Consultant Nurse, Nursing Documentation Group. Practice Development Matron

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1 Falls Prevention Toolkit- Section 2 FALLS ASSESSMENTS and CHECKLISTS 3 rd edition September 2015 Review: September 2018 Principal Authors: Rob Morris Karen King Ellen McMahon Beverley Brady Pathway Lead Clinician for Older people Matron Additional contributors: Fiona Branch Emma Grace Faye O Callaghan Kathryn Draper Keith Knox James Saxton Dave Allen Nicola Fountain Nicky Lindley Abbie Betts Consultant Nurse, Nursing Documentation Group Senior Pharmacist Datix manager Information Support Officer Patient Safety Administrator Matron, Patient Safety Medstrom Clinical Nurse Specialist Section Content Page Section 2 Falls Assessments and Checklists Process Flow Diagram for Falls Risk Assessment and Care Planning 2 The Adult Falls Flow Chart 3 Red ( high falls risk) checklist 4 Amber ( medium) checklist 5 The AMTS Score and how to score it 6 The AMTS Template 7 Falls Specific Environment Audit Checklists 8 Falls Prevention Toolkit 3 rd Edition September Section 2 FALLS ASSESSMENTS and CHECKLISTS Page 1

2 Adult Falls Flow Chart and Planning of Care Process Falls Prevention Toolkit 3 rd Edition September Section 2 FALLS ASSESSMENTS and CHECKLISTS Page 2

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6 The AMTS Score and How to Use it The Abbreviated Mental Test Score (otherwise called the AMTS) is a very quick and easy way to assess a patient s level of confusion and their ability to understand and remember. It can be carried out by any member of the medical ream or a registered nurse. To complete an AMTS, the patients are asked the questions set out below. For each correct answer they score 1 point. At the end of the test the patient will have a score out of 10. A score of fewer than 6 is a crude indicator of cognitive impairment Delirium and/or dementia). A positive result in the AMTS should then lead to the completion of the High Risk Delirium Care Checklist. These will include a toileting regime and cohort nursing or 1:1 supervision depending on the individual needs of the patient. The medical team must be made aware of any patient scoring 6 or less and should prompt thorough medical review. The AMTS is often performed by the medical team and documented in the medical clerking on admission. If this has been carried out, please transfer the score to the nursing assessment booklet, so a comparison can be made easily with any future scores. If the patient appears to change condition, e.g. they are more confused (potentially delirious) please repeat the test and document the score in the AMTS chart (in the nursing assessment) The AMTS Questions and respective answers are as follows: Age this is the patient s age and they must reply correctly. Time- the patient needs to be able to tell the time to the nearest hour without using a watch or clock. 42 West Street - give this address and the patient needs to be able to repeat it back immediately (this will test their ability to register new information). You need to tell them that you would like them to remember the address for later. Month - the patient must be able to tell you the current month Year - the patient must be able to tell you the current year Name of Place - the patient should be able to tell you that they are currently in hospital or if you are phrasing it as where are you? they should be able to tell you they are in Nottingham. Date of Birth - the patient should be able to tell you their exact date of birth. Start of World Ward 1or 2- the patient should be able to tell you that World War 1 started in 1914 or World War 2 started in 1939 ( whichever is being used). Name of the current monarch - the patient should be able to tell you the name of the current Queen/King. Counting backward - the patient should be able to count backwards from 20-1 without any problems. Recall of address - the patient should be able to tell you the address previous given i.e. 42 West Street. The patient will score one point for each correct answer. Falls Prevention Toolkit 3 rd Edition September Section 2 FALLS ASSESSMENTS and CHECKLISTS Page 6

7 Ten Point Mental Test Score (AMTS) Must be interpreted with caution if there are problems with communication Affix Patient label here Patient name Hospital Number Date of birth. Date of Assessment AGE Must be correct TIME Without looking at a watch or clock & correct to the nearest hour 42 West Street Give this address (or similar). Ask patient to repeat it immediately (registration) and test recall at end of procedure MONTH Exact YEAR Exact NAME OF PLACE If not in hospital, can ask type of place or area of town DATE OF BIRTH Exact START OF WORLD WAR I Exact year NAME OF PRESENT MONARCH COUNT FROM 20 TO 1 (Backwards) CHECK RECALL of address Enter score above TOTAL SCORE PROBLEMS WITH COMMUNICATION Does he/she have difficulty being understood or understanding what others say or what they mean? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No PROBLEMS WITH HEARING Difficulty hearing someone talking in a quiet room? PROBLEMS WITH EYESIGHT Difficulty recognising a friend across the road or difficulty reading ordinary newsprint EVEN using glasses/lenses Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No Falls Prevention Toolkit 3 rd Edition September Section 2 FALLS ASSESSMENTS and CHECKLISTS Page 7

8 Falls Environmental Audit Checklists Areas Yes No N/A Actions/Comments These checks to be completed monthly Are all floors in good condition and good state of repair? Are all lights working and clean (including night lights)? Does the position of workstations offer clear observation of patients? Do all toilets and bathrooms have visual pictures to identify them? Are there any boxes or objects protruding from walls? Are all toilet and bathroom doors easy to open for patients? Is there a mechanism to open locked toilet doors from the outside? Are there any trailing cables causing trip hazard? Are there any other obvious trip hazards within the ward Are all call bells working? Comments Yes No N/A Action Report any faults via Carillion help Line and monitor to completion Report via Carillion help Line and monitor to completion Log new works request to have Rectify (pictures available on trust falls prevention web page) Check which of the boxes have to remain Log minor new works to have all others removed.complete risk assessment for any remaining Log new works request to have Log new works request to have Remove if able if not review need for additional sockets and action via minor new works request Rectify immediately if able Report via Carillion help Line and monitor to completion - Complete risk assessment if not easily Falls Prevention Toolkit 3 rd Edition September Section 2 FALLS ASSESSMENTS and CHECKLISTS Page 8

9 The following checks to be carried out weekly Checks Yes No N/A Actions Unless care is being carried out are all occupied and unoccupied bed spaces fully visible from the entrance to the bay, with curtains pulled back to their maximum extent. Unless care is being carried out are the curtains kept open overnight Are all bed spaces free from all clutter Is there an active Cohort Bay in use on the ward Is there a cohort poster in a visible prominent position in the cohort bay Is the Cohort Bay being effectively supervised at all times Is the call bell in reach of the at risk patients patient Check all patients identified to be at risk of fall Is there an easily accessible supply of walking aids on the ward (Zimmer frames and walking sticks etc?) And all the staff on the ward know where this is Rectify immediately and offer education to the staff working within one the ward / bay at the time. If this is not possible for any estate reason then log with Carillion help line if not easily rectifiable complete risk assessment Rectify immediately and offer education to the staff working within one the ward / bay at the time. Ensure all patients are aware of the rationale for this. Rectify immediately Obtain poster and rectify If yes to Q and no to Q ten alert the nurse in charge and rectify as a matter of urgency. Offer education to the staff working in the cohort bay/ward at the same time. Rectify immediately Discuss with ward physiotherapist to locate a accessible area to store walking aids Monitor to completion Falls Prevention Toolkit 3 rd Edition September Section 2 FALLS ASSESSMENTS and CHECKLISTS Page 9