2. Fall Prevention
o White County Medical Center follows a fall prevention
program to maximize patient safety throughout the
hospital stay by identifying patients at risk for falls
o Fall prevention is every associate’s responsibility
3. Falls Defined
o Fall: “an unintended event resulting in a
person coming to rest on the floor/ground or
other level (witnessed) or is reported to have
landed on the floor/ground (un-witnessed)
o Falls do not include when a patient is assisted
to the ground with no injury
• This is reported as a near miss
4. All Patients are at Risk
o All patients are evaluated and assessed for fall risk regardless
of age
o All patients are considered at risk for falls
o The Fall Risk Assessment tool helps to determine the level of
risk
o All patients or their guardian receive age-specific fall prevention
education upon admission and when fall risk level changes
5. Assessment
o The Fall Risk Assessment Tool is completed on admission,
daily on each 7A-7P shift, any time the patient’s condition
changes, following an in-house transfer, or after a fall occurs
o The Fall Risk Assessment tool has been modified to
incorporate such known fall precursors related to age, history of
falls, medications and mobility
o Patients are then placed at risk levels I, II, or III depending on
the Fall Risk Assessment score
6. Risk Levels
o There are three levels of fall categories as follows:
• Level I: Low/Normal Risk
• Level II: Moderate Risk
• Level III: High Risk
Level II & III patients are placed on Fall Prevention
7. Level I
o Level I (Score 0-5): Low/Normal Risk – All Patients
• Anticipate/plan for environment/equipment needs
• Beds are kept in the lowest position to the floor
• Upper side rails should be used as needed
• Call bell is to be kept in reach at all times
• Patient care areas require adequate lighting
• Patient rooms need to be kept neat and orderly
• The path to the bathroom is free of clutter
• Assistive devices are within reach
8. Level I (continued)
• Patient care equipment is kept in working order
• Promptly clean spills
• Encourage non-skid socks/slippers for ambulation
• Frequent visual checks as determined by patient need
• Offer assistance with toileting every 2 hours while awake
• Offer fluids/nutrition as appropriate
• Ambulate patient in hallway
• Relieve discomfort promptly
• Incorporate family in care of the patient
9. Level II
o Level II (Score 6-14): Moderate Risk
• In addition to the interventions of LEVEL I…
• Place Fall Prevention magnet on door
• Place “Yellow” Fall Prevention armband
on patient
• Encourage family presence and support
• Label chart with Fall Prevention sticker
• Review medications with physician
10. Level II (continued)
• Document visual checks as indicated by patient
status
• Offer and assist with the toileting/hygiene ADL’s
on a regular schedule based on patient
needs/assessment
• Ambulate with assistance only (as appropriate)
• Do not leave unattended while in the bathroom
• Place patient closer to nurses’ station if possible
• Evaluate for bed alarm prn
11. Level III
o Level III (Score 15+): High Risk
• In addition to the interventions of LEVEL I & II…
• Increase documentation of visual checks
as patient’s conditions warrants.
• Place colored non-skid slippers on patient
• Request family presence or discuss
the option of a sitter
• Evaluate for bed alarm
• All noncompliant patients will be placed on a bed alarm
12. In the Event of a Fall
o Notify the Charge nurse, unit manager, and supervisor
o Notify the physician and initiate any orders received
o Complete an ORM/Variance Report
o “Recent Fall” yellow sheet is placed in the chart for
ancillary departments and physicians to see
o “Recent Fall” yellow laminated poster is placed at the
head of the patient’s bed
