Clinical Process Guideline Evaluation of Falls/Fall Risk Deborah Ayers RN-MSN

Clinical Process GuidelineClinical Process Guideline

Evaluation of Falls/Fall RiskEvaluation of Falls/Fall RiskDeborah Ayers RN-MSNDeborah Ayers RN-MSN

Learning ObjectivesLearning Objectives Following this presentation the audience will be Following this presentation the audience will be

able to: able to: Verbalize the assessment/recognition of long Verbalize the assessment/recognition of long

term care risk for falls.term care risk for falls. Verbalize possible causes of falls in long term Verbalize possible causes of falls in long term

care residents.care residents. Verbalize cause specific interventions to prevent Verbalize cause specific interventions to prevent

or minimize resident fall risk, falls and or minimize resident fall risk, falls and complications from falls.complications from falls.

Will be able to verbalize methods of monitoring Will be able to verbalize methods of monitoring the resident’s response to fall interventions.the resident’s response to fall interventions.

Fall DefinitionFall Definition

““Any unplanned descent from a Any unplanned descent from a higher elevation to a lower higher elevation to a lower

elevation.”elevation.”

Also count near- fallsAlso count near- falls

Also count roll outs from a Also count roll outs from a mattress on to themattress on to the

floorfloor

Falls Process Guidelines Falls Process Guidelines

Assessment/Problem Assessment/Problem DefinitionDefinition

Falls Process GuidelinesFalls Process Guidelines

Assessment/Problem AnalysisAssessment/Problem Analysis HistoryHistory External FactorsExternal Factors Internal FactorsInternal Factors


Assessment/Problem Assessment/Problem AnalysisAnalysis

Refer to the (RAPs) for Refer to the (RAPs) for possible causes of fallspossible causes of falls


Assessment/Problem AnalysisAssessment/Problem Analysis

Documentation of notification of Documentation of notification of physician/extender related to significance of physician/extender related to significance of falls or falls risk in the resident. falls or falls risk in the resident.

Falls Clinical Process GuidelinesFalls Clinical Process Guidelines

Diagnosis/Cause Diagnosis/Cause IdentificationIdentification

Identify and document Identify and document risk factors in the RAP: risk factors in the RAP: External factorsExternal factors


Diagnosis/Cause IdentificationDiagnosis/Cause Identification

Identify and document risk factors in the RAP: Identify and document risk factors in the RAP: Internal factorsInternal factors


Diagnosis/Cause Diagnosis/Cause IdentificationIdentification

Physician or physician Physician or physician extender participates in extender participates in the evaluation of the the evaluation of the resident to identify the resident to identify the causes of falls or fall causes of falls or fall risksrisks


Treatment/Problem ManagementTreatment/Problem Management

Care plan should contain cause-specific Care plan should contain cause-specific interventions to prevent or minimize fall risk, interventions to prevent or minimize fall risk, falls, or complications from falls OR the care falls, or complications from falls OR the care plan is modified to accommodate the plan is modified to accommodate the expectation of continued risk.expectation of continued risk.


Treatment/Problem Treatment/Problem ManagementManagement

Documentation of the Documentation of the physician involvement physician involvement in the development of in the development of cause-specific fall cause-specific fall interventions.interventions.


Treatment/Problem ManagementTreatment/Problem Management

If the resident falls, (without another obvious If the resident falls, (without another obvious cause) the physician documentation should cause) the physician documentation should reflect a trail adjustment of medications or reflect a trail adjustment of medications or medication combinations.medication combinations.


Treatment/Problem Treatment/Problem ManagementManagement

Is there evidence to Is there evidence to indicate the care plan indicate the care plan has been implemented?has been implemented?


MonitoringMonitoring

Document monitoring of the resident’s Document monitoring of the resident’s response to interventions.response to interventions.

Document a periodic review of approaches for Document a periodic review of approaches for applicability to the current situation.applicability to the current situation.



Care plan Care plan

documentation that documentation that reflects previously reflects previously selected interventions selected interventions were re-evaluated if were re-evaluated if falling continued.falling continued.



After a fall associated with injury occurs After a fall associated with injury occurs documentation should reflect notification of documentation should reflect notification of the physician.the physician.



Document that actual Document that actual consequences were consequences were addressed, based on addressed, based on prominence of s/s, with prominence of s/s, with re-evaluation until re-evaluation until stable.stable.



Document observation for possible delayed Document observation for possible delayed consequences of a fall ( late evidence of consequences of a fall ( late evidence of fracture, subdural hematoma, etc.) for at least fracture, subdural hematoma, etc.) for at least 48 hours).48 hours).



Documentation of staff Documentation of staff awareness of awareness of policy/procedures for policy/procedures for resident fallsresident falls

ReferencesReferences

American Medical Directors Association & American Medical Directors Association & American Health Care Association Falls and American Health Care Association Falls and Fall Risk Clinical Practice Guideline, 2003Fall Risk Clinical Practice Guideline, 2003

Joint Commission on Accreditation of Joint Commission on Accreditation of Healthcare Organizations, Sentinel Event Healthcare Organizations, Sentinel Event Alert, Issue 14, July 12, 2000.Alert, Issue 14, July 12, 2000.

JSC, Ink. 1999 Update MDS User’s Manual V JSC, Ink. 1999 Update MDS User’s Manual V 2.0, Watertown, Maine2.0, Watertown, Maine

Documents

Clinical Process Guideline Evaluation of Falls/Fall Risk Deborah Ayers RN-MSN