Fall Prevention

fall risks
history of falling
(within last 3 months)

assessment
secondary diagnosis
(> 2 med dx in chart)
ambulatory aid fall physiology
all patients must be evaluated for fall IV/saline lock
potential via Falls Risk Assessment gait / transferring
Research has identified many conditions that contribute to falling. These are called risk
(weak / impaired)
during admission process factors.
mental status
initial, daily nursing assessment (forgets own limitations)
following change in medical condition
Many risk factors can be changed or modified to help prevent falls.
following change in level of care
post fall interventions They include:
assistance walking Lower body weakness
SURGICAL SERVICES/PROCEDURAL AREAS:
toileting schedule History of seizures
during pre-op phase
during Phase 2 recovery (assist w/ bed pan, to commode, Hypoglycemia
to bathroom)
Alcohol Withdrawal
bed alarm on
EMERGENCY SERVICES / FSER: Vitamin D deficiency (that is, not enough vitamin D in your system)
1-2 person assist out of bed
once per encounter Difficulties with walking and balance
SAFETY Rounding
with change in patient status (includes Physical Environment) Use of medicines, such as tranquilizers, sedatives, or antidepressants. Even some
Include in ALL handoff/report over-the-counter medicines can affect balance and how steady you are on your feet.

post-fall Fall Risk signage Vision problems

Foot pain or poor footwear
Hospital hazards or dangers such as tubing and machines that clutter the room
Injury Assessment (prior to being moved) include: vital signs, neurological, musculoskeletal, Getting up without assistance by staff
circulatory, integumentary, psychological status, and pain.
Being left unattended in the bathroom
Debriefing huddle during same shift as the fall to gather all pertinent data (must include Nursing
Leadership) Most falls are caused by a combination of risk factors. The more risk factors a
person has, the greater their chances of falling.
Notifications of the fall: Attending Physician, Nursing Leader, and patient's legal representative
(MUST be documented in the EHR)
Healthcare providers can help cut down a person’s risk by reducing the fall risk factors
Reporting: document in the Post Fall Assessment intervention within the EHR.
listed above.

Serious Safety Event reporting will be completed for all falls resulting in fracture(s) or brain
bleed(s).