Download When a Fall Occurs

By Shannon McCormick, BSN, RN, CPHRM, LHRM, Risk and Patient Safety
Consultant, Rebecca Summey-Lowman, MBA, RD, LD, CPHRM, CPPS, Risk
and Patient Safety Consultant
Mary Gregg, MD, FACS, MHA, Chief Medical Officer, SVP, Laura Martinez,
BSN, RN, MS, CPHRM, FASHRM
Preventing Falls in the Medical Office
Visitors, patients and staff are all at risk for falls in the office setting.
The Centers for Disease Control and Prevention (CDC) underscores the
significance of patient falls stating, “patient falls can cause moderate to
severe injuries, such as hip fractures and head traumas, and can
increase the risk of early death.”i Many falls are preventable and can
be avoided by identifying patients at risk for falls and where the
hazard is likely to occur and taking steps to reduce or eliminate
hazards.
Falls among Older Adults
Although injuries from falls can occur for patients at any age, older
adults are at higher risk. According to the CDC, falls are the leading
cause of fatal and nonfatal injuries in people age 65 and older.ii In
2013, 2.5 million nonfatal falls among older adults were treated in
emergency departments and more than 734,000 of these patients were
hospitalized.iii In 2013, about 25,500 older adults died from
unintentional fall injuries.iv The death rates from falls among older
men and women have risen sharply over the past decade.v Patients
with poor balance and low vision are at great risk for tripping on
uneven floor surfaces or furniture not properly placed.
Environmental Hazards
General housekeeping and maintenance focused on removing clutter
and obstacles, and improving poor floor covering conditions will also
contribute to a safe environment. According to the National Institute for
Occupational Safety and Health, some of the top environmental
hazards include:
1. contaminants on the floor (water, grease, oil, fluid, food)
2. poor drainage; pipes and drains
3. indoor walking surface irregularities
4. outdoor walking surface irregularities
5. weather conditions: ice and snow
6. inadequate lighting
7. Stairs and handrails
8. Stepstools and ladders
9. Tripping hazards: clutter, loose cords, hoses, wires and medical
tubing
10.
Improper use of floor mats and runners.vi
Safety in the Exam Room/Treatment Areas
The exam room itself poses risk for patient falls. Consider the patient
and his/her level of functioning when preparing a patient for an
exam. Patients are typically taken to the room and placed on the exam
table. A safer alternative is to place patients, whether identified as
high risk or not, in a chair while waiting to evaluated. Allow patients
to remain at “arms reach” when assisting patients onto the exam table
or being assisted to the restroom.
As cited in an article published in Physician Practice News, a North
Carolina Court of Appeals allowed a case against an ophthalmologist to
proceed after an elderly patient claimed negligence after falling off a
rolling stool. The court opined that, “Although [the] defendant's use of
the rolling chair may not itself be negligent, instructing an elderly patient
with a purse to sit on the rolling chair and move up to the examination
table without offering assistance may be found to be negligent.”vii
It is also prudent to observe patient safety precautions when drawing
blood. Asking the patient if he/she has ever felt faint before, during or
after, and blood draw may prevent a fall. If the patient is aware that
he/she gets dizzy or has in the past fainted while having blood collected,
staff can take appropriate measures to safeguard the patient during the
procedure. Consider asking the patient to lie down during the procedure.
This may lessen the risk of patient fainting and the possibility of patient
injury due to falling or sliding out of a draw chair.
Be aware of any medications such as antihypertensives, psychotropics,
sedatives, anti-epileptics, and hypnotics that may cause dizziness and
result in a fall. Offer patients the appropriate assistance when the
administering any of these medications in the office setting or when you
are aware that patients are taking these as part of their routine
medication regimen. This may be particularly important in an officebased surgery setting where these types of medications may be
administered more frequently.
When a Fall Occurs
If a fall does occur, the most important consideration is prompt
evaluation and treatment of the patient. All events related to a patient
trip, slip, or fall should be documented in the medical record, using
objective, factual information of the events, evaluation, treatments, and
patient response to interventions.
It is prudent to carefully assess the circumstances related to the
incident to determine where preventative measures can be implemented
using a post-fall report form. The National Institute for Occupational
Safety and Health (NIOSH) has an event reporting tool that was adapted
from the Bureau of Labor Statistics Occupational Injury and Illness
Classification manual (BLS 2007). Completion of a similar reporting
document may help identify ways to improve performance and
processes. The event reporting form should not be included in the
patient’s medical record.
Fall Prevention and the Physician Quality Reporting System
Underscoring the significance of fall prevention, measures are included
in the Physician Quality Reporting System (PQRS). PQRS is a
reporting program that uses a combination of incentive payments and
negative payment adjustments to promote reporting of quality
information by eligible professionals (EPs). Beginning in 2015, the
program also applies a negative payment adjustment to EPs who do not
satisfactorily report data on quality measures for covered professional
services. The measures pertaining to falls is a two-part measure.
Measure #154 (NQF: 0101) Falls: Risk Assessment, is a
measurement of the percentage of patients aged 65 years and
older with a history of falls that had a risk assessment for falls
completed within 12 months.
Measure #155, is the percentage of patients aged 65 years and
older with a history of falls, and who had a plan of care for falls
documented within a 12 months period of time.
According to one study, although one out of three older adults (those
aged 65 or older) falls each year, less than half talk to their
healthcare providers about it.viii Providers are encouraged to perform
proactive risk assessments on patients aged 65 years and older with a
history of falls and develop an individualized fall prevention
intervention care plan.
According to the guidance from the Center for Medicare and Medicaid
Services (CMS), a falls risk assessment is a clinical evaluation that
should include the following, but are not limited to:

A history of fall circumstances

Review of all medications and doses

Evaluation of gait and balance, mobility levels and lower
extremity joint function

Examination of vision

Examination of neurological function, muscle strength,
proprioception, reflexes, and tests of cortical, extrapyramidal, and
cerebellar function

Cognitive evaluation

Screening for depression

Assessment of postural blood pressure

Assessment of heart rate and rhythm

Assessment of heart rate and rhythm, and blood pressure
responses to carotid sinus stimulation, if appropriate

Assessment of home environmentix
The falls risks assessment should be followed by direct intervention on
the identified risk.
The plan of care must include:
Consideration of appropriate assistance device
The medical record must include: documentation that an assistive
device was provided or considered OR referral for evaluation for an
appropriate assistance device); and
Balance, strength, and gait training
The medical record must include: documentation that balance,
strength, and gait training/instructions were provided OR referral to
an exercise program, which includes at least one of the three
components: balance, strength or gait.x
Fall Prevention Resources
The Agency for Healthcare Research and Quality (AHRQ) developed Preventing Falls in
Hospitals: A Toolkit for Improving Quality of Care, AHRQ Publication No. 13-0015-EF, January
2013.
The CDC created the STEADI (Stopping Elderly Accidents, Deaths, & Injuries) Toolkit for Health
Care Providers. Among the tool kit materials are a Fall Risk Assessment Tool, a Provider
Pocket Guide for Preventing Falls in Older Patients, Guidance on Integrating Fall Prevention
into Your Practice, and a list of medications that are linked to falls. These materials can be
downloaded from the CDC website at www.cdc.gov.
The Joint Commissions, Center for Transforming Healthcare launched its seventh project which
aims to prevent falls that occur in health care facilities. The Preventing Falls with Injury Project
can be accessed on their website at www.centerfortransforminghealthcare.org
U.S. Department of Veteran Affairs, National Center for Patient Safety, Fall Toolkit can be
access of their website at http://www.patientsafety.va.gov
The information presented in this Article is intended as general information of interest to physicians and other
healthcare professionals. The recommendations and advice published herein do not reflect or establish a standard of
care and do not establish rules for the practice of medicine. The publication of this information is not intended as an
offer to insure such conditions or exposures, or to indicate that MAG Mutual Insurance Company will underwrite such
risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies
issued.
Published:
Fall Prevention Checklist
Patient Identification and Monitoring
A fall risk assessment performed
within 12 months is completed for
patients aged 65 years and older
with a history of falls
A plan of care completed within
the last 12 months is present for
patients aged 65 years and older
with a history of falls
Waiting Room
The waiting room is arranged to
provide the highest level of
visibility for the staff
Staff monitor the waiting room
frequently
Furniture is arranged to avoid
interference with traffic patterns
The waiting room is free of clutter
(e.g. toys are picked up, magazines
are in racks)
Examination Rooms
Patients are seated in a (nonrolling) chair while waiting for
the physician (not on exam tables)
If stepstool are used, they are of the
proper height and sturdy and do
not obstruct walkways
Restrooms
Call lights/bells and safety bars
are available
General Office
There are no sharp corners on
tables, desks, or chairs
Yes
No
Comments
There are no indoor surface
irregularities such as worn or
damaged carpet
Uncarpeted floors are not highly
polished or slippery
Wet floor signs and barriers are
available and used as appropriate
There are handrails on stairs
Glass door have emblems
Exits signs are clearly marked
The office is free of clutter, loose
cords, hoses, wires, and medical
tubing
The floor is free of such as water,
grease, oil, fluid, food, soaps
General Office
Walk-off mats, paper towel holders,
trash cans, and umbrella bags are
used near entrances and water
fountains to minimize wet floors
Mats are large enough so that several
footsteps will take place on the mat
(if there is water around or beyond
the mat, the mat may not be large
enough
Mats have slip-resistant backing
Any drip pans, such as of ice are
properly maintained to prevent
water spillage
There is adequate indoor lighting
Outside the Office
The outdoor walking surface are
free of irregularities
Yes
No
Comments
Ice and snow are promptly removed
from parking lots, garages, and
sidewalks
There are no large separations or
changes in elevation on walkways
Staff Awareness
New employees receive safety
training related to fall prevention
Other
Completed by:____________________________________________
Date of completion:________________________
*This checklist is not exhaustive and may not provide for a comprehensive assessment of all risks unique
to your organization.
Checklist components adapted from information contained in:
Department of Health and Human Services. (2010). Slip, Trip, and Fall Prevention
for Healthcare Workers. DHHS (NIOSH) Publication No. 2011–123, National Institute
for Occupational Safety and Health, Centers for Disease Control and Prevention,
Morgantown, West Virginia
Post Fall Report Form
Confidential
Name of Person Associated with Event:
Date/Time of Event:
Name of any Witnesses:
Location of Event:
Assessment of the Event:
1. What was the first initiating event?
☐ Slip
☐ Trip (includes caught on)
☐ Loss of Balance
☐ Unknown
2. Which choice best described the Slip, trip, fall (STF) injury event?
A fall from an elevation, such as
☐ A fall while standing on a chair
☐ A fall from a ladder or stepstool
☐ A fall down stairs or steps
☐ A fall from a non-moving vehicle
☐ Other fall from an elevation (describe)
A same-level fall, such as
☐ A fall while walking
☐ A fall from a chair while sitting
☐ A fall while tripping up stairs
☐ Other same-level fall (describe)
☐ Unknown
3. Were there any hazards present that may have contributed to the
injury event?
☐ Contaminant (examples: water, soap, body fluid, grease/oil)
☐ Cord or tubing
☐ Object
☐ Ice or snow
☐ Surface irregularity
☐ a curb or wheel stop
☐ Bodily reaction (examples: awkward posture, reaching, crouching,
object handling)
☐ Lack of space/restricted pathway
☐ Chair or stool
☐ Lighting
☐ Inappropriate of malfunctioning footwear
☐ Unknown
☐ Other
________________________________
Person Completing Report:
__________________________________
Date/Time Report Completed
Checklist components adapted from information contained in:
Department of Health and Human Services. (2010). Slip, Trip, and Fall Prevention
for Healthcare Workers. DHHS (NIOSH) Publication No. 2011–123, National Institute
for Occupational Safety and Health, Centers for Disease Control and Prevention,
Morgantown, West Virginia
The tool was adapted from the Bureau of Labor Statistics Occupational Injury and
Illness Classification manual (BLS 2007).
References
i
Centers for Disease Control and Prevention. "Older Adult Falls: Get the Facts."
www.cdc.gov. July 1, 2015.
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html (accessed
July 30, 2015).
ii
—. "Ten Leading Cuases of Death and Injury." www.cdc.gov. March 31, 2015.
http://www.cdc.gov/injury/wisqars/leadingcauses.html (accessed July 30,
2015).
iii
—. "Ten Leading Causes of Death and Injury." www.cdc.gov. March 31, 2015.
http://www.cdc.gov/injury/wisqars/leadingcauses.html (accessed July
30, 2015).
iv
—. "Older Adult Falls: Get the Facts." www.cdc.org. July 1, 2015.
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
(accessed July 30, 2015).
v
—. "Older Adult Falls: Get the Facts." www.cdc.org. July 1, 2015.
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html (accessed
July 30, 2015)
Centers for Disease Control and Prevention. "Older Adult Falls: Get the Facts."
www.cdc.gov. July 1, 2015.
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
(accessed July 30, 2015).
Department of Health and Human Services. (2010). Slip, Trip, and
vi
Fall Prevention for Healthcare Workers. DHHS (NIOSH) Publication No.
2011–123, National Institute for Occupational Safety and Health,
Centers for Disease Control and Prevention, Morgantown, West Virginia
ECRI Institute. "Patient Injured in Fall from Rolling Office Chair Sues
vii
Physician Practice." Physician Practice News, 2014.
viii
Stevens, J.A, M. F. Ballesteros, K. A. Mack, R. A. Rudd, E. DeCaro, and G.
Adler. "Gender Differences in Seeking Care for Falls in the Aged Medicare
Population." American Journal of Preventative Medicine 43 (2012): 59-62.
ix
Centers for Medicare and Medicaid Services. "PQRS CMS Measure Groups:
Measure #154 (NQF: 0101) Falls Risk Assessment." 2015.
x
Center for Medicare and Medicaid Serices. "PQRS CMS Measure: Measure
#155: Falls Plan of Care." 2015.