FALL PROTOCOL Goal: to provide a mechanism for assessment of falls with a focus on prevention, prompt investigation and immediate interventions with care plan updates. Focus will be on knowing the residents personal preferences, daily plans and schedules and life work to better intervene to prevent falls. Upon admission all residents will be assessed for fall risk utilizing form. This assessment will be updated with each MDS completed. If the resident is at risk for falls, the care plan will note this with individualized interventions. If a resident falls, an incident report will be completed with the MD and the family notified. Immediately with injury and on the day shift otherwise. If a resident falls, an indepth investigation will be instituted by the charge nurse completing the incident report. Focus of this initial investigation is to weed out medical issues that cause people to fall (active UTI, drop in BP and new medications). An immediate intervention must be instituted while this process occurs. If a fall is witnessed by staff, the charge nurse will interview and document the exact specifics of what lead to the fall. The staff member will review the charge nurses summary of this interview and then sign and date the interview statement. The charge nurse will also sign and date the summary. The DON and Administrator will be notified for all witnessed falls due to potential for ANE issues. If a fall in unwitnessed, the charge nurse will interview each staff member and document their interactions with the resident from the beginning of the shift until the incident occurred. Each staff member will review the summary written by the charge nurse during the interview and sign and date the summary. All staff include: NA s, CMA s, charge nurses, RA s. etc. The unit manager or DON will then complete the investigation by reviewing the incident report, nursing documentation, discussions with therapies and the consultant pharmacist as needed and review all staff statements for potential abuse and neglect issues. A summary will be written regarding the outcomes found with corrective actions noted. The care plan should also be updated and/or revised, based on the investigation for every fall. Therapies and restorative programs should be considered with gait or balance issues that lead to the fall. Implement exercise classes that focus on gait and balance. Review wheelchair safety (locks, foot rests, tipping and proper fit) and safe use of electric wheelchairs. Review footwear in use. Consultant pharmacist will be notified regarding drops in BP and new medications started for their input regarding the cause of the fall. A log of every fall will be kept for the facility. Each resident who falls will have an individual fall log to analyze facility trends. Trend analysis will be presented at QA meetings. Audits will be conducted for staff follow through utilizing the protocol. Education regarding fall prevention and this protocol will occur in orientation and in inservice classes. Fall investigations can be kept in each residents chart or in a separate notebook with the resident s individual log. This information is shared with surveyors.
Nurses note shiftly for three days post fall Fall risk notes anticoagulant use, as appropriate Care plan notes falls with updates with every fall Facility QA protocol for resident using Coumadin, falls and hits his/her head with/without head obvious head injury
FALL LOG Month: Date Resident Date Resident
Falls Protocol Interventions Amount of Assist - Mode of Transport Rise slowly from sitting position Do not leave resident unattended in W/C or on the toilet Walking programs - Walk to dine Wheelchair safety assessment by therapies Safe use of electric wheelchairs-assessment Continence - maintenance of Assessment if becomes incontinent U/A, C & S PVR, Urology consult Restorative / Rehabilitation training program Routine toileting with peri care Environment Call light within reach No clutter Clear path to bathroom Night light on at night Toilet every 2 hours Low bed - mattress on floor - padded floor Non slip strips on floor by bed Alternative seating Body props Assistive equipment close to the resident Leave bathroom light on at night Therapies (muscle weakness & functional impairments) PT/OT Consult Restorative programs - ambulation ROM - maintenance - active / passive Weight bearing status Perform ADL's while sitting Adaptive equipment (Gait, Balance issues) Walker, cane, quad cane Gait belt Positioners Wear shoes / socks Anti Tippers on W/C or Merry Walker Splints Cardiac chair Bedside commode Copyright, DPA Associates, Inc., Kansas City, MO 1997
Pain Diagnosis Medications / effect Activities Distraction Structured Activities Something to hold - being needed Exercise class Social activity ADL training Psychosocial 1 / 1 visits Therapeutic touch Attend to relocation stress Reminiscence Nursing Routines Daily ambulation Toileting schedules Supervised ADL's Place resident in high visibility area area monitored Frequent reminders to resident not to get up without help - put in writing Tracking of wanders Offer fluids / snacks Check for constipation Awake at night: Toilet Offer snack Assess for pain Bring to nurses area Place in recliner Ask resident to "assist" you Sensory - vision / hearing Opthamology / Audiology evaluation Adaptive equipment available and used (glasses, hearing aides) Communication board Face resident when speaking Medications that put the resident at high risk for falls Diuretics Laxatives Barbiturates Tranquilizers Pain meds Hypnotics Antihypertensives Eye drops Copyright, DPA Associates, Inc., Kansas City, MO 1997
Facility: Resident Name: Room # Fall Investigation Staff Initial Investigation (must be completed within 12 hours of the incident). All abnormals must have interventions. If environmental issues, note this and do not proceed. If not environmental, complete the following: 1) Postural blood pressures: 2) Dip stick urine-if contributed to a fall (If abnormal, get U/A, C and S): 3) Medications started within the past 30 days (list): 4) Accucheck (if diabetic): 5) Pulse ox: Interventions instituted based on initial investigation (circle) Note with if refused: Fall from bed/found on floor: keep light on, mattress on floor, pad on floor, check q 15 minutes, toilet q1hour, offer food/fluids, non skid strips on floor, sleep in shoes and socks, move to hallway Fall from chair/found on floor: activities to keep hands busy, toilet more frequently, dycem on chair, put to bed, wears shoes and socks at all times, wedge cushion, recliner, merry walker Fall while ambulating: clear path, light on, assist will all ambulation, call light available, toilet more frequently, glasses on, bedside commode, shoes and socks on, check q 15 minutes, monitor BP, visible at all times, merrywalker Signature STOP HERE Date: Diseases: Cardiac arrhythmia's Circle those issues which apply - perform noted assessment Hypotension (complete on all residents) Syncope Parkinson's Hemiplegia Seizure disorder Arthritis Assessment VS, Heart Rate - (?RRR) BP lying, standing By personal account or observed By hx By hx By hx, observed, medications used By hx, medications used Outcome Copyright, DPA Associates, Inc., Kansas City, MO, 1997 1 of 4
Pain Osteoporosis CHF Bladder dysfunction Acute Conditions UTI Mobility Unsteady gait Lower extremity Dysfunctional Fear of falling Balance Use of assistive device-safe Perception Hearing Vision Sensation Assessment Outcome By hx, describe, medications used By hx, medications used By hx, resp. status, edema, SOB, O2 use Nocturia, new incontinence, medical workup, dx Dip stick urine, U/A, C&S Observation PT consult Describe, dx Arthritis, muscle weakness, foot disorders Balance test from MDS Therapy consult Hx loss Bedside testing hx glaucoma, cataracts, macular degeneration Bedside testing - Ability feel pain - feet / hands Medications (circle) All medications reviewed with consultant pharmacist with first fall Subsequent falls: new meds( started within 2 weeks of incident) Antihistamine lethargy, balance problems Antihypertensives Postural BP, dizziness Seizure medications-dizziness Benzodiazepines hangover effect Cathartics/laxatives- diarrhea Copyright, DPA Associates, Inc., Kansas City, MO, 1997 2 of 4
Psychotropic Diuretics Appliances / Devices Used Walker, cane or merry walker Personal alarms/bed alarms/chair Physical Restraints Type in Use/date started Environment Obstacles low/high beds, side rails Glare, poor lighting Slippery Wet floors Uneven surfaces Patterned carpet Objects in hallway Recent move into / in Facility Aggressive resident nearby Time of day Meal time (hungry) Standing still Walking in crowded area Reaching for something Bowel / bladder urgency Bending over Assessment Outcome Hypoglycemic agents dizziness, syncope-high or low blood sugars Narcotics extreme drowsiness, disorientation Sedatives / Hypnotics lethargy, mental changes Gait and balance problems, mental changes, urinary retention Goes to bathroom frequently PT/OT Consult, safe in use, restorative programs Documented working PT/OT consult Copyright, DPA Associates, Inc., Kansas City, MO, 1997 3 of 4
Transfer devices Footwear faulty Low chairs/toilets No grab bars Improper walking Devices Cognitive Status (circle) Confused / dementia Alert / Oriented Recent Change? Yes / No delirium Depression Judgement issues Behavior (circle) Cooperative Uncooperative/resists care/violent/abusive Recent Change? Yes / No ADL s from MDS Bed mobility Transfers Eating Toilet Assessment Outcome Dx Acute conditions-uti Dx, medications used Dx, medications used, behavior monitoring sheets Self performance Amount of Support Stable, improvement, decline Concerns about abuse/neglect? Conclusion: Course of action: Date: Signature: Copyright, DPA Associates, Inc., Kansas City, MO, 1997 4 of 4
PHARMACY CONSULTATION Nursing Facility: Resident Name: Reason for consultation: falls: # in the past 30 days weight loss: % past 30 days; % past 180 days change in behavior: describe: hydration fecal impaction appetite loss constipation skin breakdown: describe: pain management Comments: Assessor: Date: Consultant Pharmacist review of current medications for possible cause of the problem noted above. Suggestions and recommendations. Signature: MD comments: Date: Date: Please fax to: Attention:
STAFF INTERACTION STATEMENTS (Unwitnessed fall etc) This form is to be used to document staff interactions with the resident from the beginning of the shift up to the incident. The interview is conducted by the charge nurse. Note time of the interaction and what the staff member did for the resident. Time of incident: Place of incident: 1. Certified Nursing Assistant (Name): Cues: call light within reach, side rail up, wheelchair locked, personal alarm attached and working, wheelchair locked 2. Certified Nursing Assistant (Name): Cues: call light within reach, side rail up, wheelchair locked, personal alarm attached and working, wheelchair locked 3.Certified Nursing Assistant (Name): Cues: call light within reach, side rail up, wheelchair locked, personal alarm attached and working, wheelchair locked
4. CMA (Name): Note medications passed and times 5. Charge nurse (Name): Comments: Tool completed by: Date: Time:
WITNESS STATEMENT (witnessed fall etc) This form is to be used to document the staff member who witnessed the incident. The interview is conducted by the charge nurse. The Director of Nursing and the Administrator must be notified for a witnessed incident. Time of incident: Place of incident: Name of the witness: Title: Describe what happened: cues: status of the call light, side rails, wheelchair or any other adaptive equipment, lighting, liquids on the floor, liquids spilled, personal alarms on, sounding, use of gait belts, lifts, care plan followed Interviewer: Interviewee signature: By signing this statement I am assuring that the data above is correct and accurate.
AUDIT #15: FALLS F 323/324 Threshold for compliance: 100% Time spent: Number to be audited: LTC and skilled: 5 each 1, 2, 3, 4, 5, 6, 7, 8 Clinical record Unit/hallway/neighborhood: Resident interview Frequency: Monthly Observation Auditor: Charge nurse Family interview Other Auditor: Date: Resident name and RM # 1. Incident report completed 2. NN for the incident 3. Follow up NN (72 hours shfitly) 4. MD/family notified 5. Care plan updated 6. Therapy consult PRN 7. Pharmacy consult PRN 8. Investigation completed
ITEM EXPLAINATION 1. All items on incident report completed 2. There is a NN for the incident with vital signs and assessment documented 3. MD and family were notified. Immediately with injury and on the day shift without injury 4. Care plan updated with the fall 5. Therapy consult documented for the fall 6. Pharmacy review for medication as an issue 7. In depth fall investigation completed. All items reviewed.