti-flammatory agents, Vasodilators
      • Alcohol, aspirin, tobacco
    • Examples:
      • Anti-Diabetic – stimulates insulin release from the pancreatic cells
        • Examples:  Glipizide, Glyburide, Insulin’s
        • Side effects:
        • Hypoglycemia
        • Nausea
        • Fatigue
      • Antipsychotics – given with behavioral symptoms related to dementia, psychoses or other psychiatric disorders
        • Examples:  Mellaril, Haldol
        • Side effects:
          • Postural hypotension – drops in BP, dizziness
          • Over sedation, confusion, drowsiness
          • Tardive dyskinesia – involuntary movement
          • Akathisia – extreme desire to move, pacing
          • Parkinson’s – tremor, gait disturbance
          • Anticholinergic effects – blurred vision,  urinary retention, disorientation, hallucinations, assault
        • Alternatives:  behavior management plan
      • Benzodiazepines – used to reduce anxiety and aid sleep
        • Examples:  Ativan, Halcion, Valium, Librium, Dalmane
        • Side effects: 
          • Decreased alertness
          • Drowsiness
          • Confusion
          • Slowed reaction time
          • Unsteadiness
          • Gait disturbance
        • Alternatives:  sleep hygiene measures to reduce need for drug; behavior management skills for agitation.
      • Diuretics – promote diuresis by decreasing rate at which sodium & chloride are reabsorbed
        • Examples:  Furosemide, Chlorothiazide
        • Side effects:
          1. Hypovolemia
          2. Orthostatic Hypotension
          3. Electrolyte imbalance
          4. Urinary incontinence
Extrinsic or External Risk Factors

Definition:  related to the environment; may include:

  • Broken bed or chair wheel locks
  • Clutter
  • Electrical cords in pathway
  • Inadequate lighting
  • Inappropriate footwear (soft-cushion soles or ill-fitting shoes)
  • Inappropriate fit or condition of assistive devices
  • Hard-to-reach personal items or inaccessible shelves
  • Lack of handrails in halls and bathrooms
  • Low chairs or soft chairs
  • Low toilet seats
  • Mechanical restraints – Limiting freedom of movement and personal autonomy has been known to result in deconditioning and muscle atrophy that can increase functional decline
  • Throw rugs and loose carpet
  • Uneven floors, raised thresholds
  • Wet or slippery floors
Interventions for Intrinsic (Individual-related) Factors
  • Hand clenching and ankle dorsiflexion exercises performed before standing
  • Therapy
  • Pain management
  • Physical therapy or exercise program that includes balance and gait training
  • Offer frequent toileting (at least every 2 hours) or follow individualized toileting schedule, if appropriate
  • Restorative program to improve mobility, lower extremity strengthening and/or coordination
    • Specialized and individualized activities
    • Implementing special hobbies
    • Supervised walking program
    • Seated balance exercise training
  • Surgery if the falls are due to osteoarthritis
  • Training in the use of canes and walkers
  • Vision evaluation and correction
  • Monitor and eliminate or reduce medications when appropriate. 
    • Consult physician, Medical Director, Pharmacy Consultant
    • What medications is the individual taking?
      • How many medications is the individual taking?  The larger the number of medications the higher the risk for falls.
      • Are antidepressants, hypnotics, anxiolytics, antipsychotics, antihypertensives or diuretics being used?
      • Can the medication program be modified (e.g., lowering doses) or can medications that are associated with fall risk be eliminated?
      • Can a different type of drug be used such as the use of dopaminergic drugs for Parkinson’s disease?
Interventions for Extrinsic (Environment-related) Factors
  • Bathrooms
    • Secure commode extenders
    • Secure grab bars by commodes, in the tubs and/or showers and insure they are at an appropriate level
    • Keep call bell within easy reach from commode, shower and tub
    • Use nonskid mats in tubs or showers if they are not otherwise equipped with slip-proof bottoms
  • Beds
    • Repair or replace broken bed wheel locks
    • Keep bed wheels locked
    • Check bed rails to make sure they operate properly and latch securely.
    • Use side rails appropriately
    • Consider using half length side rails
    • Controls for the bed should operate properly to control bed height and positions of the head and foot of the bed
    • Keep bed at appropriate height for transfers
      • When lifting or transferring individuals, NEVER leave individuals alone before the procedure is complete.
      • Do not leave a individual sitting on the edge of the bed
      • After giving care to a individual in bed
        • Make sure side rails are in proper position for the specific individual. 
        • The call bell must be placed within the individual’s reach
        • The bed must be at the lowest level.
    • Use a firm mattress
  • Clutter
    • Occupied individual’s rooms are cleaned and put in order daily
    • Keep at least a 2 foot wide clear path around bed and to bathroom and lounge chair
    • Remove cords from walking area
    • Remove unused equipment and items from room and bathroom
    • Anytime anyone sees trash on the floor or in the stairways, that person picks it up.  Discard trash in the proper container.
  • Devices
    • Alarms/Motion sensors
      • Bed alert
      • Chair alert
    • Seating items, lap buddy, roll belt
    • Check for proper positioning in wheelchair, including use of wedges, etc.
    • Raised toilet seats
    • Low beds
    • Floor/landing mats
    • Activity boxes
    • Hip protectors, safety helmets
    • Monitors
  • Equipment
    • Scheduled regular maintenance of wheelchairs, walkers, canes
      • Canes & walkers must have rubber tips on all parts that touch the floor
      • Wheelchairs should be in good working order with footrests that can be raised and lowered.
      • The wheel brakes should keep the chair from moving as the individual is transferred in and out of the chair
    • Replace or repair broken equipment as a priority.
    • Assess ambulatory assistive devised for the correct “fit” PRN.
    • Label individual’s personal equipment with their name and instruct staff, visitors and individuals to use only their equipment.  Do not share equipment among individuals.
    • When replacing equipment neither lowest price nor highest price guarantees the best for the money.  Advise is obtained from the therapy department; a variety of vendors, and other facilities about their experiences and recommendations.
    • All call bells must be in working order.  The system is tested monthly to be sure the individual can call for help in an emergency.
  • Floors
    • All staff are responsible for cleaning up spills immediately.  Floors must be kept dry at all times.
    • Contrast between different floor coverings are reduced
    • Thresholds that were higher than ½” have been removed or lowered
    • Decrease cluttered pathways
    • Carpet edges are kept tacked down and transitions between floor coverings smooth and even.
    • Broken or missing tiles and linoleum are replaced immediately
    • All floors are kept clear of rugs, towels, bedding and clothing
    • Foot stools and other small equipment are stored until needed and put away again
  • All footwear should be
    • Non-skid
    • Well-fitting, in good condition, and provide adequate support
    • Shoes with Velcro instead of laces making it easier for individuals to slip them on and off and to prevent tripping on laces
    • Labeled for each individual
    • Available
    • Worn at all times
    • Gripper socks may be worn to bed or at other times
  • Furniture
    • Make all furniture stable
    • Keep bedside table accessible from bed
  • Lighting
    • Replace burned out or flickering bulbs immediately
    • Use appropriate amount of light and full wattage bulbs
    • Use night-lights
    • Light hallways and stairs well
    • Reduce glare by using lampshades and frosted light bulbs
    • Make light switches and cords easily accessible for all individuals
    • A durable non-glare reading light is securely mounted to the wall, integrally wired with a switch within reach of the individual in bed.
  • Miscellaneous
    • Use clothing that is easy for individual to put on or pull up
    • Ensure glasses are clean and hearing aides are working properly
    • Instruct staff to perform frequent safety checks of rooms, hallways and common areas to decrease physical hazards and obstacles
    • Keep halls, stairways, and walkways clean, dry, and free of obstacles.
      • Linen carts, laundry hampers, and individual equipment should be kept out of the way.
      • Halls and doorways must be clear of obstacles
      • Never block the door to an exit or stairway.
    • All individual-use corridors have handrails on each side of the corridors
Other Interventions
  • Place individual in view of staff when out of bed
  • Keep personal belongings and fluids within reach; provide walker or wheelchair storage pockets.
  • Education program for individual and staff about safety, sitting, standing, locking brakes on wheelchair before standing, etc.
In the Event of a Fall

Policy: All falls will be documented on an incident report and reported to incident hotline and nurse.  Individuals will be assessed and care planned by team to prevent repeat falls or falls resulting in an injury.  If there are any questions regarding the details of a fall, the fall will be investigated.

All falls will be tracked and trended on a monthly basis using the Incident Monthly Trackingand Monthly Accident/Incident Analysis.  Data is to be evaluated by the Interdisciplinary team.  Data will be reviewed monthly during the UI Review. 

  • When a individual is falling and a staff member is beside the individual, the staff member should give the individual support by:
    • Easing him/her to the floor by grasping the individual’s clothes or the gait belt if the individual was being walked
    • Allow the individual to slide down your leg so that you can control the direction of the fall
    • Try to protect the individual’s head
    • Call a nurse to immediately assess the individual for injury
  • Immediate action
    • When a individual falls or is found on the floor
      • Do not move the individual
      • Do not place anything under the head
      • Call for assistance.  Do not leave the individual alone.
      • Cover with a blanket to keep warm and provide dignity, if needed.
    • The nurse will immediately assess the individual for injury. 
      • If indicated, a Neurological check: pupils-orientation-tremors-response to stimuli.  Use the Nurses’ Neurological Check Form.
      • Check blood pressure
      • Skin & wound check
      • Pain assessment, verbally and visually.
      • If emergency intervention is indicated:
        • Call ambulance
        • Notify guardian
        • Have staff member stay with individual and continue to monitor condition
        • If there is indication of pain or trauma, leave individual where found until EMS arrives
        • Call emergency room to notify them that individual is coming for evaluation
        • Complete transfer form and place in transfer folder to send with individual
      • Contact physician and document contact and response.  Follow physician’s orders.
    • Provide appropriate treatment for the injury and prevent complications.
    • Monitor individual neuro checks if indicated by potential head injury.
    • Monitor individual for signs and symptoms of pain
    • Notify physician immediately if pain is present or develops
    • Call Incident Hotline-document incident report
  • Investigation of the fall
    • Review physical assessment of the individual immediately after the fall, such as individual’s mobility, blood pressure
    • Review individual’s history and habits based on prior assessments or observations
    • Assess the location where the individual was found
    • Assess environmental conditions (lighting, wet floor, time of day, etc)
    • Assess information about the individual’s condition (spell of illness, lightheadedness or weakness, etc.)
    • Does the individual have any unmet needs that led to the fall?
      • What are the needs?
      • How can they be addressed in order to reduce the risk of future falls?
    • What do the individual and witnesses say concerning the circumstances of the incident?
    • If no one saw the accident/incident, document what you see.  Do not assume what happened.  If individual is capable of telling you what happened, document “Individual states…..”
    • Documentation of preventative measures that have been taken must also be documented in the medical record and on the care plan.
    • The determination of whether or not a individual is placed on the “at risk” list will be based on the fall risk assessment, the physical assessment of the individual, and an investigation of the facts surrounding the incident.
    • The above investigation will be documented in the medical record at the time of the fall
    • All documents are analyzed to determine patterns, trends, casual factors which will be used as the basis for improving these fall policies and procedures and set up special in-service training as necessary.
    • Assure that immediate interventions are in place.
    • Assure that care plan has been updated.
  • Individuals who experience multiple falls regardless of interventions and are subjected to possible injury may be evaluated and assessed for a least-restrictive device.  Both physical restraints and limiting ambulation in an effort to prevent falls may actually worsen lower extremity weakness and increase the risk of falls.   
    • If the fall team feels this is necessary to protect the individual from injury, the physician will be notified, the family will be contacted and the concern discussed with the individual, if appropriate. 
    • All standard restraint policies and procedures will be followed.
  • Personal alarm devices will be used as deemed necessary by the fall prevention team.  Personal alarms are used based on the fall risk assessment and may be used as an emergency measure by the nurse or supervisor in order to keep the individual safe until the team evaluates the individual through Human Rights/Behavior support polls.
Performance Improvement
  • All falls will be tracked and trended on a monthly basis. 
    • Data will be reviewed at UI review  
  • Data will be analyzed for total number of falls, patterns/repeat falls, trends and causal factors. 
  • Data will be used to improve care plans
  • Data will be used to improve this fall risk management program
  • Set measurable goals and objectives for care in the context of individual wishes and advanced directives. 
  • Document individual’s response to interventions and alter interventions if not successful.
In-Service
  • All new hires are educated in the program as part of their orientation
  • All staff are in-serviced to the Fall Prevention Program at a minimum
  • Include staff training on transferring skills and strategies to improve individuals’ gait, balance and strength.
  • Interim in-service is provided, as needed, based on frequency and severity of the fall

Last Revised: 6/8/21

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