Download Rouge Valley Falls Prevention Program Policy Draft

ROUGE VALLEY HEALTH SYSTEM
NURSING STANDARDS MANUAL
CATEGORY: PROFESSIONAL PRACTICE
NUMBER:
SUBJECT: FALLS PREVENTION PROGRAM
DATE:
2006/12
REVISED:
APPROVED BY:
PAGE: 1 of 4
PURPOSE:
To provide a falls prevention program for the care of vulnerable patients with the aim of increasing patient safety.
POLICY OR STANDARD:
The falls prevention program shall provide a process for the identification and management of patients at risk of falling or who have had a fall
for use by members of the interdisciplinary health care teams by:
 Use of a Falls Risk Assessment Tool
 Establishing strategies for falls prevention
 Developing and implementing appropriate plans of care for falls prevention
 Providing education for patients and families on falls prevention.
 Continuing monitoring and evaluation of the effectiveness of the strategies
GUIDELINES:
Within twenty-four hours of admission unit staff shall:
Assess the patient for falls risk using the adapted Morse Fall Risk Assessment Scale ( Appendix A )
Assess the patient for personal and environmental safety using the falls prevention interventions list ( Appendix B )
Institute an individualized interdisciplinary plan of care, which will include a regular toileting schedule as a primary prevention measure.
Document fall risk level and the required interventions in the care plan and the integrated patient record
Institute regular patient supervision as a further prevention measure
Provide education for the patient and family on falls prevention strategies to increase patient safety including the use of the brochure on Falls
Prevention ( Appendix C )
When a patient falls, unit staff shall:
Complete the Incident Reporting Process as prescribed
Reassess the patient using the fall risk assessment tool and the falls prevention interventions checklist
Provide added education for the patient and family to reduce the risk of further falls.
Reassess/revise/modify the care plan
When there is a change in patient status unit staff shall:
Reassess the patient using the fall risk assessment tool and the falls interventions checklist
Provide education to the patient and family as necessary
Reassess/revise/modify the care plan
DOCUMENTATION:
Unit staff shall use the following to document falls risk and interventions implemented:
 The falls risk assessment scale
 The safety checklist
 The environmental checklist
 The care plan
 The integrated patient record
REFERENCES:
Barnett, Karen. Project Manager, Mid Yorkshire Hospitals NHS Trust: Reducing Patient Falls
Project. January 2001 – March 2002
Cashin-Farmer, Bonnie. Fall Risk Assessment. Best Practices in Nursing Care to Older Adults. The Hartford Institute of Geriatric Nursing.
Number 8, May 2000.
UHN Fall Safety and Restraints Committee. Protecting Yourself from falls in the Hospital. 2003
Chang, John T. Interventions for the Prevention of Falls in Older Adults: Systematic review and meta-analysis of randomized clinical trials.
BMJ 2004; 328
Florida Hospital Association. Building the Foundations for Patient Safety. Patient Safety Steering Committee November 2001
Foundation of Nursing Studies Dissemination Series. Reducing Patient Falls in an Acute General Hospital. 2002
Gillespie, Lesley. Preventing Falls in Elderly People. BMJ 2004: 328.
Haines, Terry. Effectiveness of targeted Falls Prevention Programme in subacute hospital setting: randomized controlled trial. BMJ 2004: 328
National Centre for Patient Safety 2004. Falls toolkit
RNAO Best Practice Guidelines. Prevention of Falls and Fall Injuries in the Older Adult. Revised March 2005
Tideiksaar, R. Falls in Older people: Prevention and Management. ( 3rd. Ed. ). Baltimore: Health Professions Press. 2002.
Toronto Homes for the Aged. Resident Manual. Falls Management Policy. Revised March 2005
US Department of Veterans’Affairs. Veterans’ Affairs Approach to Patient Safety.
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APPENDIX A
Falls Risk Assessment Tool
Adapted from:
The Morse Falls Risk Assessment Tool
The Pinderfields and Pontefract Hospitals NHS Trust Patient Falls Risk Assessment Tool
Score
Category
Admission
Assessment
Date:
Initial:
1. History of falls
Score 25 if patient has
a history of falls or has fallen during present
admission
Secondary Diagnosis
More than one diagnosis
is listed in the patient’s chart
2. Assistive Devices

None/bedrest/nurse assist

Cane/walker/wheelchair

Uses furniture as support
( ‘Furniture Walking’ )
3. Gait

Normal

Weak

Impaired
Post-Surgery
First
Mobilization
Date:
Initial:
Change in
Patient Status
Post - Fall
Assessment 1
Post – Fall
Assessment 2
Date:
initial
Date:
initial
Date:
Initial:
25
15
0
15
30
0
10
20
4. Mental Status

Oriented to own abilities
0

Overestimates/forgets limitations
15
TOTAL SCORE:
Morse Fall Score
High risk 45 or more
Low risk 0 - 24
Medications which increase fall risk
Secondary Diagnosis Examples
Delirium
Dementia
Depression
Dehydration
Parkinson’s Disease
Diabetes
Hypertension
Stroke
CAD
CHF
Osteoporosis
STAFF IDENTIFICATION
Name ( Please print )
Hypnotics
Benzodiazepines
Anti-hypertensives
Anti-psychotics
Post-surgery analgesia
Tricyclic antidepressants
Patients 70 yrs or over taking more than 4
medications
Initial
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APPENDIX B:
Fall prevention Interventions to increase patient safety
Categories
Yes
Interventions:
Orientation of patient and family to surroundings
Seek family involvement in patient care
Ensure effective communication with patients & families
Language interpretation aids in place as necessary
Address any other patient/family concerns & document
Ensure adequate nutrition and hydration
If appropriate, establish a regular mobilization schedule
Ask for non-slip footwear for patient if necessary
Mobilization with Assist x 1
Mobilization with Assist x 2
Ceiling lift
Mechanical lift
Use of glide sheet
Toileting Q2H /plan to suit individual patient needs
Elevated toilet seat
Commode at bedside
Commode brakes on
Side rails
Bed at lowest point
Bed brakes on
Patient able to use call bell & call bell placed within reach
Lighting cord accessible
Mobility aids close by
Wheelchair brakes on
Patient belongings within reach
Ensure visual & hearing aids are clean,
in working order and in use
No unnecessary clutter
Fluid spills cleaned up ASAP
All electrical cords; oxygen tubing tucked out of the way
Place patient within sight of unit staff
Review medications if necessary
Teaching
Added Patient teaching
Added Family teaching
No
Yes
No
Comments
APPENDIX C:
Brochure on fall prevention for families
( See attached )
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