NURSING SERVICE DEPARTMENT Policy

Doc. No.

PATIENT FALLS AND Rev. No.

Page No.
00
Page 1 of 2
MANAGEMENT Effective Date:

1. PURPOSE:
To promote a safe environment through fall risk assessment and implementation of
universal fall safety interventions to reduce the risk of falls

2. SCOPE:
This covers fall risk assessment and management in order to reduce the risk for
falls. All adult in-patients will be assessed for Fall Risk within 24 hours of admission,
whenever there is significant change in the patient’s condition, or if the patient
experiences a fall.

3. POLICY:
Effectivity of this procedure can be attained upon the implementation of the following
policies:
3.1. All in- patients will have the Universal Fall Safety Interventions implemented on
admission
3.2. All patient who had a previous fall or has significant impaired mobility or balance
may be at higher risk for falls
3.3. The greater number at risk categories identified on the Fall Risk Assessment
Profile, means the patient is at higher risk for falls
3.4. Additional individualized fall safety interventions shall be implemented
3.4.1. As deemed appropriate by the staff nurse
3.4.2. For patients who have had a fall within 3 months prior to admission
3.4.3. For patients who have major mobility impairments different from their
baseline

4. DEFINTION OF TERMS:
4.1. Fall – is an abrupt, uncontrolled, downward change in the position, affected by
physiological, psychological and or environmental factors in which the potential
for injury exists or in which an actual injury occurs
4.2. Near Fall – occurs when a potential fall is prevented through purposeful actions
4.3. Repeat Faller – is an individual who has had two or more falls within the last
month

5. PERSONNEL RESPONSIBLE:
5.1. Staff Nurse – shall be responsible for the following:
5.1.1. Reviews patient’s history and baseline functioning including history of falls
and change in mobility.
5.1.2. Initiates Universal Fall Safety Interventions for all adult in patients

Prepared by: Reviewed by: Approved by:

AILYN B. PINEDA, RN MAN GELIA M. MARTINEZ,RN ROBERTO A. ESPOS, JR.,MD,
FPPS, MHSA
Assistant Chief Nurse Hospital Administrator Chief of Hospital
 NURSING SERVICE DEPARTMENT Policy
Doc. No.

PATIENT FALLS AND Rev. No.

Page No.
00
Page 2 of 2
MANAGEMENT Effective Date:

5.1.3. Assesses the patient within 24 hours of admission, whenever there is

significant change in the patient’s condition, or if the patient experiences a
fall
5.1.4. Screens for categories of fall risk using the Fall Risk Profile in the nursing
history sheets
5.1.5. Reviews, revises, monitors and documents changes
5.1.6. Reviews the Fall Risk Profile and areas of risk every shift
5.1.7. Implements Additional Individualized Fall Safety Interventions whenever
necessary
5.1.8. Identifies all adult in-patients who have had a fall within 3 months prior to
admission, while in the hospital or who have major mobility impairments
different from their baseline or by clinical judgment
5.1.9. Teaches patient/family/substitute decision maker strategies to reduce risk
falls
5.1.10. Collaborates with other health care team regarding individualized
interventions

Prepared by: Reviewed by: Approved by:

AILYN B. PINEDA, RN MAN GELIA M. MARTINEZ,RN ROBERTO A. ESPOS, JR.,MD,
FPPS, MHSA
Assistant Chief Nurse Hospital Administrator Chief of Hospital