Nursing EVIDENCED-BASED PRACTICE ASSIGNMENT REGISTERED NURSING STUDENT

Administrative Policy & Procedure

Subject: Adult Fall Risk Assessment and Management - (Inpatient/Observation and Emergency Department (ED))

Effective Date: 02/20/2023

Primary Responsibility: Chief Nursing Officers

Executive Summary:

It is the policy of Atlantic Health System (AHS) to implement a fall risk assessment and fall management plan which outlines risk reduction strategies to prevent patient falls and a safe environment.

The purpose of the policy is to provide a fall risk assessment and individualized fall prevention interventions for emergency department (ED) patients and Inpatient/Observation patients 18 years of age and older, who have been identified as a falls risk. An individualized fall prevention plan will be established for patients identified at risk for falls.

Definitions:

Patient fall: an unplanned descent to the floor or extension of the floor (e.g., trash can or other equipment), with or without injury to the patient. All falls are to be included whether they result from physiological reasons (fainting) or environmental reasons (slippery floor). Also included are assisted falls, when a staff member attempts to minimize the impact of the fall.

Practitioner: a physician, dentist, podiatrist, fellow, resident, certified nurse midwife, advance practice nurse, or physician assistant, credentialed to perform the procedures described in this document.

Procedure:

Assessment:

Patients will be assessed for a fall risk utilizing an approved evidenced based fall risk assessment tool.

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Reassessment:

• Patients will be reassessed for fall risk by a nurse every shift. • Patients will be reassessed for fall risk upon transfer to another level of care within the facility. • Patients will be reassessed for fall risk when there is a noted change in the patient’s condition.

This may include but is not limited to: a. Alteration in mental status, i.e., as a result of delirium, sedation, change in medication. b. Alteration in vital signs. c. Post fall.

Interventions:

1. Patients who are identified as a fall risk will be provided appropriate recommended interventions, per nursing clinical judgment, as outlined in Appendix A.

2. Post Fall Interventions a. Assess the patient’s condition, complete a post fall assessment, and document

findings b. Provide immediate supportive care c. Contact the practitioner for medical assessment/intervention d. Report if a fall is unwitnessed to a practitioner to discuss consideration of routine vital

signs and neurological assessments e. Schedule and perform any ordered post fall assessment or diagnostics STAT f. Hold any routine care and testing until patient is cleared by a practitioner g. Initiate high risk interventions, if not already implemented h. Complete post fall evaluations (i.e., “Swarm” - post fall huddle) i. Notify manager or designee of all falls j. Notify risk manager of all falls resulting in moderate to severe injury

Documentation:

1. Documentation of fall risk assessment/reassessment is completed by utilizing the fall risk assessment tool.

2. Document Fall Prevention Plan of Care/Interventions 3. Document education provided to the patient and/or family 4. If a fall occurs, record each occurrence in the patient’s electronic health record and

include: a. Description of the event and date and time of occurrence b. Notification to practitioner including date and time notified c. Notify designated family member/emergency contact when applicable. d. Complete post fall patient assessment e. Follow up diagnostic procedure or treatment

f. Protective measures and/or additional interventions instituted/changed after fall

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5. Complete a report with the electronic event reporting system, pursuant to the Atlantic Health Event Reporting policy.

Quality Monitoring:

1. Determination of the program effectiveness will be evaluated by each site and at the system level, based on overall hospital fall rates.

2. Report out at unit or site-specific huddle.

References:

Joint Commission 2023 Hospital Accreditation Standards – Provision of Care – PC.01.02.08 EP 1 & 2

https://www.jointcommission.org/sea_issue_55/ Sentinel Event Alert 55: Preventing falls and fall-related injuries in health care facilities

Johns Hopkins Fall Risk Assessment tool www.hopkinsmedicine.org/institute_nursing reviewed 5/2017

National Database for Nursing Quality Indicators (NDNQI) reviewed 5/2017

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care (Agency for Healthcare Research and Quality) reviewed 5/2017

CMS Resident Assessment Instrument -MDS 3.0 RAI Manual v1.14 and MDS forms, effective October 1, 2016; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment Instruments/NursingHomeQualityInits/MDS30RAIManual.html

Review/Approval Summary: AHS Practice Council (APC) AHS Policy Oversight Committee (APOC) and AHS Nursing Leadership

Origination Date: 02/08/2018 APC Approval Date: 02/17/2023

Last Revision Date: 12/05/2019 APOC Approval Date: 02/01/2023

AHS Nursing Leadership Approval Date: 02/17/2023

Page 3 of 4 APPENDIX A – Fall Prevention Intervention by Risk Category

Low Fall Risk Moderate Risk High Risk

Fall Risk Score: 0-5 points Fall risk score 6-13 points Fall Risk score > 13 points

Maintain Safe Environment, including • Remove excess equipment/ supplies / furniture from rooms and hallways • Bed in the lowest position • Assure adequate lighting especially

at night • Keep floors clutter / obstacle free

with attention to path between bed bathroom/commode

• Coil and secure excess electrical and telephone wires

• Clean all spills in patient rooms or in hallways immediately. Place signage to indicate wet floor danger.

Basic safety interventions: • Orient patient to surroundings

including bathroom location use of bed and location of call light.

• Educate patient / family about fall risk assessments, fall injury risk, routine and special interventions for fall prevention

• Encourage patients / families to call for assistance when needed “Call don’t fall”

• Place call bell and frequently needed objects within patient reach • Answer call bell promptly • Keep bed in lowest position • Keep top two side rails up as an enabling device while in bed

• Secure brakes on beds, stretchers and wheelchairs

• Use properly fitting nonskid footwear (encourage personal appropriate footwear)

• Ensure special instructions given for vision and hearing impaired

• For patients that require assistive devices ensure that patient is safe and independent with use prior to leaving device within reach.

• Purposeful rounding

Communicate Fall Risk: • See low fall risk • Identify patient at risk for falling with yellow ID band and room identifier • Communicate fall risk to all providers

including during transport and transfers

• Consider transfer on stretcher when appropriate.

Implement measures listed under low fall risk AND: • Assist with mobilization/ ambulation

and transfers

• Supervise and /or assist bedside sitting personal hygiene (ADL’s) and toileting as appropriate

• Reorient confused patients • Establish elimination schedule, including the use of bedside commode / urinal, raised toilet seats as appropriate

Evaluate need for: • Physical Therapy consult if patient has

a mobility impairment, decreased strength decreased balance and /or decreased endurance

• Activation of bed alarm, chair alarms/ toilet alarms as per nursing judgement

• Consider using restraint alternatives

Communicate fall risk: • See low and moderate fall risk

Implement measures listed under low/moderate risk AND:

Implement the following: • Remain with patient / direct

observation when toileting (in bathroom / using a commode or urinal)

Evaluate need for: • Moving patient to room with best visual access to nursing station

• 24-hour supervision / constant observer

Consult with LIP regarding the need for:

• Physical therapy consult if patient has a mobility impairment, decreased strength, decreased balance and/or decreased endurance.

• Pharmacy review for potential medication changes

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