FALLS CARE PATHWAY ALGORITHM ASSESSMENT & MANAGEMENT OF PATIENT AT RISK OF FALLS. Yes Gait/Balance Problem

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1 1 atient ame: HS umber: FLLS CRE HWY IC DEFIIIO his IC is intended as a guide in providing care for the patient and their family. his multidisciplinary document will work in conjunction with standard documentation. rofessionals are encouraged to exercise their own professional judgement, however any alteration to the practice identified within this IC must be recorded. If appropriate, patients can come off the pathway. Overall Objectives of this care pathway Older people present following a fall (or a collapse) for many reasons. he aim of this pathway is to determine how and why the fall occurred, what were the consequences, and assess how the risk of further falls can be reduced. Healthcare professionals should use their clinical judgement and consult with patients when applying the recommendations, which aim at reducing the negative physical, social and financial impact of falling (ICE Guidelines). he HS, working in partnership with borough councils, takes action to prevent falls and reduce resultant fractures or other injuries in their population of older people. (SF) LGORIH SSESSE & GEE OF IE RISK OF FLLS Recurrent Falls and/or Falls risk score >5 Check for Gait/Balance roblem Yes Gait/Balance roblem Commence Falls Care athway o roblem Identified Single Fall o Intervention *ote: he Falls athway can be commenced by all members of the D at any time during the patient s admission, e.g. if a patient is medically unstable on admission they may become appropriate for the pathway at a later stage. lease ensure ame, Designation and completed in admission document before writing in this IC. Issue Date: / Review date: Version: ilot 3 Fundamentals of Care (2003), Royal arsden Hospital anual of Clinical ursing rocedures (2008), Roper-Logan-ierney odel of ursing (2000), Effective rehabilitation for older

2 2 atient ame: HS umber: roubleshooting Guidance atient has Fallen If Loss of Consciousness contact Doctor to ssess IEDIE CIO - Check for Injury - Complete check of Vital Signs & euro Obs Injury Sustained o Significant Injury anage as appropriate, contact Doctor to ssess and inform relatives anage as appropriate and inform relatives Complete IR1 Form and include the following additional details: - Location of fall - Reason for fall Commence Falls athway (if not already in use) Issue Date: / Review date: Version: ilot 3 Fundamentals of Care (2003), Royal arsden Hospital anual of Clinical ursing rocedures (2008), Roper-Logan-ierney odel of ursing (2000), Effective rehabilitation for older

3 FLLS CRE HWY 3 atient ame: HS umber: ROBLES IDEIFIED ROBLE & EED IDEIFIED atient is at risk of falling. Individual roblem and eed: ED SSOCIE URSE DE & IE GOL SEES GOL SEES o reduce the risk of falling. o provide appropriate management of falls. o ensure the Hospital Environment as safe as possible. Individual roblem and eed: DE & IE GUIDELIES Guidelines for completion of this Care lan: age Section itle Guidance on completion g 1 IC Objectives Objectives and algorithm for management of patients at risk of falls. g 2 roubleshooting Guidance - if patient has a fall on the ward. g 3 roblems & Goals o be completed by Registered urse commencing plan. g 4 Interventions o be completed by Registered urse. his section should be completed in full on Day 1 and all individualised needs written in detail, i.e. patient needs help with What? When? and How? *ote: minimal assistance should not be written. g 5 rogress Chart ll staff (each shift) should refer to the details contained in the care pathway (g 3 & 4) and complete the progress chart by inserting for et, X for Unmet or / for ot pplicable. ny action recorded as Unmet must be reported in the variance reporting section (g 6). g 6 Variance Reporting his section is for all staff to record variances. If Fall occurs detail as a variance. g 7 rogress otes his section is for staff to record progress and details of any individual needs. USE O DOCUE COUICIO WIH IE / CRER / RELIVE ll ages Outcome easure lease use the following Level of Independence Score to document patient progress at the end of each week. Outcome easure / Level of Independence Score: 1 = requiring the help of two or more persons 2 = requiring maximum help of one person 3 = requiring moderate help of one person 4 = requiring minimum help of one person 5 = fully independent Ref: Effective rehabilitation for older people. Eshun (1999) Issue Date: / Review date: Version: ilot 3 Fundamentals of Care (2003), Royal arsden Hospital anual of Clinical ursing rocedures (2008), Roper-Logan-ierney odel of ursing (2000), Effective rehabilitation for older

4 Variance Code F (a) (b) (c) (a) (b) (c) (a) (b) FLLS CRE HWY IERVEIOS IERVEIO Falls History & Risk ssessment Completed Risk Score on Initial ssessment: Identify patient at risk by inserting Falls Risk Card on current admission file Give assistance as stated at patient s pace enabling independence as far as possible. Referrals: hysiotherapist Occupational herapist ssess need for referral to other specialist as indicated, e.g. pharmacy, podiatry, optometry, social worker, etc rior to discharge: Referral to falls programme/s, home hazard assessment, follow up, etc. Follow Up with whom: Date: atients in the most appropriate position on the ward, i.e., close proximity to the bathroom & nurses station. Ensure close observation of patients in an appropriate area. Intentional rounding of patient by named staff, particularly where patient has high falls score and is confused / demented. Environmental rounding - Ensure that: - atient s call bell is at hand and responded to promptly when rung. - Bed space is as clutter free as possible. - Belongings, food and water are in proximity. ssess the use of footwear. Ensure that appropriate footwear is brought in for the patient. If this is not possible and foam footwear is used, ensure that these are of the correct size and in good condition. Leave bed in low position when patient is unattended. Use a chair, of appropriate height for the individual (Hips should be flexed at 90 and feet should be flat on the floor) Ensure that a bed rails assessment is completed and use if applicable and not detrimental to patient safety. If indicated record and monitor pt's lying and standing B if pt B drops more than 20mm HG inform medical Staff, if fall attributed to fluctuations in B. atient/carer educated regarding, risk of falls, falls prevention strategies, etc. If appropriate explain to the patient the importance of asking for help when walking. atient information leaflets provided i.e. Slips, trips, & falls, osteoporosis, postural hypotension, dietetics, etc amed ssociate urse Review of care plan. atient ame: HS umber: Issue Date: / Review date: Version: ilot 3 Fundamentals of Care (2003), Royal arsden Hospital anual of Clinical ursing rocedures (2008), Roper-Logan-ierney odel of ursing (2000), Effective rehabilitation for older 4 Level of independence score: rior to admission to hospital: Day 1 of this Care lan: CIO KE / COES dd appropriate details to ensure individualised care. Falls Risk Reassessed and recorded on chart hysio - Date:. O - Date:. harmacist Date:.. Other, please state: rior to Discharge: Day Hospital Where: Falls Clinic Sure Feet elecare Home Hazard ssessment Bed Rails: Yes / ppropriate Care lans initiated obility Date:. Continence Date:. Discussed with atient Discussed with Carer / Relative ame: Wk 1 - Date:../../.. Sign: Wk 2 - Date:../../.. Sign: Wk 3 - Date:../../.. Sign: Wk 4 - Date:../../.. Sign: DE & IE

5 Indicate: et FLLS CRE HWY rogress Chart: Weeks atient ame: HS umber: his chart is to record the ongoing assessment and management of the atients care plan as outlined on page 3 & 4. lease ensure each shift inserts the date and the initials of the staff member completing the interventions. If an intervention outlined in the Care lan has not, for whatever reason, been completed then this must be marked as unmet (X) and detailed in the variance reporting section pg 6. Some interventions can be determined as ot pplicable and documented by inserting / in the appropriate box. WEEK 1 ot pplicable / IIILS DY Day 1. Day 2. Day 3. Day 4. Day 5. Day 6. Day 7. SHIF ED OF WEEK 1 LEVEL OF IDEEDECE SCORE: Falls Risk Reassessed Score: ction aken / Document in rogress otes Indicate: et WEEK 2 ot pplicable / IIILS Indicate: et WEEK 3 ot pplicable / IIILS Indicate: et WEEK 4 ot pplicable / IIILS ED OF WEEK 2 LEVEL OF IDEEDECE SCORE: Falls Risk Reassessed Score: ction aken / Document in rogress otes ED OF WEEK 3 LEVEL OF IDEEDECE SCORE: Falls Risk Reassessed Score: ction aken / Document in rogress otes ED OF WEEK 4 LEVEL OF IDEEDECE SCORE: Falls Risk Reassessed Score: ction aken / Document in rogress otes Issue Date: / Review date: Version: ilot 3 Fundamentals of Care (2003), Royal arsden Hospital anual of Clinical ursing rocedures (2008), Roper-Logan-ierney odel of ursing (2000), Effective rehabilitation for older

6 FLLS CRE HWY VRICE REORIG VRICE CODE 6 atient ame: HS umber: If Fall occurs detail as a variance below, including details of how, where, when and action taken. (complete IR1 where required) RESO/CIO KE/COES DE & IE Issue Date: / Review date: Version: ilot 3 Fundamentals of Care (2003), Royal arsden Hospital anual of Clinical ursing rocedures (2008), Roper-Logan-ierney odel of ursing (2000), Effective rehabilitation for older

7 FLLS CRE HWY 7 atient ame: HS umber: ROGRESS OES LESE DOCUE COUICIO WIH IE / CRER / RELIVE RESO/CIO/COES DE & IE Issue Date: / Review date: Version: ilot 3 Fundamentals of Care (2003), Royal arsden Hospital anual of Clinical ursing rocedures (2008), Roper-Logan-ierney odel of ursing (2000), Effective rehabilitation for older