Nursing: Fall Prevention

2.  To decrease the incidence of falls.
 To decrease the severity of falls.
 To improve environmental safety.
 To provide comprehensive assessment.
 Enhance staff knowledge
 Improve patients and families
confidence.

3. Unplanned descent to
the floor with or without
injury with interaction
between an extrinsic
and intrinsic factor.

4. “An event which results in a
person coming to rest
inadvertently on the ground
or floor or other lower
level”.
Excluded:
- major internal event e.g. stroke
- being hit by an external force e.g.
knocked over

5.  Varied by service, age, length of stay.
 7.5 % of all patients experienced at least one fall
 24.8% of all patients aged more than 65 experienced at least
one fall.
 Less than 3 years old pediatric patient has high risk of fall.
 Of those that fell, 30.1% experience an injury
 Impaired cognition and narcotic use where universal risk
factors across services.
Half of all hospital falls were related to going to the
bathroom.

6. Intrinsic
 Age
 Gender
 History of Fall (past 2
mos.)
 Medications
 Health conditions
 Cognitive
 Health conditions of
patients
 Tethers
 Incontinence or
urgency
 Diminished
strength/vision/hearing
/sensation
Extrinsic
 Wet and cluttered floors
and pathways
 Floor surface
 Foot wear
 Distance to bathroom
 Height of toilet
 Bathroom layout/grab
bars
 Response to call light and
staffing ratios
 Poor lighting
 Incorrect bed height
 No assistive devices
 Tethers
 Staff not using gait belts
 Not having eyeglasses,
hearing aids.

11. What can we do to prevent fall?

13.  To enhance each patient’s mobility and
encourage independence by removing the
risk of falls where possible and reducing
both the incidence of falls and injuries
that may accompany falls.

14. A fall Prevention Nurse will assign
Monitor cases of falls / monthly
Assessment
Coordinate with the administration

15. For evaluating fall risks and need for assessment and
interventions or modification of the plan of care, the
following constitutes a “Fall”
 Found on the floor
States they fell
Witnessed fall, slips, or trip
Slides on to the floor assisted or unassisted
Eased to floor assisted or unassisted
Rolls or slides off bed or chair onto the floor
Falls off or out any equipment

19.  Risks levels for falls
Monitor pts/hourly
Put signage
Document

25.  Education
 Care Plan

27. Extrinsic intrinsic
 Hand clenching and
dorsiflexion exercise
before standing
 Pain management
 Training in the use of
cane or and walkers
 Vision evaluation and
correction
 Monitor
 Secure commode
extenders and grab
bars
 Repair or replace
broken bed, side rails
and wheelchair
 Keep bed appropriate
height
 Don’t leave patient
unattended
 Check positioning
 Floor kept dry
 Foot wear be non skid.

29.  Easing him/her to the floor by grasping
the patient’s clothes .
 allow the pts to slide down bend your legs
so that you can control the direction of the
fall
Try to protect the pts’ head
Assess the patient for any injury

31. 1.Record the details of prior
of fall, fall, results of fall
and intervention.
2.Morse fall score, notify the
fall prevention nurse
3.Document in Nurses notes,
clinical audit, OVR and
incident fall assessment.

32. 1.Determine if the patient’s gaits
confidence was affected.
2.Assess the future fear of falls.
3.Use education to manage the
expectations and fears of the
family and direct care staff.
4.Post fall counseling should take
place as soon as possible after
the fall.

33. 1. All falls will be tracked and trended on a
monthly basis
2. Data is to be evaluated by the fall
prevention nurse.
3. Data will reviewed and signed by the
Medical Director, Administrator and Nursing
Director.
4. Assessment of data will be reported to
Clinical Audit team.
5. Data will be analyzed for total number of
falls, patterns/repeat falls, trends and
casual factors.

34. 6. Data will used to improve care plans
7. Data will be used to improve this fall risk
management and loss control program.
8. Set measurable goals and objectives for
care in the context of resident wishes and
advanced directives.
9. Document resident’s response to
interventions and alter interventions if not
successful.