Download 1. Controlled lowering of the falling person

Slips, trips and falls policy
Slips, Trips and Falls (In-patients) Policy
Policy Number
LNWHT/CC/004/2016
Ratifying Committee
Date ratified
Name of author
Clinical Quality and Risk Committee
12th April 2016
Lead Nurse / Senior Nurse Quality and Clinical Standards
Name of ratifying Group
Date issued
Patient Safety Group
May 2016
Review date
May 2018
Target audience
Trust wide
Equality Impact Assessment
Associated policies
Yes
Slips, Trips and Falls (non-clinical)
Health and Safety Policy
Incident Reporting
RIDDOR reporting policy
Risk Management Policy and Guidance
Manual Handling Policy
Bedrail Policy
Safe and Supportive Observation Policy
Workplace Policy
Provision and Use of Work Equipment Policy
Health and Safety at Work etc. ACT 1974 and its
subordinate Regulations and Approved Codes of Practice
Key legislation considered
Circulated for consultation to
North West London Hospitals NHS Trust
Falls Group members
Slips, trips and falls policy
Contents
Section
Title
Page
1
Introduction
3
2
Statement of Intent
3
3
Scope of Policy
3
4
Definitions
4
5
Duties and Responsibilities
4-7
6
Falls Management Process
7 – 11
7
Training and awareness raising
12
8
Monitoring
12
9
Review and Development
13
10
References and Bibliography
14
Appendices
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
Appendix N
Management of patients who fall in Hospital and Health
Centres
Falls Risk Factor Assessment
Dementia and Delirium assessment
Falls Risk Care Plan
Bedrails Risk assessment Matrix and Plan
Bed Rails Assessment Tool
Mental Capacity Assessment
In-patient Care Plan for bedrails
Post Fall Care Bundle
Medical Report Following a Fall
Patient information Leaflet
Falls Assessment Pathway
Post Fall Protocol
Equality Impact Assessment
15 - 21
22
23
24 - 25
26
27
28
29
30
31
32
34
35
36
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Slips, trips and falls policy
INTRODUCTION
Patient falls are among the most commonly reported patient safety incidents to the
National Patient Safety Agency (NPSA). Approximately 208,000 falls are reported each
year in acute hospitals, according to NRLS data (NPSA 2010). The majority of falls result
in “low” or “no” harm (96%) with the remaining 4% resulting in moderate, severe harm or
death. Falls can cause distress, pain, injury, loss of confidence and mortality. (NICE
CG161 2013).
Falls are most likely to occur in older patients aged 65 and over ( NICE CG 161 2013) but
patients of all ages may fall, due to underlying conditions, acute illness, recovery from
anaesthetic or trip hazards (Patient Safety First 2009).
Preventing patients from falling is a particular challenge in hospital settings because
treatments and interventions that ensure a patient’s safety sometimes hinder their
independence. Rehabilitation always involves risk and a patient who is not allowed to walk
without staff assistance may become a patient who depends on such assistance.
The main aim of this policy is to promote a proactive approach to the problem of patients
slipping ,tripping or falling and this is done by undertaking comprehensive risk
assessments of each patient’s personal; clinical; manual handling, needs and
requirements. By doing this, a comprehensive picture is built up so that suitable actions
can be undertaken and measures put in place, so as to prevent our patients slipping,
tripping or falling.
In the interest of providing a reasonable degree of freedom for individuals, some degree of
risk will exist. All harm cannot be eliminated but staff must show that they have reduced
risk as far as reasonably possible. Patient and carer views must be included in planning
interventions which will seek the right balance between promoting independence and
dignity and minimising risk of harm.
Patients in hospital may be at risk of falling from a bed, chair, toilet seat etc. for many
reasons including poor mobility, dementia and delirium, visual impairment and the effects
of their treatment or medication. Although patients can be at risk of falling whilst in
hospital, interventions can be put in place by health care professionals to minimise the risk
of falls occurring.
This policy should be read in conjunction with the Slips Trips and falls (Staff) policy and
Incident Reporting policy.
STATEMENT OF INTENT
This policy was created to provide an overarching framework for reducing the risk of
patients falling and minimising the impact on patients when falls do occur.
Staff must identify risk factors and undertake appropriate interventions that will reduce the
likelihood of patients falling. The aim is to protect patients from risk of harm, while
maintaining their right to make decisions and maximise their activity, confidence and sense
of independence.
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Slips, trips and falls policy
SCOPE OF POLICY
The policy applies for all adult patients admitted as an in-patient at LNWH NHS Trust and
its principles apply to all other out-patients and emergency patients who attend clinics or
departments on the Trust premises; this includes the community bedded units. It also
applies to all staff responsible for in-patient areas.
This policy is primarily concerned with patients who slip, trip or fall at or near ground / floor
level in a ward/ clinic environment. However there is the possibility that patients can fall
from much higher places or levels, and therefore this policy must be read in conjunction
with the Slips, Trips and Falls (including falls from a height) Trust Policy and procedure’
which provides more detail as to how to prevent ‘people’ per se, falling from higher levels
or places on Trust premises.
4 DEFINITIONS
Slip
Slide accidently causing the person to lose their balance: this is
either corrected or causes a patient to fall
Trip
Stumble accidentally often over an obstacle causing the person
to lose their balance, this is either corrected or causes the
person to fall
Fall
The generic term used in this policy to describe any slip, trip or
fall. A fall has been defined as “an unintentional event whereby
an individual comes to rest on the ground or another lower
level, with or without loss of consciousness” (NICE, 2004).
Bed rails
Rails that can be raised to lessen risk of patient falling out of
bed.
Low-rise Bed
A bed designed to provide floor-level nursing with a height
adjustable function. The bed is suitable for patients where
there is risk of falling and bed-rails are not appropriate.
DUTIES AND RESPONSIBILITIES
5.1
Chief Executive
Along with Trust Board, has overall responsibility for ensuring this policy is fully
implemented across the Trust and associated systems assure safe and effective fall
management processes.
5.2
Medical Director
Responsible for ensuring Medical staff comply and adhere to the policy.
5.3
Chief Nurse
Executive lead responsible for ensuring robust arrangements and resources are
available to support the requirements of this policy.
5.4
Risk Management Team
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Slips, trips and falls policy
Responsible for the following falls-related tasks:
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5.5
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Keeping record of each fall on electronic Datix incident reporting system
Reporting incidents to appropriate Trust groups and committees (i.e. Falls Group,
Patient Safety Group, Health and Safety Group) and if appropriate external agencies
such as the NPSA
Assists divisional governance committees with analysis of incidents and the
production of themes and trends reports for appropriate Trust groups
Ensuring all RIDDOR reportable incidents are reported to the Health and Safety
Department who will inform the HSE as per the requirements of the Trust’s RIDDOR
Policy.
Providing advice and support to managers about development and implementation
of remedial actions
Providing training on generic risk assessments, which includes assessing fall
hazards
Distributing, collating responses and acknowledging CAS (Central Alert System)
notifications relevant to falls
Director of Estates and Facilities
Reduces threats posed by physical environment by ensuring:
Good practice is followed when new or refurbished flooring is introduced
Contractors and sub-contractors are monitored to avoid unnecessary trip hazards
Suitable equipment is available with procedures in place for cleaning, servicing and
maintenance of all equipment, floor coverings, grounds and pathways
Roads and pathways on Trust premises are suitably maintained and treated during
adverse weather conditions
Effective maintenance programmes are in place to combat potholes/ poor road
surfaces
Good lighting in all areas to reduce risk of people misjudging surfaces
Effective systems to report slipping hazards and instigate timely responsive action
Risk Assessments are carried out in all common areas to identify tripping hazards
and implement corrective actions
All areas in the Trust have been assessed for Disability Discrimination Act (DDA)
compliance and action plans are formulated to mitigate any hazards/risks
5.6 Health and Safety Team
 Advises on falls related environmental risks and proposes appropriate actions
 Review all the Datix incident reports to assess whether a patient’s slip, trip or fall,
falls within the reporting requirements of the RIDDOR 2013 Regulations; and if
necessary, undertake any investigations as necessary to ascertain the
circumstances of the incident, report the incident to the Health and Safety
Executive and make recommendations to prevent reoccurrences.
5.7
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Moving and Handling Team
Will provide advice and support to managers and staff on the following:
Selection of equipment to support patients vulnerable to falling
Use of appropriate equipment for raising the fallen person
Training staff on patient handling risk assessment and documentation and in-house
support as required
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Slips, trips and falls policy
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5.8
Procedures for evacuating patients off the floor post falls including fallen patient
with fractured neck of femur or fallen person who sustains a spinal injury
Full day Foundation Manual Handling for Overseas Nurses and newly recruited
HCAs
Prevention of manual handling related falls
Access to equipment for management of falls on the inpatient sites
Safe manual handling after an inpatient fall (Quality statements 1 & 2 of NICE
Quality Standard 86 and NPSA RRR01 2011)
Divisional Heads of Nursing (DHON) / HON and Clinical Directors
Oversee the implementation and monitoring of this policy by:
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5.9
Reporting results of key performance indicator relating to falls to clinical governance
groups and the Falls Group
Ensuring monitoring of compliance is undertaken within clinical management
structure
Reviewing risks related to in-patient falls and verifying that risks mitigation controls
are in place as defined in this policy and Risk Management Strategy Policy and
Guidance
Ensuring falls incidents investigation action plans are completed within their area of
responsibility
Matrons
Support and supervise the Senior Ward Manager/Charge Nurse in implementing
this policy:
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Leading investigation of serious risks, developing action plans to mitigate risks and
escalating any barriers to this policy’s implementation to line manager
Ensuring compliance on this policy and patient falls assessments are audited within
their area of responsibility at least quarterly
Reporting results of key performance indicator relating to falls to the Matrons, Head
of Nursing and Divisional HON meeting
5.10 Ward/ Department Managers
Responsible for ensuring:
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Staff read and understand this policy and any related policies, and this requirement
is identified as part of the appraisal process
Staff attend training to enable them to implement and monitor compliance of the inpatient falls Policy
Staff are trained and encouraged to use suitable moving and handling equipment
Moving and handling equipment is readily available and is regularly serviced and
maintained.
Staff complete and document in-patient falls risk assessment tools and relevant
tailored management plans within agreed time frames
Falls-related incidents and injuries are promptly managed and investigated – using
the Datix incident reporting system – and escalated
Participation in multidisciplinary patient-specific risk assessment tools and care
plans
The development of future strategies for service area following investigation of falls
related incidents
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Slips, trips and falls policy
5.11 Clinical Staff
All medical staff, nurses, pharmacists and allied health professionals should:
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Assess patients and participate in completing risk assessment tools and
development of individual patient care plans. Recommend any specific patient
controls (depending on individual risk assessments) and support any required
escalation of care.
Optimise patient care to prevent a fall
Report any environmental hazards in their working area that they are unable to deal
with themselves
Undertake falls awareness training offered by the Trust (e-learning)
5.12 All employees
Each member of staff is required to:
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Attend relevant training as required (section 7)
Read and comply with this policy
Promptly report any potential hazards or falls to person in-charge of area and
ensure these are rectified
Report all falls and near misses using Trust’s incident reporting system- DATIX
5.13 Trust Falls Group
Meets bi-monthly and reports quarterly to the Patient Safety Group.
The group acts as an advisory body identifying areas of best practice, key risks, action
plans and any outstanding fall-related gaps that need addressing. It also reviews and
monitors compliance with regulatory requirements and guidelines.
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Raises any issues that require disclosure to the Executive Team or require
executive action.
Researches best practice and oversee the development and monitoring of agreed
action plans to ensure the Trust meets National Standards and NPSA, NICE
recommendations.
Reviews incident themes and trends and reviews actions from falls related incidents
investigations.
Reviews training needs with Education and Development Team
Monitors falls key performance indicators
Raises awareness and communicates with other relevant Trust groups
Audits effectiveness of Falls Policy and management process
Works seamlessly with other elements of fall provision within wider community.
FALLS MANAGEMENT PROCESS
6.1
Measures that may be implemented to minimise the risk of inpatient
falls
General interventions and environmental checks
All patients must be orientated to the bed, toilet and bathroom and ward area on
admission. Drinks, food, walking aid and belongings must be placed within easy reach
of the patient whether in bed or sitting in the chair.
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Slips, trips and falls policy
The ward environment must be clutter free and clear from obstacles. All staff has
responsibilities to take reasonable care for the health and safety of themselves and
others. Spillages should be isolated and cleaned immediately and hazard signs should be
displayed. Identified hazards and incidents must be reported.
Call Bell
Every patient must be shown how to use the call bell system, and be able to demonstrate
how it works. The call bell must be in sight and in reach of the patient. Patients must be
reassured and encouraged to use the call bell.
If a patient has cognitive impairment, communication problems and/or lacks capacity to
use a call bell, there must be a documented alternative plan to ensure patients
individualised needs and requirements are met.
Eyesight and Hearing
Patients have access to own, clean spectacles and hearing aids that work.
ENT/optometry and audiology referrals made as required.
Footwear
Patient’s footwear must be assessed on admission as appropriately well-fitting and nonslip, Relatives/or carers should be encouraged to provide appropriate footwear. Only
consider Falls Reduction Socks if patient’s gait normal, if not involve physiotherapist for
assessment.
Referral to podiatry, chiropody and/or orthotic assessment may also be required for
medical reasons and patients, who are required to wear anti embolism stockings or boots
post operatively, must be risk assessed and advice given to minimise the risk of falling.
Any advice given to patients / relatives must be clearly documented in the patient notes.
Positioning and observation of patients
Patients who are identified as at risk of falling will be commenced automatically on hourly
intentional comfort rounding. This level of observation is assigned to all patients identified
at risk of falling and every hour a patient will be seen and needs met, for example toileting
offered and providing drinks. An orange wrist band will be worn by the patient to alert the
multidisciplinary team that patient is at risk of falls.
Some patients may need to be positioned in a more observable bed. This may be in bay
or a side room close to a nurse’s observation station. Any patient who needs to be moved
to a side room, for infection prevention issues and the side room is unobservable; a risk
assessment of the patient’s risk of falls must be carried out and interventions
implemented to minimise the risk of falling.
Some patients, who are identified as at high risk of falling, may require enhanced
observation in the form of cohort nursing or 1:1 Specialling. Some patients who are
confused, exhibiting walking behaviours and are unsteady will be at greater risk of falling
and 1:1 specialling may be required. The level of supervision required and provided
needs to be recorded in the risk assessment and care plan documentation (see Trust
Safe and Supportive Observation Policy)
Low profile beds
Low profile beds can be used if a patient is assessed as “at risk of falling from a bed but
bedrails are inappropriate/or unsafe”.
Consideration should be given to the use of low profile beds and patients should be
assessed individually to ensure that this is the safest and appropriate method of
preventing a patient potentially falling from their bed. This will form part of the bed rail risk
assessment.
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Slips, trips and falls policy
Cognitive impairment and Delirium
Clinical staff are able to assess patients for any acute changes in cognitive function by
carrying out cognitive tests such as the Abbreviated Mental Test Score (AMTS).
Patients who are confused and wandering in ward areas can be at risk of falls, so it is
important that sources of delirium (such as infection) are identified and treatment
commenced. A urinalysis must be performed in patients who are either confused or have
urinary symptoms during admission, to rule out the possibility of urinary infection causing
falls and delirium.
The Trust Dementia and Delirium Assessment should be completed for all patients
identified at risk of falling, admitted with a fall or has had a fall as an inpatient (Appendix C)
Medications and lying & standing blood pressure
Patients can be at risk of falling if they are on certain medications which may be sedating,
induce confusion or continence problems, cause symptomatic hypotension or systolic
drop on standing. As part of a multi factorial assessment, medical staff with pharmacist
involvement will be able to complete a risk/benefit review of patient’s medications.
The Royal College of Physicians (RCP) through a project called FallSafe, advise that
there should be no prescribing of new night sedation (unless there are documented
medical reasons to do so). There is a comprehensive list of “medicine and falls in
hospital” available (Implementing FallSafe, Royal College of Physicians 2012).
Osteoporosis/bone health review must be considered, and if necessary interventions for
falls and bone health treatment commenced (NICE guidance CG 146 Osteoporosis:
assessing the risk of fragility fracture Aug 2012)
Patients who are admitted with a fall/or collapse or syncope (faint) will require completion
of a lying and standing blood pressure. The need to complete this measurement will be
based on an initial medical assessment on admission to hospital, in addition to
investigating underlying causes of unexplained falls or collapse.
Patients recovering from post-operative procedures may be at risk of falling and as the
anaesthetic medication wears off patients may be more susceptible to postural
hypotension.
Continence and Toileting
Patients can be more at risk of falls if they have urgency or incontinence. A full
assessment including urinalysis needs to be undertaken and referral to continence
service as appropriate.
A patient who is assisted to use the commode or taken to the toilet, must be risk
assessed if left alone for any length of time. The risk assessment must include reviewing
a patient’s ability to use the call bell to request assistance and balancing this with privacy,
dignity and autonomy of the patient.
Balance and Mobility
On admission, all patients receive a moving and handling assessment which is
periodically reviewed during the patient journey. As part of the assessment, each patient
will be assessed for their physical capability and what activities they would be expected to
undertake in a toilet or bathroom to ensure the risk of falls is minimised.
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Slips, trips and falls policy
Physiotherapy staff will review patients who require balance, mobility and strength
assessment. Mobility aids will be provided as appropriate and advice given to both
patients and staff of plans to reduce the risk of falls.
Occupational Therapists will complete a functional assessment and also a home hazard
assessment in the community.
Patients, relatives and carers
If a patient is identified at risk of falling, discuss plan of care with both the patient and
relatives/or carers explaining the risk and prevention measures being taken and provide
the information leaflet for patient and relatives about risk of falling (Appendix K).
Relatives/carers must be informed of an inpatient fall at the earliest opportunity (with the
patient’s consent) and be given time to discuss the incident and an explanation of
interventions that have been implemented to mitigate further falls occurring
6.2 Falls Risk Factor Assessment
All in-patients must be assessed for the risk of slips, trips and falls on admission to each
clinical area/ward using the Falls Risk Factor Assessment Form (Appendix B).
For patients assessed to be at risk of falling, slipping or sliding out of bed, an assessment
must be undertaken using the Bed Rails Risk Assessment Matrix (Appendix E). The
Bed Rails Assessment Tool (Appendix F) must be used on admission and reviewed
weekly to determine if bed rails should be used or continued to be used.
If the mental status of a patient is in question or a patient has impaired judgement such as
confusion, significant memory loss then a Mental Capacity Assessment must be
completed (Appendix G)
All inpatients must have a Falls Risk Factor Assessment Form and Bed Rails Risk
Assessment Form within 6 hours of admission. Following assessment, the Falls Care
Plan and Interventions (Appendix D) must be completed.
Table 1: Time frames for completion of falls risk factor assessment and
bedrails/trolley rails assessment/care plan and review in all inpatient facilities
Accident and Emergency (A&E)
On arrival (adults only) Complete the
Risk Assessments / action plan in ED
Inpatient
Within 6 hours of admission including
transfers from ED and assessment
wards
Within 6 hours of transfer
Transfer to another area
Following a fall or change of condition
(see below)
Within 6 hours
If patients length of stay > 7 days
Repeat falls and bedrails
assessment every 7 days
If the risk to the patient has changed significantly i.e. “condition change”, due to mental or
physical condition which increases the risk of a fall, this warrants immediate risk review
but within 6 hours.
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Slips, trips and falls policy
Examples of “condition change” that would require a repeat assessment include:
• Patient has a slip, trip or fall
• Patient
has
undergone
a
procedure
under
general
anaesthetic/sedation
• Patient’s medical/surgical condition has declined e.g. may
have developed confusion/delirium due to an infection
• Patient’s mental status or capacity has declined, increasing risk of
falling
• A decline in the patients mobility or balance
• A patient who was initially assessed as immobile or “unlikely to move
unless assisted”, is now mobilising, but is “unsafe” and requires supervision
These examples are not exhaustive and staff must use clinical judgement. Some patients
may require continuous risk factor review on a daily basis.
6.3 Falls Care Plan Completion and implementing interventions
All patients identified at risk of falling, following the completion of a falls risk assessment,
must have a falls care plan completed (Appendix D). The falls care plan details good
practice guidance on necessary interventions to reduce the risk of falls.
The following interventions in this section provide a comprehensive list of multi-factorial
interventions that should be considered, based on individualised falls risk factors. It is
important to review the interventions implemented, within the timeframe indicated in section
6.2 (Table 1).
6.4 Care Plan for the Use of Bed Rails
Once a patient has been identified as at risk of a fall – and an assessment has been
undertaken outlining the need for the use of bedrails – the In-Patient Care Plan for Bed
Rails (Appendix H) must be commenced.
6.5 Falls Risk Symbol
Patients who are identified as at risk from falling will have a symbol placed on the boards
behind their bed. This pictorial symbol is used in addition to the verbal and written
handover identifying those patients assessed as at risk of falling.
6.6 Handover for Transfer of Patients
All in-patients being transferred from one clinical area/ward to another must be included in
a specific handover of all the assessments and care plans to ensure that the management
of this risk is emphasised to the new clinical area.
6.7 Reporting a Slip, Trip or Fall.
Irrespective of where they occurred, all instances of falls must be reported on the Trust
incident reporting system DATIX. The slip, trip or fall (including near- misses) must be
documented within the patient’s records and both medical staff and the patient’s next of kin
should be informed
6.8 Post Fall Assessment and Management
When a patient is found after a fall the Post Fall Care Bundle must be completed
(Appendix I) and Management of Patients Who Fall in Hospital and Health Centres
(Appendix A) followed.
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Slips, trips and falls policy
A LAMINATED POST FALL PROTOCOL (Appendix L) SHOULD BE AVAILABLE FOR STAFF
TO FOLLOW AND A SAFETY HUDDLE INSTIGATED AFTER EACH FALL TO REVIEW THE
INCIDENT AND LEARNING SHARED TO PREVENT FURTHER FALLS (as per NICE
Guidelines).
6.9
Post Fall Medical Assessment
Following a slip, trip or fall within in-patient settings, a medical review needs to be
undertaken using the Medical Report Following a Fall (Appendix J).
Regarding timing of investigations post fall the NICE Guidelines recommend:For adults who have sustained a head injury and have any of the following risk factors,
perform a CT head scan within 1 hour of the risk factor being identified:
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GCS less than 13 on initial assessment in the emergency department.
GCS less than 15 at 2 hours after the injury on assessment in the emergency
department.
Suspected open or depressed skull fracture.
Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid
leakage from the ear or nose, Battle's sign).
Post-traumatic seizure.
Focal neurological deficit.
More than 1 episode of vomiting
Patient’s GP must be informed of inpatient fall and /or identified falls risk.
Training and awareness-raising
All Trust staff will be made aware of the requirements of this policy and their associated
responsibilities. They are also required to attend mandatory clinical Risk Assessment
Training and the mandatory Moving and Handling training every 2 years. All clinical staff
are expected to undertake the Falls awareness training offered by the Trust.
Staff line managers will monitor compliance of training at staff appraisals. Further
information on training requirements is available via Education and Development
Department.
Monitoring
The Trust monitors the implementation of the Slip, Trips and Falls policy by a number of
mechanisms listed in the table below:
Aspect of
compliance or
effectiveness
being
monitored
Monitoring
method
Individual
or
department
responsible
for the
monitoring
Requirement to
undertake risk
assessments
described
within this
Audit
Heads of
Nursing
(HON)
Frequency
of
monitoring
activity
Group /
committee
forum which
will receive
the findings/
monitoring
report
Six monthly Falls Group
Committee/
individual
responsible
for ensuring
that the
actions are
completed
Divisional
HON/HON and
Matrons forum
Matrons
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Slips, trips and falls policy
policy
Completion of
Falls Risk
Factor
Assessment
and post fall
action record
Training
Falls Group
Audit
Heads of
Nursing
Matrons
Six monthly Divisional
HON/HON
and Matrons
forum
Data
Education
Annual
Interrogation and
from ELMS
Development
Team
Falls Group
Falls Group
Falls Group
HR , Training
and Education
committee
This policy will be reviewed by the Falls Group and monitored by each Directorate in their
Clinical Governance meetings. The responsibility to monitor and to raise awareness of
how to prevent and to manage slips, trips and falls in each area will rest with each
Directorate with advice from the Falls group when necessary.
The Risk Management Team will keep records of all incident forms and provide reports to
the falls group and relevant committees/groups. Reports provided to the falls group and
Patient Safety will include the incidence of patient’s falls, common themes and trends. All
falls incidents investigation ((Internal Critical Investigation and Serious Investigation) report
will be presented by the Divisional Governance Coordinators or representative to the falls
group for information and discussion that will influence the Trust falls strategy and policy
review
Matrons/Departmental Managers must review each incident with support from divisional
governance coordinators and when appropriate involve other personnel (e.g.
physiotherapists, occupational therapists, the moving and handling facilitator and estates
staff if appropriate). The review aims to ensure effective actions have been implemented
to avoid similar incidents in the future either to staff, a patient, contractor or visitor. All
incident Forms will be used to monitor and review falls statistics to establish any trends.
8.1 Compliance
Compliance with this policy will be monitored via the Clinical Incident Reports and conduct
of audit (see monitoring above). Benchmarking will be undertaken via participation on
National Falls Audits and NHS Safety Thermometer survey results. Recommendations
from the national reports and audits will be reviewed by the STF Group and supported by
the Trust Clinical Audit Team.
Review and development
This policy will be reviewed every two years or as required by changes in operational
practices and to reflect national requirements when required.
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Slips, trips and falls policy
References, Sources and Bibliography
NICE CG161 Falls: Assessment and Prevention in Older People (June 2013)
NICE Quality Standard 86 Falls in Older People: Assessment after a fall and preventing
further falls (March 2015)
Brown, H. (2010). Graded Response Observation Chart (Leeds Teaching Hospitals Trust Revision date: November 2012)
Department of Health (2001): National Service Framework for Older People Standard Six:
HMSO, p16
Department of Health High (2009): Quality Care for All the journey so far HMSO
Mowbray C, Betts M, Douglas S, Taylor R, 2006 (unpublished presentation for Disabled
Living Foundation, Islington): To hold or not to hold? Managing the falling and fallen client
– An everyday occurrence
NICE (2004): Guidelines for assessment and prevention of falls in older people
NICE: Head Injury. Issue Date: September 2007
NMC (2009): Record Keeping: Guidance for Nurses and Midwives
NPSA (2007 & 2010 reports): Slips, Trips and Falls in Hospitals www.npsa.nhs.uk
Patient Safety First campaign: ‘How to’ guide for reducing harm from falls
National Back Pain Association (NBPA/RCN), (1997): Guide to the handling of
patients Middlesex
ProFaNE, Prevention of falls http://www.profane.eu.org
Resuscitation Council (UK), (2001): Guidance for Safer Handling During
Resuscitation in Hospitals, London
Subbe CP, Kruger M, Rutherford P, Gemmel L (2001) Validation of a modified Early
Warning Score in medical admissions
Tappen et al (2000) Effects of combined walking and conversation intervention on
functional mobility of nursing home residents with Alzheimer Disease
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Slips, trips and falls policy
Appendix A
MANAGEMENT OF PATIENTS WHO FALL IN HOSPITAL AND HEALTH CENTRES
A risk assessment is the key to the successful management of falls; it is not possible to exclude the
risk completely. There are two situations that staff may find themselves in:


When a person starts to fall or is falling
When a person has already fallen and is on the floor
Although it is a reactive response to try to catch a falling person, the current advice is that this
should not be done. Understandably, the healthcare staff within the Trust may not feel comfortable
with that approach, but they must at all times consider their own health and wellbeing above that of
the patient/other person.
Figure ..: examples of high-risk practices
The Guide to handling of patients, (NBPA/RCN, 2011), stated that “poor manual handling practices
including assisting people who were falling or had fallen resulted in 5000 injuries per year. Manual
handling risk increases when people fall because a handler may attempt to catch, support or
intervene with a falling person or because they attempt to retrieve the fallen person manually.
Where it is impractical to demonstrate manoeuvres to manage a fallen person, it has been
acknowledged that theoretical and pictorial discussions regarding systems to manage the fallen
person are sufficient.
BackCare in 2005 advocates that lowering a falling person to the ground is only appropriate if we
assume that staff are standing by the side of the person slightly behind; the person is falling is
backwards or directly downwards; the person does not resist; the person is not significantly taller or
heavier than the staff; and that there is sufficient space with no obstructions.
Therefore, staff MUST NOT hold a patient or other person up if they are falling or fainting.
General rules for management of a falling person
The management of falling person may be achieved in a number of ways, but the general rules do
not change.
 Do not support the person when they are falling, but allow them to slide to the floor/ground
 Do not catch or control the descent of a falling person
 Consider your own health and safety above that of the falling person
Unsafe practice when a person is falling:
 Rushing up to ‘catch’ a falling person
 Trying to hold a collapsed/falling person upright.
A Person on the Floor – (A Fallen Person/Patient)
Approach the management of any fallen person in a calm and systematic manor, before carrying
out the following assessment;
15
Slips, trips and falls policy
Assessment
 Check for danger – make area safe for yourself and the person
 Check the person – ‘ABCDE’ (first aid measures), medical and physical assessment
 Stay with the person - Do not attempt to move the person until he/she has calmed down;
exception would be if there is a danger of a person injuring themselves.
 If appropriate place a pillow under the person’s head and keep the person warm.
 Do not give a pillow if a spinal or head injury is suspected.
 If you suspect serious Injury seek Medical Attention. Call 999 in the community locations or call
the Doctor (on call) in the hospital settings
 Any person who has fallen and has a suspected head, back, pelvic or lower limb fracture must
not be manhandled or hoisted off the floor. To prevent further injury, a scoop stretcher must be
used by suitably trained nurses, clinicians or paramedics to lift the patient off the floor / ground.
Consideration must also be given to the use of a spinal board with neck / spine and fracture
immobilisation
Scoop stretchers can be obtained from the accident and emergency departments.
Strategies to Manage a Falling Person
The Guide to handling of patients, (NBPA/RCN, 2011) states that Organisations should refrain
from blanket of no intervention systems and should focus on risk management strategies to reduce
the risk of falls.
1. Controlled lowering of the falling person
The extent of risk of catching the falling person is significant.
This technique should only be used if the patient can weight bear fully or partially. The
assumption is that:
The handler is standing by the side of the person and slightly behind before the person starts to fall
 The person is falling backwards or slightly directly downwards
 There is sufficient space with no obstructions e.g. beds commodes
 The person is not resisting
 No significant height and size difference between the patient and the staff member
 Release hold of patient and get behind patient once behind patient place one foot in
front of
the other to form a stable base
 Bend the knee of the leading leg
 With both hands open grasp the patient by holding on to the trunk near the hips
 Allow patient to slide down leading leg until they are lowered safely to the floor.
 Handler should avoid flexing the back, and should kneel behind person
 Staff to ensure they have performed a dynamic risk assessment and consider factors
mentioned above
Figure 2: Represents the stages of lowering of a falling person in a controlled manner
1.1.
Redirecting a fall on the stairs
Patient with weight bearing activity undertaking stair mobility
16
Slips, trips and falls policy
1.2.1
Ascending the stairs
Staff to position themselves behind the patient with arm outstretched behind providing a support
figure

If the patient starts to fall on the stairs, staff to use body weight to redirect patient to higher
step
1.2.2
Descending the stairs
 Staff to stand in front and to the side of the patient figure
 If a patient starts to fall, staff to use outstretched arm and body weight to redirect patient to on
to the step behind.
2.0
FALLEN PATIENT
Prior to assisting the fallen person staff should always check the following:





No environmental hazards are in situ and there is safe and clear access
Airway Breathing Circulation (ABC)
Check for injuries, bruising, possible fractures, pain and behavior. This assessment should be
performed by trained members of the team.
Adequate staff to assist
Staff are trained to support the process
2.1
Supervised approach (minimal assistance to the fallen person)
Independent transfer from the floor (using 1 or 2 chairs or stools)










Position the chair at the head of the fallen person
Verbally instruct patient to bring one arm across chest until arm is flat on the floor
Instruct patient to move other arm away unto their side into side lying
Instruct patient to push up in to sitting and go on all fours facing the chair
Instruct patient to face the chair an position for arm on chair seat
Ask patient to bend one knee and place foot flat on floor
Instruct patient to push up with their hands and forearms
Instruct patient to push up, straighten legs and turn to sit on chair
If required another chair or stool can be placed behind the patient for them to sit backwards
Person completes the process with minimal supervision from healthcare staff.
2.2
Backward chaining – 1 chair
Position the chair at the head of the fallen person






Verbally instruct patient to bend knees up and to bring one arm across chest
Instruct patient to move other arm away from the body and roll unto their side into side lying
Once on the side, instruct patient to bring the arm on the chest across the body and place
palm flat on the floor
Instruct patient to push up in to sitting and go on all fours facing the chair
Instruct patient to push up, straighten legs and turn to sit on chair
Person completes process with minimal supervision from healthcare staff.
2.3
Sideway transfer – 1or 2 chairs
Ensure there is a stable platform [1 or 2 stable stool(s)/chair(s) – preferably no arms] at the
person’s side. Encourage the person to get into half kneeling position by:


Placing their near hand onto chair seat
Bringing their near leg through, foot flat on the floor
17
Slips, trips and falls policy


The person’s other hand is on their bended knee or they use it on the floor/another chair by
their side. Ask the person to push down with near hand on the chair and at the same time on
their raised knee / floor/ chair with their other hand.
When the person pushes down on the seat, encourage them to bring through their foot while
swinging their hips round to sit onto the seat.
2.4
Supervised movement from the floor – 2/3 chairs.
(Most people will find it easier to use 2 chairs - one on each side to push down)



Ask the person to get on all fours and then into a half kneeling position
With one hand on each chair ask the person to push down on the chairs while swinging their
hips sideways lift himself onto one of these chairs.
Or
Pushing down onto the chairs to come up into a standing position, then a third chair is placed
behind the person to sit down.
2.5
If the person is unable to kneel, but co-operates then try the following:
 Assist the patient to sit forward on the floor
 Place a foot stool or chair cushion behind them
 Ask the patient to place their hands behind themselves on the side of the stool / cushion and
digs their heels in (knees bent) and push themselves onto the stool/cushion.
 This is repeated gradually onto higher surfaces until the person is able to stand.
 If the fall occurs near stairs ,the patient can utilise the stairs by pushing themselves up onto
the stairs and using the banister to pull up into standing
Note: If a person is on the floor and cannot roll onto ‘all fours’ or sit up on the floor, equipment
must be used, unless the situation is life-threatening.
3.0
HOISTING A PERSON FROM THE FLOOR WITH A SLING HOIST
Before deciding how to assist the person, the person must be assessed. DO NOT hoist someone
with suspected spinal injury or fracture. You must:
(a)
Be aware of the person’s ability:
 Are they fully dependant, unable to weight bear or unable to turn in order to move onto hands
and knees?
 The persons weight must be less than the Safe Working Load (SWL) of either the hoist or the
sling,
 Consider their medical condition, pain, skin condition
 Can they co-operation,
 Are there any attachments (catheters, drips etc.).
(b)
Check that the hoist is suitable for the task:
 The sling goes with the hoist, the sling is a correct size for the person, and that you are
competent to use this hoist.
 Check the hoist and the sling as required by the Lifting Operations and Lifting Equipment
Regulations (L.O.L.E.R.)
Hoist inspection:
 Service label: Last maintenance/service date of the hoist - within last 6 months.
 Hoist in working order – Check that the hoist goes up & down; brakes work; hoist legs open &
close; power supply is OK: hoist battery charged or alternative battery on charge
 SWL of the hoist and the sling – the smallest one of these must be more than the patient’s
weight.
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Slips, trips and falls policy
Sling inspection:
 Is the sling safe to use – Check that the material, seams and stitching is intact and not torn,
straps and/or clips are not broken, washing instructions, sling number and Safe Working Load
(SWL) is visible and that the sling is clean.
 Patient Specific Slings, check as above and ensure the person’s name and the date of issue is
recorded on the sling and that it is used for one person only. The sling must be discarded if
soiled, or following a person’s discharge or if the ’do not wash’ sign has disappeared or
changed to a round circle with a line across.
Staff:
All staff must ensure that they are:



Fit for the task
Familiar with the use of the hoist and the sling and able to use it safely.
Familiar with the emergency stop and lowering mechanism of the hoist.
(c)
Assessment of the area
 Consider the space for hoisting and ensure it is safe to proceed.
 If more space is needed for hoisting, slide the person using a transfer slide sheet (pillow under
the person’s head) to an area that has sufficient space.
 Should a person fall in an area where there is no hoist, one can be obtained from the nearest
ward, as all wards in the Trust have a hoist.
PROCEDURE FOR HOISTING A PERSON FROM THE FLOOR
There must be at least 2 or 3 staff present.












2 staff kneel on the floor and roll the person onto a sling or
Insert 2 slide sheets under the person and slide the sling between the slide sheets by rocking
back on their heels. The top slide sheet is removed once the hoist sling is in position.
or
2 staff sit the person forward using the elbow to elbow grip and position the sling behind the
persons back. This move should only be attempted providing that the person is lightweight,
Has strength in both arms and s able to flex their knees slightly.
To aid with connection of the sling to the hoist spreader bar one staff could kneel on the floor
with the person’s head and shoulders resting on their knees. This can provide reassurance for
the fallen person.
or
The person may be able to sit forward against an upturned chair with a pillow against the
backrest rather than resting their head on the staff’s knees.
In preference, if the person is able to bend their knees, the hoist can approach from slightly
sideways to the person.
The hoist legs open fully.
Move the hoist to fit one hoist leg fit under the person’s bended knees and the other just past
the person’s head that is resting on a pillow.
or
When the hoist is in position, brakes are applied while the spreader bar is lowered and the sling
is attached to prevent the person pushing or kicking the hoist away. For ARJO hoists the
brakes are released before starting to lift the person off from the floor. For LIKO hoist the
brakes are kept on until the patient is just starting to lift from the floor.
Do not apply brakes when lowering the person onto the bed.
Management of a person who has fallen in a confined space after completion of the
assessment
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Slips, trips and falls policy
4.0
Unsafe Techniques
These manual techniques should NOT be used when assisting a person off from the floor:
‘Arm and leg lug’
‘Underarm drag lift’
Shoulder lift
Canvas and pole
Use of a Pat slide
5.0




Manual lift from the floor
A full risk assessment must be carried out taking into account:
The environment
Individuals carrying out the lift
Positioning of the trolley or the bed
The person on the floor
Remember:
This is a high-risk technique and should only be used if there is no other option. All members of
staff should be made aware of the risks to themselves and be given an option to refuse to assist in
the transfer. A minimum of six – seven staff are required and therefore help should be requested
from other departments/wards if necessary.
All staff taking part must be able to bend their knees and should have no current musculoskeletal
disorders.
Listed below are the situations that can be defined as exceptional and may, as a last resort require
manual lifting:

In the event of evacuation e.g. fire.

Where the use of a hoist may be contra-indicated e.g. suspected spinal injury
In this case a spinal board should be used. (Spinal board is kept in A&E Department at Ealing
Hospital).

Medical or life threatening situations e.g. where there is imminent danger of harm if the
patient is not moved or where a patient is brought to the Accident and Emergency Department
in a private vehicle or of their own volition and may require immediate assistance.

Cardiac or respiratory arrest - a person on the floor; the person should only be lifted once
stabilised or when a clinical decision has been made and ‘a sufficient’ number of ‘fit’ staff has
arrived to assist as it is deemed more appropriate to continue resuscitation on a better height
surface. In the first instance’ if necessary, use a slide sheet/transfer sheet to move a patient to
an area where resuscitation can start. The Liko Viking XL hoist with a stretcher attachment
and sling for lifting horizontal patients from A&E should always be the first choice rather than a
manual lift.
A trolley or a bed must be ready on its lowest level with a slide sheet on it. The person should
be rolled and a lifting sheet placed underneath. Additional staff may be required to support the
person’s head and one at their feet.

A ski sheet or a ski pad should be used.
Appropriate equipment should be kept ready in the areas where it is likely to be needed. Regular
auditing will indicate the equipment that is needed, for example the question ‘should a scoop
stretcher be purchased’ should be based on incidents when it would have been more appropriate
than the lifting sheet or the spinal board that are currently available in the Trust. Incidents of
heavier patients collapsing on the floor would indicate the need for a MANGA Lifting cushion –
CAMEL or ELK – not currently available in the Trust.
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Slips, trips and falls policy
A lifting sheet is specifically designed for transferring or lifting a person and will have an
appropriate Safe Working Load (SWL) and handholds. All wards and departments should have at
least one lifting/transfer sheet. The number of lifting/transfer sheets should be based on the
department’s annual generic risk assessment for managing of falls.
[If the resuscitation on the floor was unsuccessful then a sling hoist must always be used to lift the
body onto a trolley/bed, ensuring that the privacy and dignity of the patient are maintained].
Pat Slides must not be used for the task of lifting a person from the floor
6.0
Procedure for Managing Fallen/Collapsed Person in Non-Clinical Areas or Hospital
Grounds
Action to be taken If a person falls/collapses inside the Hospital Buildings
If an incident is reported to you that a person has collapsed/fallen in the common areas of the Trust
i.e. inside the building:
 Dial 2222 immediately, report as a medical emergency.
 Switchboard to fast bleep the medical team and the Clinical Site Practitioner
 The Site Practitioner and the medical team to attend the area to provide medical assistance.
Action to be taken if a person falls/collapses in the Hospital Grounds
If a person falls/collapses in the Hospital Grounds
 Dial 2222 immediately and report as a medical emergency
 If outside the Hospital building switchboard will call an ambulance for medical assistance.
Incident Report
 A Datix incident form must be completed at the time with details of any witnesses/persons
involved and notified a member of the Risk Management Team within 3 days.
 RIDDOR Reportable Serious injury Deaths must be reported to Health and Safety Executive
(HSE) immediately.
In Working Hours:
This must be escalated to a Senior Manager in the service (i.e. General Manager, Assistant
Director or Community Service Director and Risk Management Team.
Out of Hours:
This must be reported to the:
Acute:
Community:
Clinical Site Practitioner
Senior Manager on call via Ealing Hospital switchboard.
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Slips, trips and falls policy
Appendix B
Falls Risk Factor Assessment
To be completed for all Adult inpatients as per Trust Policy
PATIENT NAME:
Hospital / NHS No:
Date of admission:
Repeat the assessments within 6 hours
 Of transfer
 If the patient’s condition changes or post fall
 Post-operatively / post procedure (if sedation
used)
 Every 7 days
Complete assessment for every patient
within 6 hours of admission
FALLS RISK FACTOR ASSESSMENT
If Yes (Y) to any of the
following 8 questions –
the interventions
identified in the Falls
Risk Care Plan overleaf
must be completed
Falls Risk Factors
Questions
1. Is the patient 65
years or above?
2. History of falls
before admission?
3. Admitted with a
fall/collapse?
4. Fall since admission
5. Patient or
relative/carer
anxious about falls
6. Tries to walk alone
but unsteady and/or
unsafe?
7. Is patient Delirium /
Dementia
(assessment)
8. In your professional
judgment, is the
patient at risk of
falling?
Ward:
Ward:
Ward:
Ward:
Admission
Assessment:
Date:
Review
Assessment:
Date:
Review
Assessment:
Date:
Review
Assessment:
Date:
Time:
Time:
Time:
Time:
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N Reason
Y/N Reason
Y/N Reason
Y/N Reason
PRINT NAME:
SIGNATURE:
22
Slips, trips and falls policy
NHS number
Hospital Number
Name
DOB
Male/Female
Appendix C
DEMENTIA AND DELIRIUM ASSESSMENT
MANDATORY FOR ALL EMERGENCY
ADMISSIONS AGED ≥ 75 YEARS
Exclusions:
Unconscious/severely unwell
Assessment declined by patient with capacity
Communication / sensory difficulties
Doesn’t understand English / no translator
STEP ONE: FIND PATIENTS WITH DEMENTIA OR DELIRIUM (complete within 72 hrs)
1 Does the patient already have a formal diagnosis of dementia?
YES
NO
2 Was the patient admitted with delirium - CAM positive?
YES
NO
YES
NO
YES: STOP form and continue with best practice
NO: go to Question 2
YES: go to STEP TWO and follow NICE Guidelines to treat delirium
NO: go to Question 3
3 Ask the patient / family / carer:
‘Has the patient been more forgetful in the last 12 months to the
extent that it has significantly affected their daily life?’
YES: go to STEP TWO
NO: STOP form and continue with usual care
Signature
Name in capitals
Contact number
STEP TWO: ASSESS AND INVESTIGATE
A: AMT (from clerking booklet)
B: Clinical history
(ask patient / family / carer)
1. How old are you?
2. What is your date of birth
3. Repeat “42 West Street”
1/0
1/0
-
When did the memory
problems begin?
I am going to tell you an address.
Remember it as I’ll ask you about it later.
4.
5.
6.
7.
What year is it?
What time is it?
Name of this hospital
Recognise two people
1/0
1/0
1/0
1/0
How did the memory
problems begin –
gradually/suddenly?
Do you remember my name or job?
Do you remember this person’s job?
8. What was the date of WW1
9. Who is the current monarch
10.Count backwards from 20
11.Recall “42 West Street”
1/0
1/0
1/0
1/0 Do
you remember the address I told you
the start of the assessment?
Total AMT score:
at
Date
C: Physical examination/
investigations/medication review
Reversible causes of cognitive
impairment identified:
a. Physical examination
b. Investigations: FBC, U&E, Ca,
LFTs, TFT, CRP, B12, folate, CXR,
ECG, urine dip, MSU, HIV,
treponemal serology, consider CT
head
c. Medication review: especially
antipsychotics
Answer:
Have memory problems
stabilised or been getting
worse?
/10
(AMT ≤7:consider dementia)
Signature
Name in capitals
Contact number
Date
STEP THREE: REFER ON FOR FURTHER DIAGNOSTIC ADVICE OR FOLLOW-UP
Delirium / inconclusive diagnosis – ask GP to re-assess at 4 weeks post discharge and consider
referral to memory clinic as necessary.
Suspected dementia – inform GP of suspicion and tests performed so far, ask GP to re-assess at
4 weeks post discharge and consider referral to memory clinic.
Delirium /suspected or known dementia
If concerns about mood, behavioural disturbance, antipsychotic treatment or diagnostic complexity
consider referral to the Dementia Matron +/or Liaison Psychiatry (via ICE at NPH or white card at CMH).
Signature
Name in capitals
Contact number
Date
23
Slips, trips and falls policy
Appendix D
Falls Risk Care Plan and Interventions
To be completed by Nursing Staff
ALL ACTIONS MUST BE CLEARLY DOCUMENTED IN PATIENT NOTES
PATIENT NAME:
Hospital / NHS No:
Interventions
Ward:
Ward:
Ward:
Ward:
“Yes” – Interventions required and in place
“N/A” – Not needed or required
“U” – unable to provide/achieve
State reason in additional comments
section
Initial
Assessment:
Review
Assessment:
Review
Assessment:
Review
Assessment:
Date:
Date:
Date:
Date:
Time:
Time:
Time:
Time:
Display Falling Leaf symbol above patients
bed
Patient has an orange name band on
Call bell within reach and patient
understands how to use it
Footwear is well fitting and nonslip. Provide
alternative if required
Implement minimum hourly “Intentional
rounding”
Patient needs positioning in an observable
area of ward?
State where positioned
Enhanced level of observation required?
State which
 Cohort nursing
 Specialling (1:1 constant supervision)
If bed rails not recommended and patient at
risk of falling from bed is a Low profile bed
required? (refer to guidance)
Toileting and Continence issues
Assess if frequency &/or urgency/mobility
issues
Urinalysis required/completed?
Complete continence assessment/refer for
further advice?
Refer to Moving & handling care plan for
toileting requirements
Patient able to access walking aids
Patient needs a full mobility and functional
assessment
Refer to OT / Physio for assessment
Spectacles are well fitting and clean
Check patient wearing as needed
hearing aids are working – Check battery
Patient, relative/carer information leaflet
“Risk of Falling” must be given
Additional Comments
(Please use this section to state reasons
why unable to provide or achieve
interventions)
MSSU
Dipstick
Physio
OT
PRINT NAME:
SIGNATURE:
PRINT DOUBLE SIDED
24
Slips, trips and falls policy
Appendix D
Falls Risk Care Plan and Interventions
To be completed by Medical Staff
ALL ACTIONS MUST BE CLEARLY DOCUMENTED IN PATIENT NOTES
PATIENT NAME:
Hospital / NHS No:
Interventions
Ward:
Ward:
Ward:
Ward:
“Yes” – Interventions required and in
place
“N/A” – Not needed or required
“U” – unable to provide/achieve
State reason in additional comments
section
Initial Assessment:
Review
Assessment:
Review
Assessment:
Review
Assessment:
Date:
Date:
Date:
Time:
Time:
Time:
Date:
Time:
Consider Trust Dementia and
Delirium assessment
Postural Hypotension if applicable
(Supine / Erect)
Lying and standing blood pressure to
be commenced and recorded on
NEWS chart
History of blackouts or syncope
Medication Review with help from
Pharmacist
1. Drugs that increase the
chance of a fall
2. Bone Health
3. Use of anticoagulation
LMWH / NOAC

Unable to see/recognise pen/watch
from 2m
Hearing (cannot hear conversational
speech)
Additional Comments
(Please use this section to state
reasons why unable to provide or
achieve interventions)
PRINT NAME:
SIGNATURE:
PRINT DOUBLE SIDED
25
Slips, trips and falls policy
Appendix E
Bedrails Risk Assessment and Plan
Risk matrix tool
MENTAL STATE
Risk matrices provide a familiar format that is easy to understand but may over-simplify some
decisions. For example, in the matrix below there are more relevant elements that the matrix suggests
including vulnerability to injury and visual and spatial awareness.
Patient is confused and
disorientated
Use bedrails with care
Bedrails NOT
recommended
Bedrails NOT
recommended
Patient is drowsy
Bedrails recommended
Use bedrails with
care
Bedrails NOT
recommended
Patient is orientated and
alert
Bedrails recommended
Bedrails
recommended
Bedrails NOT
recommended
Patient is unconscious
Bedrails recommended
N/A
N/A
Patient is very immobile
(bedfast or hoist
dependant)
Patient is neither
independent nor
immobile
Patient can mobilise
without help from
staff
MOBILITY
Using the matrix and professional judgement, to support decision making, also consider the
following questions and decide if bedrails are recommended

Is this patient at risk of falling, slipping or sliding out of bed?
Yes
No

Does this patient have capacity to consent to use of bedrails?
Yes
No

If yes, has verbal consent been obtained for the use of bedrails?
Yes
No

If no, has a decision been made in the patients best interest?
Yes
No

Are bedrails, mattress and bed in safe condition?
Yes
No

Are bedrails recommended?
Yes
No
Date:
Review Date
Sign and Print Name:
Continue bedrails use
Discontinue bedrails use
Name/signature
26
Slips, trips and falls policy
Appendix F
Attach Patient Label
Ward:
……..…………………
Bed Rails Assessment Tool
Complete this form for every patient on admission and review weekly to determine if the
bed rails (side rails / cot sides) on the bed should be used.
Admission
1
2
3
4
5
6
Week 1 Week 2
Week 3
Week 4
Date
Does the patient use bed rails at
home?
YES NO
History of falling out of bed at
home / on the ward
YES NO
Altered level of consciousness
YES NO
Mental status - impaired judgement
such as confusion, significant
/severe Memory loss
YES NO
(**if the answer to question 4 is
YES, complete the Mental Capacity
assessment over leaf)
Poor sitting balance
YES NO
Poor spacial awareness (e.g.
Visual neglect of one side of
environment due to CVA)
YES NO
Signature:
If the answer is YES to any of the questions above – USE BEDRAILS
If all the answers are NO – DO NOT USE BEDRAILS unless the patient request to have bed
rails.
Bed rails to be used
Bedrails not needed / NOT to be used
If patient’s head / body is smaller than average adult consider use of bumpers with side
rails / paediatric bedrails if bedrails are needed
Use of bedrails discussed with ………………………………patient / relative.
Date: ……………………..
Signature: ………………………….
27
Slips, trips and falls policy
Appendix G
Name
x
Date of birth
addressograph
label
here
Hospital/NHS No.
Ward
MENTAL CAPACITY:
(If the answer to question 4 in the Bed
Rails Assessment Tool was YES)
If the patients assessment indicates the use
of bedrails the following questions about the patient’s ability to retain information and make
decisions about the use of bed rails must be asked;
–
–
–
–
Does the patient understand why bedrails are used?
Can they repeat the question?
Do they understand why they need or do not need bedrails?
Can they tell you in their own words why they do not want bed rails to be used?
Yes
Yes
Yes
Yes
No
No
No
No
Outcome:
1. If the answers are YES = Patient is able to understand and able to make decisions:
USE BEDRAILS as indicated by the assessment over leaf – discuss with the patient; BUT if the
patient refuses to have bedrails regardless of the assessment indicating the use of bedrails –
DO NOT USE BEDRAILS.
2. If the answers are NO = Patient is unable to understand or retain information
about the use of bedrails:
If the assessment indicates the use of bedrails, but the patient is unable to understand or
retain the information about why bed rails should be used - discuss with members of MTD
(available at the time), meanwhile USE BEDRAILS for the patient’s safety and document the
decision in the patient’s notes as for the best interest of the patient.
WHEN NOT TO USE BED RAILS ON A
PATIENT’S BED
NOTE: Consider other options rather than use
of bed rails




When a patient has chronic confusion and
is able / is attempting to climb over the bed
rails
When a mobile patient is acutely confused
and disoriented
Independently mobile patient unless they
request the use of bed rails



-
Leave the bed on its lowest height position when
no care is provided and use the ‘lock out facility’
of the bed
Nurse nearer the nurses station for better
observation, call bell near, adequate lighting
One to one supervision
Use low-rise bed:
keep the bed on the floor level when no care is
provided
always consider the need for crash mats on the
floor by the bed. – DO NOT USE both bed rails on a
low-rise bed frame
28
Slips, trips and falls policy
Appendix H
Name
Date of Birth
Hospital / NHS No
IN-PATIENT CARE PLAN FOR BED RAILS
Ward
To be reassessed each shift and amended as circumstances change.
WARD :
Care plan start date:
Named nurse / nursing team:
Problem: ______________________ is at risk of rolling/slipping/falling out of bed
Desired outcome: For _________________________ to remain safe at all times using bedrails as
appropriate
NURSING ACTIONS:
1. Ensure patient safety at all times. This could mean using bedrails in the first instance until a more indepth risk assessment takes place. The results of the risk assessment could indicate that bedrails may
be required permanently.
2. Patient assessment must include mental capacity assessment to ascertain whether the patient has the
ability to make decisions regarding the use of bedrails.
3. If the patient does not hold the necessary capacity an immediate discussion with the members of the
MDT (available at that time) must be held and a decision made regarding the use of bedrails.
4. Obtain consent from the patient to use bedrails where appropriate.
5. Inform patient/family/carer about the decision to use or not to use bedrails.
6. Any decisions regarding the use or not of bedrails must be documented in the nursing notes. The
names of all the people involved in the decision making must also be documented.
7. Ensure bedrails are in good working order. If bedrails found to be faulty, beds should not be used and
must be reported to the Huntleigh technician on ext. 6009. Out of hours the bed with the faulty bedrails
must be removed from service and replaced with a fully operational bed (can be obtained via the
porters). Ensure reported to ext. 6009 as soon as possible after the event.
8. Ensure bed is maintained at its lowest position when the patient is not being attended to. Staff must also
ensure that the lock-up facility (up and down function) on the bed is used.
9. Consider moving the patient to an area where he/she can be more easily observed.
10. If unsuccessful implementing the above or patient is still experiencing falls consider the use of a low rise
bed.
Signature :
ANY CHANGES TO CARE PLAN
1.
Print name:
SIGNATURE & NAME
DATE
2.
3.
ALL ENTRIES MUST BE IN BLACK INK, MUST BE SIGNED AND NAME PRINTED
29
Slips, trips and falls policy
Appendix I
Ward /Department
Patient Addressograph
Date ----/---/------ Time ---:--FALLS CARE BUNDLE
Falls Care Bundle
Actions : Tick the appropriate box in each element and date and sign
Section 1 If the patient has been assessed as being at risk of falling or has had a fall whilst on the ward.
Actions Section 1
Yes
No
N/A
Date
Time
Signature
Time
Signature
Falls Risk Factor Assessment initiated within
6 hours of admission
Complete Cot side /Bedrail assessment. Ensure
patient/ carer is aware or the outcome of the
assessment.
Does the patient need a low rise bed? Is the
bed at its lowest point?
Review Staffing ratio; is there a need for the
patient to have 1:1 care (Refer to Safe and
Supportive Observation Policy)
Position the patient in an easily observed area of
the ward, ensure the patient is given the nurse call
bell and all personal equipment is placed within
easy reach of the patient. Ensure night light is on
POST FALL ACTIONS
Section 2 To be completed if the patient has sustained a fall All actions to be completed
If the patient has sustained a fall as an inpatient complete the following below
Yes
No
N/A
Date








Injury assessment for fracture and spinal
injury
Injuries assessed equipment and staff used to
manage patient safely as per manual
handling policy
¼ hourly observations using Glasgow Coma
Scale and NEWS score for the first hour1
hourly for 4 hours
After 4 hours as clinically appropriate
Medical Team Informed
Medical Report following a Fall (Appendix J)
completed and filed in patients notes
All Clinical Interventions such as CT / X-ray
completed within 4 hours
Any injury sustained to be documented in the
patients notes


Incident report completed
Any patient injury to be escalated to ward
manager for root-cause analysis
Patients relatives informed
Ensure that GP / community services are aware of the patient falling and are referred to the appropriate services
[
]
Peel off this sticker and place in notes when completed. Patient Detail information to be placed in audit folder
Please complete the following for audit.
1. Initial Assessment completed
2. Patient Environment Reviewed
3. Cot – Side Assessment completed
4. Staffing Reviewed
5. 1 :1 special Required
6. Observations Completed hourly following fall
7. Medical Report completed by Doctor
8. Incident Report (Datix) Completed
9. Relatives / Carers informed
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
30
Appendix J
Medical Report Following a Fall (attach to medical notes)
Medical Report following a Fall
Site(s) of injury
(mark with an X)
Patient Name:
Hospital/NHS No
Date of Birth:
Reviewed By:
Sign:
Date and time:
Datix Incident Number:
Assessment:
History:
Cause of fall (Exclude new problem e.g. MI, PE, stroke, delirium):
Examination:
Lying and standing BP(if possible), CVS, RS, Abdomen, Neurology
P
BP lying
standing
GCS:
E=
/4
V=
/5
M=
/6
=
/15
Injuries
Cognitive Assessment: Is patient known Dementia or New Delirium
Yes / No
None
Gait Assessment:
Involve physiotherapy and OT
Bruising
Investigations ordered:
Must have ECG if Chest Pain, LOC,SOB or no recent ECG
Laceration
Medication review:
Stop unnecessary drugs. Consider bone protection / Discuss with
Ward Pharmacist
Fracture
Consider footwear and visual problems:
Which may need onward referral
Other
Specify
31
Appendix K
Preventing falls in hospital
This leaflet is to tell you how we try to prevent patient falls, and what you and your visitors
can do to help.
Sometimes patients experience a fall while in hospital. This may be because of a sudden
change in health, disorientation due to unfamiliar surroundings, the effect of new
medication, or mobility and balance problems.
Unfortunately accidents can happen at any time, but we will do our very best to minimise
this risk, respecting your freedom to move around and your wishes at all times. We hope
the information below will assist you, your relatives and carers to reduce the chance of a
fall while you are in hospital. However, if you have any questions, don’t be afraid to ask us
for help.
Our advice to patients

If you have fallen at home in the past 12 months please let us know.

If you have a fear of falling please let the nursing staff know.

Listen to the advice from the therapists and nursing staff.

Use the nurse call bell for assistance if you feel weak, unsteady or dizzy.

Do not get up in the dark alone; use the call bell for help.

Keep everything you need within easy reach.

Ensure you have your glasses, hearing aids and dentures.

Bring any walking aids from home.

Use any walking aids given to you by the physiotherapists.

Wear non-slip well-fitting slippers or shoes.

To help prevent you tripping, wear clothes that are not too long or too loose.

Report any problems such as spills, trailing wires or cables to staff.

Ask your relatives or carers to take items home to reduce bedside clutter.

Be careful when standing up or getting out of bed, take your time.

Don’t use hospital furniture for support as it may not be stable enough
32
Our advice to visitors







Please replace anything that you have moved during your visit.
Inform nursing staff before you leave and ensure that the patient realises you are
leaving.
Ensure the patient has well-fitting non slip footwear and clothing that is not too
loose or long.
Discuss any falls prevention and walking aids that the patient uses at home with
nursing staff and bring them in if needed.
Ensure the patient has their glasses, hearing aids and dentures with them.
Tell us if the patient has had any previous falls.
Minimise clutter by taking unnecessary items home.
Looking after patients who may be at risk of falling
Although falls cannot always be prevented, we assess all adult patients on admission to
reduce the chance of them having a fall.
If you or your relative is assessed as being at risk of a fall, these are some of the steps we
may take to minimise this risk;





Moving the patient’s bed to a more suitable position on the ward
Using bedrails to stop a patient from rolling or sliding out of bed.
Using an ultra-low bed [which is lower to floor level] when bedrails are not suitable.
Sometimes a padded mat or mattress will be placed on the floor next to the ultra-low
bed.
Carefully monitoring the patient, which may be continuous or at set periods of time.
Using other falls prevention aids as directed by the nursing staff.
Please remember
The measures detailed in this leaflet are designed to minimise the risk of patients falling
whilst in hospital. However we cannot restrain patients or deprive them of their liberty and
we will always adhere to patients’ wishes, or act in their best interests if they are unable to
express their wishes.
Some patients will still fall even if we have done all the things mentioned in this leaflet,
being in hospital does not mean we can prevent falls. However, by working in partnership
with patients, their relatives and carers we aim to minimise the risk of falls.
Further information
If you have any further concerns regarding falls please do not hesitate to ask a member of
staff.
33
Appendix L
FALLS ASSESSMENT PATHWAY
Adult Patient Admitted
Complete Falls Risk Factor Assessment Form
Within 6 hours of Admission
Answer YES to any of
the Questions
NO to all
Questions
Complete Falls Risk Care Plan
and Interventions
Nursing and Medical Team
Assessments
Repeat the Assessment
 If the patient’s
Complete Bedrails Risk
Assessment and Tool
Condition Changes
 Post Fall
Complete Mental Capacity
Assessment if indicated
 Post Operatively /
Post Procedure
 Every 7 days
Commence Bedrails care plan if
bedrails required
PATIENT FALLS
Follow Post Fall Protocol
Complete Falls Care Bundle
Ensure Post Fall Medical Report Completed
Incident Form Completed
Repeat the Assessment
34
Appendix M
POST FALL PROTOCOL
Has the Patient
Sustained an
injury
NO
Observe the patient for
any signs of deterioration
Report Incident on Datix
Complete Falls Bundle
and
Post Fall Medical Report
YES
Check Patient for
signs or symptoms
of Fracture and
Potential for Spinal
Injury before Patient
is moved
NO
Observations to be carried
out every ¼ hour for first
hour and hourly for 4
hours then review
Use the NEWS & Glasgow
Coma scale
Escalate deterioration as
appropriate.
YES
Ensure that you have
enough staff and the right
Equipment to move the
patient
Spinal scoop, flat lifting
hoist and Neck Collars
can be found in A&E
Community Hospitals –
Call Emergency Services
Call Medical team to
review the patient
Medical Team to
Complete Post Fall
Report
Patient must be seen
within 1 hour
If patient needs CT Head
this must be performed
within 1 hours of referral
After each fall a Safety Huddle (MDT Discussion) must take
place to review the incident and lessons learnt shared 35
Appendix N
EQUALITY IMPACT ASSESSMENT SCREENING TOOL
Directorate / Department
LONDON NORTHWEST HEALTHCARE NHS
TRUST
Policy or Operating Procedure or
Guidelines Title / Service
Name and role of Assessor
Date of Assessment
SLIPS, TRIPS AND FALLS POLICY (In-patients)
SENIOR NURSE – QUALITY AND CLINICAL
STANDARDS
JANUARY 2016
Yes/No
1
2
Race, Ethnic Origins (including
gypsies and travellers) and
Nationality
NO
Gender (including gender
reassignment)
NO
Age
Religion, Belief or Culture
Disability – mental, physical and
learning disability
Sexual orientation including
lesbian, gay and bisexual people
Married/or in civil partnership
Pregnant
Is there any evidence that some
groups are affected differently?
NO
NO
NO
NO
NO
NO
NO
3
Is there a need for external or user
consultation?
NO
4
If you have identified potential
discrimination, are any exceptions
valid, legal and/or justifiable?
NA
5
Is the impact of the policy/Guideline
likely to be negative?
NO
6
If so, can the impact be justifiable?
NA
7
What alternatives might enable
achievement of the policy/
guidelines without the impact?
NA
Can we reduce the impact by taking
different actions?
NA
8
Comments
Does the policy/Guideline affect
one group less or more favourably
than another on the basis of:
Recommendation Full Equality Impact Assessment required:
Assessor’s Name: U.Hicks
NO
Date: 25.01.16
36