Policy/Procedure Title Fall Assessment / Risk Manual Location MountainView Regional Med-
Reduction ical Center
Policy/Procedure # Effective 12/23/08 Page 1 of 6
Department Generating Policy Nursing
Affected Departments All Clinical Areas
Prepared By Dawn Tschabrun Dept/Title Nursing Administration /Chief Nursing
Officer
Dept / Committee Approval Date/Title
(If Applicable)
Dept / Committee Approval Date/Title
(If Applicable)
Dept / Committee Approval Date/Title
(If Applicable)
Medical Staff Approval Date/Title
(If Applicable)
Board Approval (If Applicable) Date/ Title
PURPOSE
MountainView Regional Medical Center is concerned about and committed to the safety of its
patients. Falls account for a significant portion of injuries in hospitalized patients. The Hospital
has a responsibility to prevent harm to patients resulting from falls and to educate patients and
families about fall prevention. The Hospital will routinely assess each patient’s risk for falling
and take action to reduce the risk of falling, and, if a fall occurs reduce the risk of injury. All
Clinical Directors and staff are responsible for supporting the fall reduction program.
DEFINITIONS
A FALL is defined as a sudden, uncontrolled, unintentional, downward displacement of
the body to the ground or other object, excluding falls resulting from violent blows or
other purposeful actions.
A NEAR FALL is a sudden loss of balance that does not result in a fall or other injury.
This can include a person who slips, stumbles or trips but is able to regain control prior to
falling.
An UN-WITNESSED FALL occurs when a patient is found on the floor and neither the
patient nor anyone else knows how he/she got there.
Fall Assessment / Risk Manual Location MountainView Regional Med-
Policy/Procedure Title Reduction ical Center
Policy/Procedure # Effective 12/23/08 Page 2 of 6
FALL FACTORS
Intrinsic – Includes factors that address a person’s physiological condition (related to the
person’s condition).
Extrinsic – Includes factors that address the physical environment.
Additionally, these risk factors can be either anticipated or unanticipated. The anticipated
risk factors are the ones that we can address before a patient falls.
Intrinsic Extrinsic
(Related to the person’s condition) (Related to the environment)
-Recent history of falls (most signifi- -Environment (wet floor, floor glare, cluttered
cant factor) room, poor lighting, loose tubing, cords, etc)
-Incontinence, etc. -Inappropriate or lack of footwear
-Cognitive/psychological status -Low toilet seat
-Mobility / balance/ strength problems -Wheels on beds or chairs
Anticipated
-Dizziness/vertigo -Restraints (including side rails in the up
-Postural hypotension position)
-Age (over 65 years old) -Prolonged length of stay
-Osteoporosis (can lead to pathological -Unsafe equipment (unsteady IV poles)
hip fractures and increases likelihood -Broken equipment
of fracture if a fall occurs) -Beds left in high positions
-Overall poor health status
-Home Medications
-Seizures -Individual reactions to medications
Unanticipated
-Cardiac arrhythmias
-CVA or TIA
-Syncope
POLICY
I. INPATIENT UNITS:
A. Initial assessment: Upon admission, each patient will be assessed for fall risk and a level
of risk assigned. The three levels will be low risk, moderate risk, and high risk. These
levels build upon each other, as described below.
Fall Assessment / Risk Manual Location MountainView Regional Med-
Policy/Procedure Title Reduction ical Center
Policy/Procedure # Effective 12/23/08 Page 3 of 6
B. Reassessment: Each patient will be reevaluated once a shift and as needed using the same
criteria as the initial assessment. If there is a change in the level of fall risk, the appropri-
ate level of interventions will be implemented. Additional interventions can be imple-
mented based on the staff’s judgment regardless of the level assigned.
Any time there is a change in the patient’s physical or mental status, the staff will
re-evaluate the patient for a change in fall risk potential. The change in the pa-
tient’s level of risk for falls will be documented along with the change in either
mental or physical status. The change in the interventions will also be docu-
mented.
Staff will educate patients and families in how to reduce the risk of falls. This in-
formation will include how to prevent falls in the home environment as well as
how to reduce the risk of harm from falling while hospitalized.
C. Using this assessment information, a “Fall Risk Assessment” is completed and docu-
mented on the medical record. Points are assigned to various factors that can place a pa-
tient at risk for fall. Based on the points assigned for each area identified, the patient is
considered to be low, moderate or high risk for a fall.
II. OUTPATIENT AREAS:
A. Patients who utilize the outpatient services at MountainView Regional Medical Center
who exhibit unsteady gait or who use assistive devices will be offered assistance as
needed in transferring to or from chairs.
B. Patients on stretchers who are awaiting treatment or testing will have both side rails up.
C. Patients who have been given medications that could be associated with a risk for fall
should remain in view of staff or be protected using interventions noted above.
D. Brakes are kept locked at all times on beds/wheelchairs/carts when transferring patients.
PROCEDURE FOR PERFORMING FALL RISK ASSESSMENT
Using patient specific assessment data described in this policy, a fall risk assessment is com-
pleted and documented on the medical record. Points are assigned to various factors that can
place a patient at risk for fall.
Fall Assessment / Risk Manual Location MountainView Regional Med-
Policy/Procedure Title Reduction ical Center
Policy/Procedure # Effective 12/23/08 Page 4 of 6
Criteria Response Options Score
The patient received the following classes of medications in the past 48 None 0
hours: 1 med class 5
Moderate sedation or general anesthesia 2 med classes 10
Narcotics 3 med classes 15
Cardiovascular/Anti-hypertensives 4/more med classes 20
Hypoglycemics
Anti-seizure medication
Sedatives
Antidepressants/psychotropics
HX of falls in the past 30 days No 0
Yes 15
Altered Mental Status/Confusion/Disorientation No 0
Intermittent 5
Yes 15
Gait/Balance No issue 0
General Weakness 5
Parkinsons 10
Assistive device 15
Unsteady gait 15
Sensory Deficit (glasses, hearing aide, neuropathy, CVA with deficits) None 0
Neuropathy 2
Hearing deficit 5
Vision deficit 5
CVA w/mild deficits 5
CVA w/major deficits 10
Elimination No issue 0
Urgency 5
Foley 5
Flexiseal 5
Incontinent & independent 5
Incontinent & Dependent 10
Age Less than 65 0
65 to 70 5
over 70 10
Environmental hazards None 0
Oxygen 2
IV tubing 2
Foley catheter 5
NG/feeding tube 5
Drug and Alcohol Use None 0
Smoker 5
Recent illicit drug use 20
ETOH use of 2+ drinks daily 20
Risk Level Score Action
Low Risk 0-9 None required; reassess per policy
Moderate Risk 10 to 20 Basic safety plus bed alarm at night and staff assist to bathroom or commode
High Risk 21+ Basic safety plus high risk interventions
Based on the points assigned for each area identified, the patient is considered to be low, mod-
erate or high risk for a fall. Interventions described below are implemented based on this as-
sessment.
Fall Assessment / Risk Manual Location MountainView Regional Med-
Policy/Procedure Title Reduction ical Center
Policy/Procedure # Effective 12/23/08 Page 5 of 6
INTERVENTION STRATEGIES
Intervention Strategies
Level of Risk Area of Risk
Gait /
High Med Low Frequent Altered Eli- Environmental Balance Multiple Sensory
Interventions (21+) (10 to 20) (0-9) Falls mination Hazards Deficit Medication Deficit
Bed in low position with brakes
locked x x x x x x
Orient/Re-Orient to Environment
(bathroom, call light, etc.) x x x x x x x
Call light in reach of patient & able
to utilize. x x x x x x x
Lock moveable transfer equipment
(beds, wheelchairs, stretchers)
when transferring patients x x x x x x x
Non-slip grip footwear x x x x x x x x
Floor surfaces clean, dry and clut-
ter free. x x x x x x x
Utilize night light x x x x x x
Top side rails in "UP" position x x x x x x x x
Educate patient/family regarding
fall prevention strategies x x x x x x x x x
Patient access to bedside table
(personal articles including assis-
tive device(s), hearing aides, eye
glasses, telephone, etc.) x x x x x x x
Drape tubes / catheters out of pa-
tient way x x x x x x x x
Patient to call for assistance. As-
sist to bathroom/bedside com-
mode. Standby for shower x x x x x x x
Place color armband (yellow) on
patient. Implement yellow fall
check on door. Mark chart. x x x x x x x x
Toilet patient every 2 hours x x x x x x
Bed alarm at night x x x x x
Medication Review x x x x x
Move patient closer to nurses sta-
tion x x x x x
Bed/Chair alarm at all times x x x x
Staff do not leave patient unat-
tended (bathroom, bedside com-
mode, shower) x x x x x x
Family or staff in room if patient
up in chair x x x x x x
Consider having family stay with
patient 24/7. x x x x x x
Fall Assessment / Risk Manual Location MountainView Regional Med-
Policy/Procedure Title Reduction ical Center
Policy/Procedure # Effective 12/23/08 Page 6 of 6
POST FALL PROCEDURE /MANAGEMENT
A. Initial post-fall assessment
a. Immediately assess the patient for injury and find out what happened.
i. Date/time of fall
ii. Patient’s description of fall if possible
1. What was patient trying to accomplish at time of fall?
2. Where was the patient at the time of the fall (room, bathroom,
hallway)?
iii. Family / Provider notification
iv. Vital signs (temperature, pulse, respiration, blood pressure, orthostatic
blood pressure –lying, sitting, standing).
v. Current medications (were medications given, was a medication given
twice?)
vi. Patient Assessment
1. Injury
2. Probable cause of fall
3. Comorbid conditions (dementia, heart disease, neuropathy, etc)
4. Risk factors (gait/balance disorder, weakness)
vii. Other factors
1. Mobility aid?
2. Footwear?
3. Sensory aid?
4. Environment
a. Bed position
b. Brakes locked
c. Lighting
d. Call light within reach
e. Bedside table in reach
f. Side rails used
B. Immediate measures to protect the patient:
a. Communicate to all shifts that the patient has fallen and is at risk to fall again.
b. Ensure hourly rounds on patient
c. Alert the physician for diagnostic and treatment interventions.
d. Put the patient on “high risk for fall” precautions and implement interventions. If
the patient is already on “high risk for fall” determine what other interventions
need to be added.