KENT HOSPITAL POLICY/PROCEDURE SUBJECT: AUTHORS: APPROVAL DATE: POLICY NUMBER: January 2012 Fall Prevention Barbara Bird, MSN, RN-BC, CCNS EFFECTIVE DATE: 8310-0005 Falls Council/ Prevention Committee January 2012 DEPARTMENTS AFFECTED: APPROVED BY: REPLACES: January 2013 LAST REVIEW DATE: NPP600-E-6 January 2015 Hospital Wide Sandra L. Coletta President/CEO Chair, CMG LAST MODIFICATION DATE: January 2015 Policy: All patients are considered at risk for a fall. It is the policy of Kent Hospital to identify and manage fall risk and implement evidence-based prevention strategies.. Purpose: The purpose of this policy is to promote fall risk prevention based on assessment of risk, to implement standardized fall prevention measures, and to evaluate patient outcomes. The patient and family are included in this process. Scope: This policy applies to inpatients, outpatient areas, also applies to all departments, employees, physicians, and volunteers of Kent Hospital, within their scope of practice. (See procedure for eception) Definitions: Fall: A fall is a sudden, uncontrolled, unintentional downward displacement of the body to the ground, or other object. An unwitnessed fall is when a patient is found on the floor. Morse scale: The Morse scale is a validated, standardized scale used to identify acute care patients at LOW, MEDIUM, or HIGH risk for a fall. This scale is a rapid method of assessing a patient s likelihood of falling, with predictive ability and reliability (Morse, 2008) if used correctly in acute care settings. Interventions will be assigned to each risk. RRT: Rapid Response Team CCL: Cardiac Catheterization Lab Cathstrap: Velcro safety device used during cardiac diagnostic testing in the cardiac catheterization lab
Fall Prevention Page 2 of 9 Quantros Patient Event Reporting System
Fall Prevention Page 3 of 9 Procedure for Assessment of FALL RISK: 1. This policy will not be used to identify fall risk on patients in the Emergency Department. The Emergency Department will identify patients at risk for a fall with a population-specific tool. 2. The Inpatient RN will obtain a Morse Fall Scale Score using the variables and numeric values listed in the Morse Fall Scale in Cerner. See page 5 of this policy. 3. Each variable is given a score. The sum of the scores is the patient s Morse Fall Risk Score. The RN will not omit or change any of the variables, and will use only the numeric values listed for each variable. Making changes in this scale will result in a loss of validity. Descriptors of each variable is provided. 4. Frequency of assessment: Every patient will be assessed by the RN: Within the shift of admission (according to policy NPP600 C 28 regarding fall risk) Every 8 hours: 0700, 1500, 2300 After any therapeutic intervention which may alter risk factors After a FALL With a change in condition When a patient is transferred to another unit ICU: RN will reassess Low risk of falling due to inability to move independently every 8 hours, and PRN (Some of the mandatory interventions associated with a LOW fall risk patient, such as toileting, safe side access, may not apply to this group of patients due to severity of illness) 5. All staff will provide appropriate mandatory interventions as noted in above Mandatory safety interventions. These interventions for patients are NOT optional, however, may not be applicable in all settings, circumstances, including outpatient settings, and ICU with LOW Risk for fall due to inability to move independently. Ancillary staff and visitors are reminded to immediately notify a member of the nursing staff for assistance if a patient with a yellow wrist band and/or yellow slippers is seen attempting to get out of bed or walk/transfer without assistance. (If possible they should stay with the identified patient until help arrives). 6. Patients who develop a decreased inability to understand their own limitations may be at an increased risk for a fall. This patient may require a more comprehensive confusion/disorientation assessment method, and targeted interventions. 7. The most recent Fall Risk Assessment is seen in the Hand-off screen. At any transfer of care (during the change of shift, or anytime the patient s care will be handed-off to another caregiver) this information must be transferred, including the circumstances surrounding the last fall, if applicable, and the plan for prevention. 8. Documentation of education provided is included in the interventions. This is in the form of a Fall Prevention brochure. 9. The signage for a MEDIUM and HIGH Risk Fall travels with the patient. The signage is placed on the wheelchair/stretcher when traveling, and returned to outside of the patient s room upon return. If the patient is on isolation, the sign is cleaned by the transporter, with hospital disinfectant, before being placed back on the outside of the patient s room. The policy for Transfer and Transport of Isolation Patients will be observed. The sign will NOT travel with the patient when transferring to another unit; the receiving RN will reassess and assign a Fall Risk.
Fall Prevention Page 4 of 9 All employees will: Be aware of the Fall Prevention Program alerts at Kent (Yellow slippers, yellow band, signage) Assure patient who is at an increased risk has assistance Be alert to environmental hazards such as spills, uneven floor surfaces, etc. and report promptly All Providers will: Receive education about falls prevention and understand the importance of compliance Identify patient deficits associated with fall risk, and inquire about appropriate referrals, as necessary. (Physical Therapy for strength/gait training, Clinical Nurse Specialist for review of fall prevention). Process for Pre op Surgical Services: 1. The RN assesses the patient in pre op area using the Morse scale. 2. Appropriate interventions are implemented for fall risk category LOW, MEDIUM, or HIGH. 3. The risk and signage remains with the patient throughout the perioperative period, then: Admitted patients Phase I Admission 1. Signage, risk and interventions remain with patient 2. The admitting RN on the unit re-evaluates, and initiates interventions Phase I Phase II Discharge 1. Signage, risk and interventions remain with patient until the patient is discharged. 2. At the time of discharge, patients who are MEDIUM or HIGH risk will be accompanied out of the hospital, and will receive education about the risk of falling at home. Admitted directly OR: 1. Signage, Risk and Interventions will be maintained, (appropriate to environment) throughout the Perioperative period. 2. Patient will be re-assessed upon arrival back on the inpatient unit. Process for Wound Recovery Center: (WRC) 7. All patients are assessed using the Morse falls scale during the RN Assessment 8. Changes in the Fall risk are assessed at each visit, interventions are implemented during treatment, (If applicable within the environment of the WRC). Signage remains with the patient 9. Written and verbal education will be provided to MEDIUM and HIGH risk fall patients Process for Outpatient IV Therapy Unit: (OPIU) 10. All patients are assessed using the Morse falls scale during the RN Assessment 11. Changes in the Fall risk are assessed at each visit, interventions are implemented during treatment, (If applicable within the environment of the OPIU). Signage remains with the patient 12. Written and verbal education will be provided to MEDIUM and HIGH risk fall patients
Fall Prevention Page 5 of 9 Process for Cardiac Catheterization Lab: (CCL) 13. All patients that are transferred to the CCL as inpatients will have interventions and signage implemented 14. Interventions and signage are maintained throughout the procedure and during post catheterization care (If applicable within the environment of the CCL). 15. All patients that are risked HIGH have cathstrap applied during procedure 16. RN in CCL evaluates the patient admitted from the Emergency Department using the Morse scale, appropriate interventions are implemented during the procedure and post catheterization 17. The RN receiving the admitted patient post cardiac catheterization evaluates the patient, and implements interventions 18. The RN receiving the patient in Outpatient after a catheterization Lab procedure maintains interventions until the patient is discharged to home. All MEDIUM and HIGH risk patients will receive written education. All MEDIUM risk patients that need assistance, and ALL HIGH risk patients, are accompanied at time of discharge. Process for Diagnostic Imaging: 19. All inpatients are assessed by the RN using the Morse scale. This risk assessment is seen on the hand-off screen, the Ticket to Ride, and the Diagnostic Imaging Requisition. 20. Staff in the diagnostic imaging department will consider this risk assessment when scheduling patients that are HIGH risk for a fall. Diagnostic Imaging staff will schedule patients that are HIGH risk for a fall when staff/volunteers are available to observe the HIGH risk patient 21. Signage remains with the patient who is MEDIUM and HIGH risk Process for discharged patients: Any patient identified as a HIGH risk for fall will not be discharged to the Hospitality Lounge. Post Fall Process for all units. RN will: 1. Assess for injury, call RRT if appropriate 2. Take vital signs including postural blood pressure if possible, include a neurological assessment, blood sugar if applicable 1. Call LIP to assess the patient 2. Re-evaluate the fall risk using Morse scale, and follow protocols for interventions, determine the circumstances surrounding the fall (from observation, staff, patient, family). Revise or develop a plan to prevent a subsequent fall. 3. Document event in medical record 4. Complete Quantros report 5. Provide written (Fall Prevention brochure) and verbal education (if not already done) to both the patient and family 6. Consider a Clinical Nurse Specialist consult if you have questions regarding the prevention of falls. (see how to consult a CNS in the Fall Prevention Binder on Unit). 7. Contact Nurse Manager, Nursing Supervisor or Clinical Nurse Specialist to complete Post Fall Evaluation form
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Fall Prevention Page 7 of 9 Mandatory safety interventions specific to LOW Fall risk patients RN C.N.A. All other Allow patient time to sit before standing to prevent orthostatic hypotension (any drop of 20 mm/hg systolic AND/OR a drop of 10 mm/hg diastolic upon posture changes (supine-sit, sit-stand) Assess, treat pain staff Assess the environment for potential hazards Bed/chair/voice alarms on (IF patient is confused, unreliable, over-estimates her/his own ability on the Morse scale). Call light within reach, demonstrates the correct use. Reorient. (if patient is confused, re-orientation is an on-going process) Communicate the patient s fall risk through hand-off. RN-RN, C.N.A.-C.N.A., RN-C.N.A. including the circumstances surrounding the previous fall and plan for prevention All patients are assessed upon admission, every 8 hours during inpatient stay and when a condition change warrants a re-assessment ICU: Low risk due to inability to move independently is Q 8 hours and PRN Encourage patient to call for help. Personal items, call light within reach Is there anything else I can do for you? Comfort rounds every hour Nonskid (non-slip) footwear NO YELLOW SLIPPERS Prevent all tubings from becoming hazards Provide written and verbal education to patient/and or family Safe-side access 2 rails up, bed in low position, wheels locked on bed, wheelchair, stretcher Walking aides, sensory aides provided Offer toileting every 2 hours, ambulate if ordered Mandatory safety interventions specific to MEDIUM Fall risk patients RN C.N.A. Allow patient time to sit before standing to prevent orthostatic hypotension (any drop of 20 mm/hg systolic AND/OR a drop of 10 mm/hg diastolic upon posture changes (supine-sit, sit-stand) Assess, treat pain All other staff Assess the environment for potential hazards Bed/chair/voice alarms on (IF patient is confused, unreliable, over-estimates her/his own ability on the Morse scale). Call light within reach, demonstrates the correct use. Reorient. (If patient is confused, re-orientation is an on-going process) Communicate the patient s fall risk through hand-off. RN-RN, C.N.A.-C.N.A., RN-C.N.A. including the circumstances surrounding the previous fall and plan for prevention All patients are assessed upon admission, every 8 hours during inpatient stay and when a condition change warrants a re-assessment ICU: Low risk due to inability to move independently is Q 8 hours and PRN Encourage patient to call for help. Personal items, call light within reach Is there anything else I can do for you? Comfort rounds every hour. MEDIUM RISK for FALL signage posted, to travel with the patient, in Ticket to Ride, also Nonskid (non-slip) YELLOW footwear, YELLOW wristband. Patients with a YELLOW wrist band and YELLOW slippers should not be walking or transferring unassisted.
Fall Prevention Page 8 of 9 Prevent all tubings from becoming hazards Provide written and verbal education to patient/and or family Safe-side access 3 rails up, bed in low position, wheels locked on bed, wheelchair, stretcher Walking aides, sensory aides provided Offer toileting every 2 hours, ambulate if ordered Consider: Asking the physician for a PT consult Consider: Advanced Nurse Clinician consult Mandatory safety interventions specific to HIGH Fall risk patients RN C.N.A. All other staff Allow patient time to sit before standing to prevent orthostatic hypotension (any drop of 20 mm/hg systolic AND/OR a drop of 10 mm/hg diastolic upon posture changes (supine-sit, sit-stand) Assess, treat pain Assess the environment for potential hazards Bed/chair/voice alarms on ALL HIGH Risk Patients. Call light within reach, demonstrates the correct use. Reorient. (if patient is confused, reorientation is an on-going process)reorientation is an on-going process. Communicate the patient s fall risk through hand-off. RN-RN, C.N.A.-C.N.A., RN-C.N.A. including the circumstances surrounding the previous fall and plan for prevention All patients are assessed upon admission, every 8hours during inpatient stay and when a condition change warrants a re-assessment ICU: Low risk due to inability to move independently is Q 8 hours and PRN Encourage patient to call for help, personal items, call light within reach Is there anything else I can do for you? Comfort rounds every hour HIGH RISK for FALL signage posted, to travel with the patient, in Ticket to Ride, also Increase observation by: charting in room, being aware of HIGH risk patient Nonskid (non-slip) YELLOW footwear, YELLOW wristband. Patients with a YELLOW wrist band and YELLOW slippers should not be walking or transferring unassisted. Prevent all tubings from becoming hazards Provide written and verbal education to patient/and or family Safe-side access 3 rails up, bed in low position, wheels locked on bed, wheelchair, stretcher Walking aides, sensory aides provided Offer toileting every 2 hours, ambulate if ordered Consider: Asking the physician for a PT consult Consider: Advanced Nurse Clinician consult
Fall Prevention Page 9 of 9 Signage for fall risk patients: Selected References: 1. Morse, J. (2008). Preventing Patient Falls. 2 nd ed. Springer. 2. National Center for Patient Safety: Fall Prevention and Management 3. Harrington, L., Luquire, R., Vish, N. Winter, M. (2010) Meta analysis of Falls-Risk in Hospitalized Patients. JONA. 4. Institute for Healthcare Improvement. 5. Cozart, H., Cesario, S. (2009). Falls aren t us: state of the science. Critical Care Nursing Quarterly, 32(2), 116-127. 6. Oliver, D., Healey, F. (2009). Falls risk prediction tools for hospital inpatients: do they work?