Definition of fall any unplanned descent to the floor, assisted or unassisted, with or without injury.

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1 1 Springfield, Illinois Patient Care Policy/Procedure Date: April, 2014 Subject: FALL PREVENTION AND MANAGEMENT: REDUCING HARM Policy: All patients are evaluated for risk of falls by the nurse on admission, daily, and with a change in patient status. Interventions are implemented to reduce fall risk as appropriate. A standardized process for reporting falls and meeting post-fall patient care needs is implemented. Definition of fall any unplanned descent to the floor, assisted or unassisted, with or without injury. Procedure: 1. Assessment A. All adult patients (18 years of age and older) are assessed for fall risk on admission and daily using the Morse Fall Risk Scale. 5A/G patients are assessed using the Edmonson Psychiatric Fall Risk tool. Pediatric patients (under 18 years of age) are assessed using the Humpty Dumpty Falls Scale. B. Additionally, patients are assessed upon transfer to a new nursing unit or with any change in the patient s condition. C. Patients with a Morse Fall Risk Scale Score > 45, Edmonson Psychiatric Fall Risk score > 90, Humpty Dumpty Fall Score > 12, or with a recent history of falls are considered to be high fall risk. D. The nurse caring for the patient may identify a patient at high risk based on nursing judgment, even in the presence of a low fall risk score. E. Risk of injury if the patient is identified to be at risk for fall, the patient is assessed for risk of injury by completing the ABCS Inquiry Risk Assessment Tool.. 2. Fall Prevention Interventions A. The Fall Prevention Plan of Care (POC) [Appendix A] is activated for patients at high risk for falls/injury. This is reviewed each shift and revised based on the patient s condition. B. All patients identified as high fall risk have the Don t Get Up Without Us signage in place (see #3d for pediatric high fall risk patients). C. Fall Prevention Intervention kits (available through Central Supply) include the following items: i. Don t Get Up Without Us door signs to be placed on the doorframe to the patient room ii. Chart stickers to identify high fall/injury risk patients

2 2 iii. TV banners to be posted on/below the TV as a patient/family reminder to not get up without MMC staff assistance. iv. Red non-skid slippers to provide immediate visual identification of high fall/injury risk patients. Patients are encouraged to wear these slippers at all times. v. In certain instances, the RN and Physical Therapist may determine that independent ambulation is an essential component of the patient s plan of care even though the fall risk assessment still indicates high risk. For these patients: a. The change in status and plan of care are explained to the patient and family. b. Red slippers are removed and the patient is provided with regular hospital slippers or instructed to wear footwear from home. c. Don t Get Up Without Us signage is removed. d. The IPOC is updated to document the changes and a note is entered in Significant Events in ClinDoc. e. Bedside report includes an explanation that independent ambulation is being encouraged even though the fall risk assessment indicates high risk. f. The RN and Physical Therapist monitor the patient closely for continued appropriateness of independent ambulation. g. Fall prevention interventions are reinstated if the patient s status declines. D. Quick-release gait belts to be used any time the patient is getting out of the bed or chair. E. For pediatric patients, standard interventions for low fall risk and high fall risk patients have been identified (Appendix B). These interventions are posted on the pediatric unit for easy staff reference. 3. Safety Trumps Privacy signs are posted in all patient bathrooms at all times. A. Patients at high fall risk are continually accompanied when in the bathroom or up to a bedside commode. B. Staff must remain within arm s reach of the patient. 4. Patient/Family Education A. Staff review the Don t Get Up Without Us Fall Prevention Guidelines brochure with the patient/family when the patient is identified as high fall risk. B. Staff will discuss individual fall risk, including the assessment process, specific risk factors, and prevention plans with the patient/family C. Staff instruct at-risk patients to not get up from bed, chair or commode without staff assistance. Families are instructed to not attempt to move patients without staff assistance. 5. Communication A. Fall risk status and treatment plans are communicated in bedside shift handoff report and in interdepartmental handoffs.

3 3 6. Documentation A. The patient s fall risk score is assessed and documented daily on the ClinDoc flowsheet under either the Morse Fall Scale, Edmonson Psychiatric Fall Risk Assessment, or Fall Risk Scale Humpty Dumpty as appropriate. B. At-risk patients are assessed further for risk for injury. Data is documented regarding age, musculoskeletal disorders, bleeding risk and history of surgery. C. The Fall Prevention POC is reviewed each shift and revised as needed based on changing patient condition. 7. Post fall patient management A. Respond to the patient s immediate care needs. i. Complete a full head-to-toe assessment for injuries or areas of pain. ii. If head injury is possible, institute neurological checks every 15 minutes X 1 hr, then every 1hr X 4, then every 4hrs X 4. iii. Return the patient to bed only after fully assessing the patient s condition. Use a total lift device if the patient is unable to get up without assistance. B. Clean and dress any skin lesions/wounds. C. Implement further safety measures as needed and include in the patient s Interdisciplinary Plan of Care. Document interventions in ClinDoc on the Flowsheet. D. Closely watch for changes in the patient s condition for at least 24 hours after the fall. Be particularly attentive to the patients who are receiving or have a recent history of anticoagulant therapy, because of the risk of bleeding. 8. Post-fall reporting A. Notify the patient s physician. i. Report patient assessment data. ii. Make recommendations as necessary for treatment and/or further evaluation i.e. CT scan, wound care. iii. Document and implement telephone orders if received. iv. Notify physician again if patient s condition changes. v. Document notification of physician and whether orders were received in Significant Event section of the ClinDoc flowsheet. B. Notify the patient s family and document notification in the Significant Event section of the ClinDoc flowsheet. C. Complete the Fall Incident report in the SENSOR reporting system. i. Complete as soon as possible after the patient s immediate needs are met. ii. The report is automatically sent to Risk Management, Nurse Manager, and Pharmacy (if medication is involved) and Nursing Outcomes Improvement. D. Document the fall in the Significant Event section of the ClinDoc flowsheet. Include details of the occurrence, the patient s condition, and physician notification. Do NOT document the completion of the Fall Incident Report in the medical record. E. Communicate the incident to fellow caregivers during that shift and to caregivers coming onto the next shift. Also communicate any safety interventions implemented and any need for further monitoring.

4 4 9. Fall outcome evaluation A. Once the patient s needs are met, the nurse, tech, and any other involved/available staff as appropriate will complete the Post Fall Huddle form (located on MemorialNet under Clinical/Patient Falls) and review the incident with the Nurse Manager or the shift Charge Nurse to determine contributing factors and ways to prevent further falls for that patient. B. Review the fall incident at the next Unit-Based Council meeting to identify means of improving safety measures to prevent similar future falls. C. Communicate to all nursing staff via 1:1 contacts. This policy has been reviewed and approved by: Marsha Prater, PhD, RN Senior Vice President & CNO Patient Care Services March, 2007 Reviewed May, 2007 Revised August, 2007 Revised April, 2009 Revised January, 2010 Reviewed May, 2010 Revised February, 2011 Revised April, 2011 Revised May, 2011 Revised July, 2012 Revised June 2013 Revised April 2014

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7 7 Appendix B Low Risk Standard Interventions (Score 7-11) Orientation to room Bed in low position, brakes on Side rails x 2 or 4 up, assess large gaps such that a patient could get extremity or other body part entrapped, use additional safety procedures Use of non-skid footwear for ambulating patients, use of appropriate size clothing to prevent risk of tripping Assess eliminations need, assist as needed Call light within reach, educate patient/family on how to use Environment clear of unused equipment, furniture in place, clear of hazards Assess for adequate lighting, leave nightlight on Patient and family education to parents and patient Document fall prevention teaching and include in plan of care High Risk Standard Interventions (Score 12 and above) Identify patient with Call, Don t Fall signage (door sign, TV banner, chart sticker) Educate parents/patient about fall prevention precautions Check patient minimum of every 1 hour Accompany patient with ambulation Place patient in developmentally appropriate bed Consider moving patient closer to nurses station Assess need for 1:1 supervision Evaluate medication administration times Remove all unused equipment from the room Protective barriers to close off spaces, gaps in the bed Keep door open at all times unless specified isolation precautions are in place Keep bed in lowest position, unless patient is directly attended Document fall prevention teaching and include fall risk in plan of care