Patient Fall Prevention Orientation Module · 1. Complete The Post Epidural Fall Risk Assessment Score (PEFRAS) tool prior to ambulating a patient after epidural or spinal assisted

Patient Fall Prevention

Orientation Module

Wheaton Franciscan Healthcare

Learning Objectives

• Define the goals of fall prevention

• Define a fall

• Identify patients at risk for falls

• Identify factors that put patients at risk for falls

• Describe fall protocols

• Identify strategies and interventions to

prevent falls

• Describe the process for monitoring patient

falls

Commitment to maintaining patient safety

• Many agencies are involved with setting standards of

care and monitoring the incidence of falls, such as :

-State and Federal Regulatory Bodies

-Center for Medicaid and Medicare Services (CMS)

-National Database Nursing Quality Indicators (NDNQI)

-Joint Commission

http://www.leapfroggroup.org/

http://www.healthgrades.com/

Commitment to patient safety

Every patient has the

potential to experience

a fall.

Falls represent a

serious hazard and

pose a threat to quality

and longevity of life,

especially in older

adults.

Goals of fall prevention

• Maintain patient safety and reduce fall risk and injury

• All education provided to patients and families regarding falls is patient and family focused

Defining Falls

• Long Term Care (LTC)

– Unintentionally coming to rest on the ground, floor or other low level (for instance falling on a piece of equipment)

• Acute care (AC) – A fall is defined as an unplanned

descent to the floor (or extension of the floor, e.g., trash can or other equipment), with or without injury to the patient

– A fall includes assisted falls- when a staff member attempts to minimize the impact of the fall

Source: NDNQI 2008

The definition for falls may

vary depending on the patient

care area

What Constitutes a Fall:

• Intercepted or assisted falls

– For instance, patient loses balance and would have fallen had it not been for staff intervention

• A fall without injury

• A patient rolls off a bed or mattress that was close to the floor

• Unless there is evidence suggesting otherwise, when a patient is found on the floor, the most logical conclusion is that a fall has occurred

How Can I Maintain Patient

Safety?

• Provide adequate lighting

• Have resident/patient wear glasses/hearing aids when awake

• Place frequently used items within reach (phone, call light, water)

• Orient patient to surroundings including: – Bathroom location

– Use of bed

– Location of call light

• Answer call light promptly


Safety?

• Maximize activity and self care

• Ambulate with an assistive device if needed (measured and fit by therapy staff)

• Rise slowly from sitting to standing position

• Use non-skid footwear

• Educate patients and family about safety concerns and strategies to minimize risk for falls and injury.

• Hourly rounding to check in with patient to meet their needs (toileting, offering fluids, repositioning)

• Bedside reporting


Safety? • Minimize environmental

hazards:

– Keep bed in low position

– Locks on beds, stretchers,

and wheelchair

– Keep floor free of clutter

and obstacles with special

attention to path between

bed and bedside commode

– Tissues, water, call light

and phone should be within

easy reach

Assessing for fall risk • Fall risk assessment tools

are used to identify patients who may be at a high risk for falling

• Each facility has their own risk assessment tool to identify which patients are at risk for falls

• You will have the opportunity to become familiar with the risk assessment tool at your site

• Identification of these risk factors are based on best practice guidelines

Common Fall Risk Factors Is there a history of falls?

Is the patient taking any medication that could increase their risk for falling?

Medications such as:

Anticonvulsants

Narcotics

Sedatives

Anti-emetics

Benadryl

Antidepressants

Psychotropics

Antihypertensives

Anesthesia

Laxatives

Diuretics

Common Fall Risk Factors Is patient mobility

compromised ?

– Ambulates or

transfers with an

unsteady gait

– Chair bound or

bedfast

– Needs assistance of

person or ambulatory

aid (cane, walker,

crutches, furniture for

support)

Common Fall Risk Factors

4. Is the patient experiencing elimination problems?

- Incontinence - Infection (UTI)

- Urinary Retention - Constipation

- Urgency

- Diarrhea

- Nocturia - Bowel preps

- Foley catheter

“Nurse Brown encourages her patients to ambulate independently”

From Nursing Matters: Is there a Nurse in the House?

Common Fall Risk Factors 5. Are there changes in mentation,

cognition or perceptual history that may increase their risk for falling?

• Confused/ disoriented to time, place and person

• Difficulty understanding, reasoning or making needs known

• Cannot follow directions

• Impulsive (quick action taken by patient without thought of consequences)

• Poor judgment regarding assistance (attempts to get out of chair or bed inappropriately)

• Is the patient aware of their own limitations?


6. Is there any physical ailment that could increase their risk for falling?

- Such as:

- Syncope (fainting, lightheaded)

- Vertigo (dizziness)

- Weakness

- Hypovolemia (blood or fluid loss)

- CVA/Stroke

Common Fall Risk Factors 7. Is there any medical or

physical impairments that could increase the risk for falling ?

- Such as:

- Head injury

- Seizures

- Hypoxia

- Multiple Sclerosis

- Guillain Barre syndrome

- Deficits in hearing, sight,

or touch


• The chronological and developmental age

of the patient should be considered

• The more risk factors the patient has, the

greater the possibility that they may fall and

sustain an injury

Fall Prevention Programs

• Identify patients at high risk for falls

• Engage ALL associates and volunteers in fall prevention

• Individualize the patient Plan of Care and reevaluate after any fall

• Always include the patient and family in fall prevention

Fall Prevention Programs All Saints

North Market

Franciscan Woods

Franklin

Iowa

Lakeshore Manor

Marianjoy

St. Francis

Terrace at St. Francis


Practice

Location

Symbol Fall prevention Program

WFH –

All Saints

Falling

star

Nurses assess all patients ages 3 years and

older for fall risk on admission

All inpatients are assessed for fall risk:

• daily

• with a change in status

• a fall

• transfer to a different level of care


Practice

Location


WFH –

All Saints

Falling

star

•Fall risk assessments are documented in

HED.

•A safety IPOC should be initiated and

updated every 24 hours for at risk patients.


Practice Location Symbol Fall prevention Program

North Market

Elmbrook

St. Joseph

The Wisconsin

Heart Hospital

“Falling

Star”

Magnet

Applies to In-Patient Units:

Fall risk assessment on admission, daily,

and when a fall occurs

Individualized plan of care based upon

patient fall risk assessment and risk factors

All In-Patients wears red slippers – as all

hospitalized patients have the potential to

fall

“Falling Star” Magnet placed on /near

doorframe – for moderate and high fall risk

Patients



North Market

Elmbrook Memorial

St. Joseph

The Wisconsin

Heart Hospital

Patients who are high risk for falling wear

a yellow high risk fall gown

Toolkit Reference Sheet for possible

interventions:

http://policy.wfhealthcare.org/PDF%20Polic

y/NM_FallToolBox-doc.pdf

http://policy.wfhealthcare.org/PDF Policy/NM_FallToolBox-doc.pdf






North Market

Elmbrook Memorial

St. Joseph

The Wisconsin

Heart Hospital

An Interdisciplinary Plan of Care

[IPOC] for Safety is required as below:

Actual Safety IPOC - Patient fell prior

to admission or during hospitalization

Potential Safety IPOC – Patient with a

SCHMID Score of 3 or above




Practice

Location


Franciscan

Woods

None-All

residents

considere

d at risk

for falls

• Risk assessment on admission and care

plan that is appropriate for each individual.

Residents are assessed with change in

condition, quarterly and annually.

• Reassessment is done after each fall.

• Observation of resident and environment

safety at beginning of each shift with CNA

rounding.


Practice

Location


Franklin

MOSH

Orange

Leaf

•Yellow wristband

•Fall risk assessment on admission and daily

•Individualized plan of care based upon

patient fall

risk assessment

Fall Prevention Programs Practice

Location


WFH –

Iowa

Medical/

Surgical

Behavioral

Health

Yellow

dot

1. If patient score is 3 or above implement a High

Risk Protocol

a. Place a yellow ID Band on the patient

b. Provide a yellow gown for the patient as appropriate

c. High Fall Risk Sign on door (CMC)

Yellow dot on door (Sartori)

d. Post the yellow High Fall Risk Intervention Sign in the

patient room and/or identify on white board that patient

is a fall risk

2. Identify on plan of care if patient is assessed as High Risk

for fall

3. Plan of care Interventions are individualized according to

the patient’s fall risk factors

4. Document those interventions you are using in addition to

the Universal Fall


Location


WFH -

Iowa

(Pediatric)

“Humpty

Dumpty”

1. Complete Pediatric Fall Risk Assessment upon admission

and daily.

2. The Pediatric Fall Risk Assessment upon admission is

documented as part of the Pediatric Admission Database

Record. Subsequent fall risk assessment scoring is

documented.

3. Nursing Interventions that are performed for each patient

correspond to the identified Risk Level.

4. Patients that have been identified as a High Fall Risk

based on the scoring criteria shall have a yellow ID band

and a “Humpty Dumpty” sticker shall be placed on the

front of the patient chart, High Risk Fall sign is placed

above bed.


Location


WFH - Iowa

(Outpatient

Services )

1. Complete Outpatient Fall Risk Assessment

upon admission

2. If patient is at risk for a fall, initiate indicated

Interventions per risk level

3. Document interventions in the nursing

narrative notes


Location


WFH - Iowa

Family

Birth

Center-

Post

Partum

Yellow

Dot

1. Complete Fall Risk Assessment upon admission and

daily

2. Using the identified criteria, document in HED

3. Patients that have been identified as a High Fall Risk

based on the scoring criteria shall have a yellow ID

band, a yellow dot placed on the nursing Plan of Care,

and a yellow High Fall Risk sign shall be placed on the

patient door

4. Documentation of interventions will be placed in Event

Summary in HED and may include, but are not limited

to: instruct patient on the use of the call light, assist

with ambulation, non-skid footwear provided to patient,

bed in low position except when nursing administering

care, monitoring the patient while in the bathroom or

shower


Location


WFH - Iowa

Family

Birth

Center-

Labor

Yellow

Dot

1. Complete The Post Epidural Fall Risk Assessment

Score (PEFRAS) tool prior to ambulating a patient after

epidural or spinal assisted delivery

2. Patients with a score of 50 or higher:

a) Patient is instructed to not attempt walking or

getting out of bed without assistance.

b) Reassess patient every thirty (30) minutes until

she can pass the “Test Stand” and can walk

independently without a walker.


Practice

Location


Lakeshore

Manor

Falling

Star

• Risk assessment on admission, quarterly,

annually, with any change of condition, and

if a fall occurs

• Observation of resident and environment at

beginning of each shift and hourly with CNA

rounding

• If a resident is high risk, they are on Fall

Precautions, additional safety measures

are incorporated in the plan of care, low

bed ordered and mat next to bed instituted


Practice

Location


Marianjoy

Caution

Club

Assessment is done on admission, weekly, after a fall,

and anytime there is an altered condition

Yellow wristband

Yellow “caution club” tag on back of wheelchair

“Caution club” magnet on door frame of patient’s room

Keep patient within sight when patient is sitting in the

wheelchair in their room

Keep patient within sight when toileting

Use bed and wheelchair alarms

Remind family and visitors to alert nurse when they are

leaving

Provide night light

Ensure call light and personal items are within patient’s

reach

Regular rounding to address patient needs

Remind patient to ask for assistance when getting up


Practice

Location


St. Francis Orange

Leaf

• Yellow wristband

• Fall risk assessment on admission and daily

• Individualized plan of care based upon

patient fall risk assessment

• Patient wears red slippers


Location


Terrace at

St. Francis

Yellow

Star

• Universal Fall Precautions apply to all residents

• Strict Fall Precautions will be initiated if a resident

has a history of falls, or has three or more

categories checked on the Falls/Injury Risk Screen

• Fall Care Plan to be completed by the nurse and will

develop an individualized Fall Plan of Care and

appropriate interventions that reflect Strict Fall

Precautions based upon fall risk factors

• Care Plan interventions must be reviewed and

modifications made following every fall with or

without injury

• A Falls/Injury Risk Screen to be done upon

admission/every fall, change of condition and

quarterly and annually.

Fall Prevention Interventions

Research shows that

targeted interventions

based on patient risk

factors are most

effective in reducing

falls

Additional Fall Prevention

Interventions • Educate patient and

family

• Use of low beds and protective pads

• Bed/chair alarm

• Patient relocation for closer monitoring

• Additional therapies (OT, PT)


• Assist with transfers

• Have the patient move at his/her own speed: “Take

your time”

• Decrease environmental stimuli

• Establish toileting schedules in collaboration with

patient

• Remain with high risk patients during toileting

• Remove tubes if appropriate (Foley catheter, for

instance) or conceal tubes


• Provide for companionship

• Encourage family to stay with patient

• Bring in familiar items from home, for instance, pictures or a calendar

• Offer comfort measures (TLC, pain medication if appropriate, non pharmacological pain relief measures)


• Offer diversional activities for instance, watching T.V., playing cards, or listening to music

• Some sites may provide an organized activity box called a “busy box”. This box contains puzzles, magazines, and other items to keep a patient busy and occupied. It is especially useful for patients who are confused, have dementia, or developmental delays

• Pharmacy consult (if polypharmacy is a risk factor)

• Purposeful hourly rounding

• Bedside reporting

Fall Prevention Monitoring

• Despite our best efforts, sometimes

patients do fall

• It is important to identify the cause of

these occurrences, modify the plan of

care, and take action to prevent them

from occurring again

• All WFH facilities monitor falls

Fall Prevention Monitoring All Saints

North Market

Franciscan Woods

Franklin or MOSH

Iowa

Lakeshore Manor

Marianjoy

St. Francis


Falls Monitoring Location Falls Monitoring Program

WFH - All Saints

• Staff RN identifies strategies and revises plan

of care (IPOC) to prevent further falls

• Occurrence reports are forwarded to Risk

Management

• Unit nursing leadership reviews occurrences

• Fall data is reported through Quality to the

NDNQI


North Market

Elmbrook

St. Joseph

The Wisconsin

Heart Hospital


Management Unit Director/PCS/Manager

reviews occurrences


of care to prevent further falls

• Falls are identified in the Quality Report and

hospital scorecard


Franklin

MOSH

•Occurrence reports are forwarded to Risk

Management.

•Unit Director/PCS reviews occurrences

•Staff RN identifies strategies and revises plan

of care

to prevent further falls

•Falls are identified in the Quality Report and

hospital scorecard


Franciscan Woods

• Each fall is initially investigated at the time it

occurs. The supervisor assesses the resident,

reviews and revises the current care plan, and

the report goes to the DON and the Falls

Team.

• Interdisciplinary Falls Team Committee meets

weekly to review each fall that has occurred

and to identify strategies to prevent further

falls.


Iowa

• Complete a Post-Fall Huddle including

notification of the house supervisor

• Incident reports are completed for all falls and

reviewed by the manager and Quality

Services

• Results are tabulated and shared with

managers to review with staff

• Falls sustaining injury are reviewed by a

member of Quality Services and the Fall

Team

• The Fall team discusses and determines if

there was some way the injury/fall could have

been prevented


Lakeshore Manor

If fall occurs:

• Occurrence report and Investigation with root

cause analysis completed

• CNA and Nurse Care Plan Updated

• Measures are put into place immediately

based on charge nurse assessment

• Falls discussed daily at morning report with

IDCPT

• All falls tracked/ monitored by QI.


Marianjoy


Management and reviewed with Nurse

Manager




hospital scorecard


St. Francis


Management.

• Unit Director/PCS reviews occurrences




hospital scorecard



After a fall, a report is completed ASAP with

statements from staff and further investigation if

needed. Documentation occurs in the progress

notes and Plan of Care. Family and MD are

notified and residents are placed on 24 hour

report. Measures are taken to reduce further

falls.

Summary

We maintain patient

safety and promote fall

prevention by providing

guidelines, standards

and policies that

protect all patients, no

matter whether they

are at risk for injury or

not

Summary

We assess our

patients and look for

risk factors that

might identify those

who are more likely

to experience a fall

Summary

We place our

patients who are

identified at risk into

our fall prevention

programs

Conclusion

We individualize

plans of care and

identify goals to meet

the needs of our

patients

Summary

And finally, we

monitor falls and

continually look for

ways to keep our

patients safe

Summary

• As a result of our fall prevention programs, we are establishing safer environments for our patients

• We continually strive to decrease the number and, more importantly, the severity of falls (those that result in patient injury)

• We accomplish this by establishing consistency within our facilities as it pertains to our guidelines, policies and procedures

• In addition, we maintain standards of care that are outlined by regulatory agencies (state, federal government, nursing quality databases, etc. )

• In doing so, we demonstrate to our patients and families our commitment to their safety

Review Committee: Jennifer Bigler, Joan Lang, Nancy Brueggeman, Kate Holmes,

Chelsea Loiselle, Christina Dzioba, Sally Strong, Cynthia Bright, Angela Corona,

Julie Becker, Debra Lewendowski, Bev Abbott, Sherry Thompson

E-learning: Diane Coppola

June 30, 2013

Documents

Patient Fall Prevention Orientation Module · 1. Complete The Post Epidural Fall Risk Assessment Score (PEFRAS) tool prior to ambulating a patient after epidural or spinal assisted