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TITLE:FALL PREVENTION PROTOCOL POLICY # F 01.5MANUAL:NURSING POLICY/PROCEDURE MANUAL
Page 1 of 5Effective Date: 10/00Approval
/s/ Kathy Hardin
 
Reviewed/Revised: 5/02; 6/02, 11/05,11/06, 2/07
Katherine Hardin, RN, BSN, JDChief Nursing Officer 
H:\SHARED\patcare p&ps\Nursing Clinical P&Ps - MR\Fall Prevention Protocol F 01.5.doc
VALUES CONTEXT
Our value of service assures that we respond to the needs of the whole person.
PURPOSE\EXPECTED OUTCOME (S)
To outline the nursing management of the patient with increased risk of falling as identified by a Fallrisk score of 50 points or greater.
POLICY
A.SUPPORTIVE DATA1.
 
A fall is defined as a sudden unanticipated change in body position in a downwarddirection, which may or may not result in a physical injury (this definition doesnot include an assisted lowering of a patient to a chair or the floor).2.
 
Identification of patients that may be at risk for an accidental fall duringhospitalization is necessary. All patients are assessed for fall risk daily at the timeof the RN assessment and reassessed if orientation or alertness deteriorates and/or a fall occurs.3.
 
Patients determined to be a fall risk and assessed to have confusion, short-termmemory loss, and/or poor safety awareness, are considered “high fall risk.”Additional safety precautions for high fall risk patients will be utilized. These precautions will include any of the following:
 
Bed near the nurses station
 
Bed alarm
 
Sitter 4.
 
Although a fall risk score is assessed daily, patients identified as at risk for fall atany time during hospitalization will remain on the Fall Prevention Protocol for theduration of hospitalization unless documented otherwise by an RN or a Physician.Any patient experiencing an accidental fall will remain on the Fall PreventionProtocol for the remainder of the admission.
 
FALL PREVENTION PROTOCOL
Page 2 of 5
H:\SHARED\patcare p&ps\Nursing Clinical P&Ps - MR\Fall Prevention Protocol F 01.5.doc
B.PERSONNELRN, LVN, CNA
PROCEDURE
A.
 
ASSESSMENT1.
 
Assess risk score (see below) daily at time of RN assessment and reassess if patientorientation or alertness changes.2.
 
Monitor gait, balance and fatigue with ambulation.3.
 
Monitor after change in medication for possible side effects:
•
 
Sedation
•
 
Hypotension
•
 
Impaired balance
•
 
Impaired elimination
•
 
Impaired reaction time4.
 
Reassess safety interventions in place and update as appropriate.5.
 
Morse Fall Scale (See Appendix A for description)The Fall Risk Score is assessed on admission and reassessed daily and for any changein orientation or level of consciousness.The Fall Prevention Protocol is implemented for adult and geriatric patients whoscore 50 or more total points
FactorPoints
History of fallingYes = 25 No = 0Presence of Secondary diagnosisYes = 15No = 0IV therapy or peripheral IV lockYes = 20No = 0Type of gaitWeak = 10Impaired = 20Use of walking aidsNormal/bedrest/wheelchair = 0Cane/crutches/walker = 15Uses furniture = 30Mental statusOverestimates/forgets own limitations = 15B.
 
CARE PLANA plan of care is developed with appropriate interventions individualized to patient needsthat may include any of the following interventions.
 
FALL PREVENTION PROTOCOL
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H:\SHARED\patcare p&ps\Nursing Clinical P&Ps - MR\Fall Prevention Protocol F 01.5.doc
C.
 
INTERVENTIONS are chosen based on assessment of patient need and appropriateness.Interventions that may be considered for an individualized plan of care include:1.
 
Place hot pink armband on patient wrist.2.
 
Place a fall risk sign in a highly visible area of the patient room.3.
 
Make notation on Kardex and mobility guidelines, “Fall Risk”.4.
 
Patients benefit from having family at the bedside to provide comfort &reassurance. Discuss fall risk status with patient and/or family upon initial scoreof 50 or greater 5.
 
Review “Tips to prevent falls” teaching sheet with patient and family.6.
 
Use gait belt to transfer patients to a commode, chair or when ambulating. Keep agait belt at bedside for patients identified as a fall risk.7.
 
Maintain bed in low position when occupied by a patient.8.
 
Maintain equipment with wheels in locked position at all times.9.
 
Remove any environmental obstacles from the patient’s walking path.10.
 
Consider bed or chair occupancy monitor as appropriate.11.
 
Reorient to surroundings and environment as needed.12.
 
Monitor patient and environment for safety at least every 2 hours.13.
 
Be alert to and investigate noises from patient rooms.14.
 
Place call light and frequently used items within reach. Utilize night light in patient room.15.
 
Offer bedpan, urinal, or assistance to bathroom at mealtime, at bedtime, and uponawakening.16.
 
Patients identified, as a fall risk will be assessed for toileting every 2 hours whileawake and PRN overnight.17.
 
Patients identified, as a fall risk will be supervised while on the commode.18.
 
Provide non-skid red slippers if available for patients without footwear.19.
 
Obtain walker, cane or wheelchair from home if patient has need of assistivedevices prior to admission. Assist with/supervise transfers and ambulation.20.
 
Consider placement in a room or area of high visibility.21.
 
Discuss benefits of continuous supervision with family as appropriate.22.
 
Communicate fall risk status at shift report and upon patient transfer to other department or unit.23.
 
Safety issues will be discussed at interdisciplinary team meetings.
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