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Applies To: All HSC Hospitals

Responsible Department: Nursing Leadership


Revised: 4/2012
Title: Fall Prevention
Patient Age Group:

Guideline
( ) N/A

(X) All Ages

( ) Newborns

( ) Pediatric

( ) Adult

DESCRIPTION/OVERVIEW
All patients, inpatient and outpatient, should be assessed for fall risk and have appropriate interventions
instituted. The Humpty Dumpty Falls Assessment Scale is a validated pediatric tool that can help
predict the possibility of a pediatric patient fall. It is based on a retrospective review of pediatric falls.
The most common elements involved in pediatric falls are included in the grading criteria of the tool.
The scoring is a cumulative calculation of defined categories.
REFERENCES
PC.01.02.08, 2012 Hospital Accreditation Standards, The Joint Commission, 2012.
http://www.jointcommission.org.
Miami Childrens Hospital Implementing a Humpty Dumpty Falls Assessment Scale and Fall
Prevention Program in Pediatric Patients 2009.
AREAS OF RESPONSIBILITY
All inpatient units and outpatient clinics including Behavioral Health and diagnostic areas should assess
patients and institute fall precautions on intake and continue them according to procedures in this
guideline.
GUIDELINE PROCEDURES
Adult Inpatient
1. On admission to an adult unit at UNMH, transfer to another unit, change in caregiver, change in
shift, or change in clinical condition, the patient will be assessed using the approved fall risk
assessment tool. Adolescent patients on an adult unit should be assessed using the approved fall risk
assessment tool for that adult unit.
2 If the patients fall assessment score is less than 3, the Standard Safety interventions to be
implemented include:
2.1 Hourly rounding;
2.2 Bed in low position;
2.3 Bed wheels locked;
2.4 Mobility support items readily available;
2.5 Night light utilized;
2.6 Non-skid footwear;
2.7 Personal items within reach;
2.8 Sensory aids within reach;
2.9 Traffic path in room free of clutter;
2.10 Patient and family education, including fall risk signage in room and handout of fall
education brochure.
3 If the patients fall assessment score is equal to or greater than 3, the Fall Risk interventions need to
be individualized to the patients needs and implemented. These will be in addition to the above
Standard Safety interventions implemented for all patients. The Fall Risk interventions included:
3.1 At risk for falls signage on door;
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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3.2 Upper half/length of bed (2) side rails up;


3.3 Use of (3) side rails up;
3.4 Use of (4) side rails up (if ordered by LIP);
3.5 Attempt to locate patient in room near nurses station;
3.6 Sitter present (if ordered by LIP);
3.7 Bed alarm set (in position/sensitivity appropriate to patient needs);
3.8 Staff/family stays with patient while toileting until return to bed or chair;
3.9 Staff/family stays with patient while ambulating until return to bed or chair;
3.10 Attempt to reduce tethering;
3.11 Medication review with LIP.
Adult Ambulatory
1. Upon registration to a clinical area the staff person with first patient contact will start the Morse
Fall Assessment Scale to determine initial risk.
2. For each ambulatory area this should include completion of the fall assessment tool if the patients
initial score is High Risk (45 points or higher) or if the patient is requesting assistance.
3. Patients in the highest fall risk category are to receive a yellow arm band to indicate level of risk.
4. The clinical staff in each of the respective ambulatory sites should be prepared to assist patients
upon their request, or if the patient is wearing a yellow arm band indicating high fall risk.
5. If the patient has a procedure with an IV, sedation, medication, casts, crutches, or other situations
during the visit that may change the initial fall assessment score, the entire assessment must be
redone prior to discharge or transfer to another level of care, transfer to the ED, or hospital
admission.
Outpatient Surgery CenterAdult and Pediatric
1. On admission to the outpatient surgery center, following regional block anesthesia, upon transfer to
the OR, transfer from OR to the PACU and when discharged from the PACU.
2. All patients receiving sedation and anesthesia are at risk for falls.
2.1 Bed will be in low position;
2.2 Bed rails up;
2.3 Patient will have assistance to the bathroom;
2.4 Patient will be instructed not to get out of bed without assistance;
2.5 Place call light within reach of patient;
2.6 Assist transfer of patient from stretcher to OR table; stretcher to chair;
2.7 Provide fall prevention education to patient and family;
2.8 Encourage family member to remain with patient pre-anesthesia if assessed per criteria as
high risk.
3. Pediatric surgery patients will be scored using the Inpatient Humpty Dumpty Scale(refer to
addendum: Patient fall safety protocol)
Neonatal, Pediatric, Inpatient and Ambulatory
1. Fall risk assessment:
1.1 Inpatient
1.1.1 Upon admission;
1.1.2 At the beginning of each shift;
1.1.3 When there is a change in patient status.
1.2 Emergency Department/Pediatric Post Anesthesia Care Unit (PACU)
1.2.1 Upon RN primary assessment;
1.2.2 At the beginning of each shift;
1.2.3 When there is a change in patient status.
1.3 Outpatient Clinics
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
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1.3.1 Upon visit to the outpatient setting;


1.3.2 When there is a change in patient status during visit.
2. Scoring:
2.1 Inpatient/Emergency Department Fall Assessment Tool will be used by the following
departments:
2.1.1 Inpatient.
2.1.2 Pediatric Emergency Room.
2.1.3 PACU .
2.2 Outpatient Fall Assessment Tool will be used by Outpatient Pediatric Primary and
Specialty Care Sites.
2.3 Methodology
2.3.1 The score is a cumulative calculation of the tool;
2.3.2 There are 6-7 parameters; each parameter receives a minimum score of 1;
2.3.3 If for some reason the items in any parameter are not applicable the child would
receive the minimal score of 1;
2.3.4 If a child falls into multiple categories in a parameter, the highest score of the
possible choices would be given;
2.3.5 Each parameter is added in a cumulative fashion;
2.3.5.1 The highest score a child can receive is 20-23;
2.3.5.2 The lowest score a child can receive is a 6 or 7. This number is dependent
on the tool used;
2.3.5.3 Any child with a score of 12 or above is considered high risk.
3. Humpty Dumpty Scale Parameters
3.1 Inpatient/Emergency Department Falls Assessment Tool
3.1.1 Age;
3.1.2 Gender;
3.1.3 Diagnosis;
3.1.4 Cognitive impairments;
3.1.5 Environmental factors;
3.1.6 Response to surgery/sedation/anesthesia;
3.1.7 Medication usage.
3.2 Outpatient Falls Assessment Tool
3.2.1 Age;
3.2.2 Gender;
3.2.3 Diagnosis;
3.2.4 Cognitive impairments;
3.2.5 Environmental Factors;
3.2.6 Medication Usage.
4. Patient Falls Safety Protocol
4.1 Inpatient/Emergency Department Falls Assessment Tool
4.1.1 Low Risk Standard Protocol (score 7-11)
4.1.1.1 Orientation to room;
4.1.1.2 Bed in low position, brakes on;
4.1.1.3 Side rails x 2 or 4 up, assess for large gaps such that a patient could get
extremity or other body part entrapped, use additional safety procedures;
4.1.1.4 Use of non-skid footwear for ambulating patients, use of appropriate size
clothing to prevent risk of tripping;
4.1.1.5 Assess eliminations need, assist as needed;
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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4.1.1.6 Call light is within reach, educate patient/family on its functionality;


4.1.1.7 Environment clear of unused equipment, furniture is in place, clear of
Hazards;
4.1.1.8 Assess for adequate lighting, leave night light on;
4.1.1.9 Patient and family education available to parents and patient;
4.1.1.10 Document fall prevention teaching and include in plan of care.
4.1.2 High Risk Standard Protocol (score 12 and above)
4.1.2.1 Inpatients will receive an armband with a yellow disk;
4.1.2.2 Peds ED patients will receive a yellow band;
4.1.2.3 Educate patient/parents on falls protocol precautions (addendum);
4.1.2.4 Check patient minimum every 1 hour;
4.1.2.5 Accompany patient with ambulation;
4.1.2.6 Developmentally place patient in appropriate bed;
4.1.2.7 Consider moving patient closer to nurses station;
4.1.2.8 Assess need for 1:1 supervision;
4.1.2.9 Evaluate medication administration times;
4.1.2.10 Remove all unused equipment out of the room;
4.1.2.11 Protective barriers to close off spaces, gaps in the bed;
4.1.2.12 Keep door open at all times unless specified isolation precautions are in use;
4.1.2.13 Keep bed in the lowest position unless patient is directly attended.
4.1.3 Document in electronic medical record (EMR);
4.1.4 Document teaching and plan of care.
4.2 Outpatient Falls Assessment Tool
4.2.1 Low Risk Standard Protocol (score 6-11)
4.2.1.1 Orientation to room;
4.2.1.2 Environment clear of unused equipment, furniture in place, clear of hazards;
4.2.1.3 Patient and family education available to parents and patient.
4.2.2 High Risk Standard Protocol (score 12-14)
4.2.2.1 Educate patient/parents of falls protocol precautions;
4.2.2.2 Accompany patient with ambulation.
4.2.3 Highest Risk Standard Protocol (score 15 and above)
4.2.3.1 Patient will be banded with a yellow band;
4.2.3.2 Educate patient/parents of falls protocol precautions;
4.2.3.3 Accompany patient with ambulation.
4.2.4 Document in medical record
5. Additional Age-based interventions to reduce the risk of falls in pediatrics should be
implemented as appropriate (based on cognitive and physical development).
5.1. For all ages of babies or children:
5.1.1 Use adequate analgesia / anxiolysis as needed to reduce restlessness.
5.1.2 Side rails must be up at least as high as the level of the baby/child when transporting,
even if the child is mobile.
5.1.3 Newborns to approximately 6 months (until baby can sit up unsupported):
5.1.4 Side rails up to at least as high as the level of the babys head.
5.1.5 If using a car seat or infant carrier in the crib, a seatbelt must be properly buckled,
and the side rails up to the level of the top of the carrier.
5.1.6 Parents will not be allowed to hold baby in arms if the parent is dozing.
5.1.7 Young siblings (unless for brief period under continuous supervision of an adult
guardian) should not hold or carry the baby in the hospital.
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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5.2 Approximately 6 months - 3 years (from time baby can sit to time child can be in adultstyle bed):
5.2.1 Young children able to stand while holding railings must have a covered crib
(jumper crib).
5.3 Approximately 3 years until school-aged:
5.3.1 Lock out side rail bed controls.
5.4 School-aged children and older:
5.4.1 Based on childs maturity level and mobility status: decide when to unlock side rail
bed controls.
5.4.2 Based on childs maturity level and mobility status: decide when family may assist
child out of bed.
5.4.3 Have personal care items, TV remote, eyeglasses, drinking cups, and ambulation
assists devices, etc. within reach of the bed.
6. Staff should document assessment and interventions other that age based interventions in the
nursing EMR or APC.
Behavioral Health Inpatient and Outpatient

1. Psychiatric Center Inpatient and Psychiatric Emergency Services Clients


1.1 On admission to unit, change in clinical status, change in medications that may contribute
to falls risk, or status post a fall, the client should be assessed for falls risk using the
approved falls risk assessment tool
1.2 If the client is considered at risk of falling, a Falls Prevention Treatment Plan developed
within Multidisciplinary treatment plan, is developed which may include any of the
following staff interventions as individualized to the clients need:
1.2.1 Close supervision while ambulating;
1.2.1.1 Provide assistance devices (for example, walker) as necessary;
1.2.1.2 Lock wheels of wheelchair, bed, gurney during transfers;
1.2.1.3 Instruct clients to call for assistance with movement as appropriate;
1.2.1.4 Provide elevated toilet seat as necessary;
1.2.1.5 Provide a sleeping surface close to the floor as necessary;
1.2.1.6 Provide the dependent client with a means of summoning help (bell or call
light) when caregiver is not present;
1.2.1.7 Assist the client with toileting at frequent, scheduled intervals as necessary;
1.2.1.8 Avoid clutter on floor surfaces;
1.2.1.9 Provide adequate lighting;
1.2.1.10Avoid unnecessary rearrangement of physical environment;
1.2.1.11Ensure that client wears shoes or slippers that fit properly and have non- slip
Soles;
1.2.1.12Educate client and family about risk factors that contribute to falls and they
can reduce those risks;
1.2.1.13 Provide CDC falls prevention brochure and other relevant client teaching
tools as necessary.
1.3 Document patients response to falls prevention related interventions in progress notes.
1.4 Revise Falls Prevention Treatment Plan in response to changes in clients falls risk
assessment.
Adult Outpatient at Psychiatric Center and other Behavioral Health Outpatient Facilities
1. The client will be assessed for falls using the Morse Falls Risk Assessment Tool or other approved
falls assessment risk tool on admission to program, with change in clinical status that may
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
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contribute to falls risk (such as an accident resulting in a lower limb castand/or with change in
psychotropic medications that may contribute to falls risk,
2. If the patient is considered at risk of falling, (score of 45 or greater on basic Morse Falls Risk
Assessment Tool) a Falls Prevention Treatment Plan is developed within the Multidisciplinary
Treatment Plan, and may include any of the following staff interventions as individualized to the
clients need:
2.1. Close supervision while ambulating in clinic or other outpatient program area
2.2. Avoid clutter in program areas
2.3. Provide adequate lighting for increased visibility
2.4. Educate client and family about risk factors that contribute to falls and how they can decrease
those risks in the home environment
2.5. Provide Center for Disease Control (CDC) fall prevention brochure and other relevant client
teaching tools as necessary.
3. For clients who are currently enrolled in behavioral health programs, a basic falls assessment
should be initially completed and then again as clinically appropriate using the Morse Falls Risk
Assessment Tool or other approved Falls Risk Tool:
3.1. If the clients score is 45 or greater on the Morse Falls Risk Assessment Tool, the complete
assessment will be done and a treatment plan completed as directed above.
Childrens Psychiatric Center Inpatient
All children and adolescents are assumed to be at a greater risk for falls secondary to their
developmental stage and developmental activities. Certain clients may be at higher risk for falls
secondary to their medical condition, medication regimen, and/or degree of sensorimotor integration
1. Age-based interventions to reduce the risk of falls in pediatrics should be implemented as
appropriate (based on cognitive, physical and sensorimotor development). Examples of such
interventions include but are not limited to:
1.1. Prevention guidance prior to and during therapeutic recreational activities
1.2. Client and family education regarding falls risks and prevention for children and adolescents
1.3. Removal of objects that could provide a small child with climbing access to elevated surfaces
1.4. Avoid unnecessary rearrangement of physical environment
1.5. Ensure that client wears shoes and /or slippers that fit properly, fasten securely and have nonskid soles
2. For those children and adolescents assessed to be at high risk for falls due to their medical
condition, medication regimen and/or degree of sensorimotor integration, the following
interventions may be added to the basic falls prevention interventions outlined above:
2.1. A Falls Prevention Treatment Plan is added to the clients Multidisciplinary Treatment Plan
which may include the following interventions as necessary:
2.1.1. Use of protective head gear or helmet as necessary
2.1.2. Use of other protective gear, such as knee guards or shin guards as necessary
2.1.3. Collaboration among members of the multidisciplinary health care team to minimize the
effects of medications that contribute to falling (for example, orthostatic hypotension
and unsteady gait)
2.1.4. Close supervision while ambulating as necessary
2.1.5. Provide assistance devices (for example, walker) as necessary
2.1.6. Lock wheels of wheelchair, bed, gurney during transfers
2.1.7. Instruct clients to call for assistance with movement as necessary
2.1.8. Provide elevated toilet seat as necessary
2.1.9. Provide a sleeping surface close to the floor as necessary
2.1.10. Provide the dependent client with a means of summoning help (bell or call light) when
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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caregiver is not present, as necessary


2.1.11. Assist the client with toileting at frequent, scheduled intervals as necessary
2.1.12. Avoid clutter on floor surfaces
2.1.13. Provide adequate lighting
2.1.14. Avoid unnecessary rearrangement of physical environment
2.1.15. Document clients response to falls prevention interventions in progress notes
2.1.16. Revise Falls Prevention Treatment Plan in response to changes in clients falls risk
assessment.
Childrens Psychiatric Center Outpatient
All children and adolescents are assumed to be at a greater risk for falls secondary to their
developmental stage and developmental activities. Certain clients may be at higher risk for falls
secondary to their medical condition, medication regimen, and/or degree of sensorimotor integration
1. Age-based interventions to reduce the risk of falls in children and adolescents should be
implemented as appropriate (based on cognitive, physical and sensorimotor development).
Examples of such interventions include but are not limited to:
1.1. Falls Prevention guidance prior to and during therapeutic recreational activities
1.2. Client and family education regarding falls risks and prevention for children and adolescents
1.3. Removal of objects that could provide a small child with climbing access to elevated surfaces
while attending program
1.4. Avoid unnecessary rearrangement of physical environment within program facilities
Diagnostic Areas
Inpatients and outpatients including Cardiac Rehabilitation, Cardiac Cath Lab, Heart Station, Vascular
Lab, and Pulmonary Diagnostics, Endoscopy Center, Neurodiagnostics, Rehabilitation Services, and
Carrie Tingly Hospital Outpatient Rehabilitation/ O&P are considered at high risk for falls due to the
expectation of chronic conditions related to high fall risk.
1. Assess and periodically reassess each patient's risk for falling, including potential risks associated
with the patient's Cognitive status, Fall History, and medication regimen/plan and take action to
address any identified risks.
2. Age-based High Risk fall precautions (interventions) will be implemented, as appropriate (based on
cognitive and physical development), for all inpatient and outpatient Diagnostic and Rehabilitative
areas.
2.1. Explore events associated with previous falls (what occurred before, during, after falls).
2.2. Discuss any changes in patient status during inpatient handoff report.
2.3. Evaluate environment for tripping, hazards, and spills.
2.4. Provide assistance and supervision during ambulation, use wheel chairs if appropriate.
2.5. Provide non-skid footwear for ambulation during ambulatory types of diagnostic or
rehabilitative treatment.
2.6. Ensure that patient has glasses or hearing aides in place prior to activities, to increase
environmental awareness.
2.7. Provide proper lighting.
2.8. Give appropriate training for assistive devices.
2.9. For all ages:
2.9.1. Use adequate analgesia/anxiolysis as needed to reduce restlessness.
2.9.2. Brakes must be set when not transporting crib/wheelchair/stretcher/bed.
2.9.3. Side rails must be up when transporting via bed/stretcher.
2.9.4. Baby/Child side rails should be at least as high as the level of the baby/child when
transporting, even if the child is not mobile.
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
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2.9.5. Other age appropriate safety interventions are utilized for newborns and pediatric
patients as mentioned above in the inpatient guidelines.
3. Inpatients If patient is identified as being at continued risk for immediate risk of fall (reports acute
symptoms of high risk symptoms) prior to discharge from an inpatient setting, include this
information in handoff communication report prior to transfer of patient.
4. Outpatients If patient is identified as being at continued risk for immediate risk of fall (reports
acute symptoms of high risk symptoms) prior to discharge from an outpatient setting, contact
departmentally specified medical personnel for additional assessment and disposition.
5. All radiology patients, including all modalities, are considered a potential risk for falls.
5.1.All In and Out patients requiring the services of radiology are considered at risk for falls.
Patients entering the area may have multiple impairments; physical, mental and
pharmacological. The department has a standard process for all patients.
5.1.1 The front desk staff observes the patients upon entering the department. If a potential risk
is identified, the supervisor / charge technologist is immediately notified.
5.1.2 The supervisor / charge technologist will communicate with the patient/family to
establish what measures must be taken while in Radiology.
5.1.3 In the event a greater level of care is needed, a nurse will be requested to assess the
patient and in the event where a higher level of medical attention is required the patient
will be transported as follows:
5.1.3.1 Inpatient: the patient will be returned to the sending unit.
5.1.3.2 Outpatient: the patient will be taken to the Emergency Department.
5.1.3.3 Patients are escorted to the exam room by the technologist providing the
imaging service. If in the event more assistance is needed the technologist
will request it, i.e. lifting help, chaperone, requesting a wheel chair.
5.1.4 When the patient is pediatric or has special needs, the risk of falls from the imaging table,
stool or chair is of additional concern. The caregivers will be utilized to provide fall
safety for the patient.
5.1.5 Immobilization methods will be utilized at all times to include sandbags, gel rolls, and
caregiver holding procedures. These immobilization techniques will be utilized as
standard procedure.
5.1.6 The radiologic imaging specialist is responsible for any and all activities within the
imaging room. Prior to commencing any exam, the imaging specialist will provide
information to the caregiver and age appropriate information to the child regarding the
process. This information will include detail of what will be happening throughout the
exam as well as child safety instruction to the caregivers. These caregivers will be
instructed to maintain complete hands-on control of the patient at all times. Caregiver
instruction will be an integral part of the procedure.
5.1.7 The imaging specialist must secure any patient before exiting the procedure room. The
pediatric patient must be in the presence of a qualified caregiver, who will remain seated
in a chair or in attendance at the side of imaging table. Should a situation arise that
requires the imaging specialist to leave the room for any prolonged amount of time, the
patient and caregiver will be taken to a waiting area until that situation is resolved. The
imaging specialist must take every precaution to assure that the patient and caregivers are
in a safe environment.
5.1.8 In the event of a fall, the immediate action shall be to call Rapid Response Team. The
Radiologist will be called for initial assessment; however, the patient will not be moved
until the Rapid Response team deems it safe. All fall events must be reported using the
Patient Safety Net (PSN) system and reported to the direct Supervisor in charge.
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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5.1.9 Fall assessment verification is documented on the Radiology Information System (RIS).
DEFINITIONS
Fall A sudden, uncontrolled unintentional, loss of upright position that results in landing on the floor,
ground or onto an object or furniture. The fall may be witnessed or unwitnessed.
Fall Prevention Instituting special precautions with patients at risk for injury from falling.
SUMMARY OF CHANGES
Replaces Fall Prevention, last revision 10/2009.
Inclusion of Humpty Dumpty Fall Assessment Scales
RESOURCES/TRAINING
Resource/Dept
Clinical Education

Internet/Link

DOCUMENT APPROVAL & TRACKING


Item
Owner
Consultant(s)
Committee(s)
Nursing Officer
Official Approver

Contact
Date
Approval
Executive Director, Carrie Tingley Hospital, Inpatient Pediatric Areas, Outpatient
Ambulatory
Director, Diagnostic Center, Nursing Practice Coordinator, Behavioral Health
Unit Director Ambulatory Surgery
Nursing Practice PP&G Sub-Committee, Clinical Operations PP&G
Y
Committee, Pediatric Practice Council
Sheena Ferguson, MSN RN Chief Nursing Officer
Y
Sheena Ferguson, MSN, RN, CNO
Y

Official Signature

Date: 8/10/2012

Effective Date
Origination Date
Issue Date

8/10/2012
6/1997
8/16/2012

Clinical Operations Policy Coordinator

ar

ATTACHMENTS
Humpty Dumpty Scale-Emergency Department
Humpty Dumpty Scale-Inpatient
Humpty Dumpty Scale-Outpatient
Humpty Dumpty Falls Safety Protocol-Inpatient and Emergency Department

_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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Attachment A

_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

Page 12 of 13

Patient Falls Safety Protocol


Low Risk Standard Protocol (score 7-11)
Orientation to room
Bed in low position, brakes on
Side rails x 2 or 4 up, assess large gaps, such that a patient could get extremity or other body part
entrapped, use additional safety procedures
Use of non-skid footwear for ambulating patients, use of appropriate size clothing to prevent risk
of tripping
Assess eliminations need, assist as needed
Call light is within reach, educate patient/family on its functionality
Environment clear of unused equipment, furnitures in place, clear of hazards
Assess for adequate lighting, leave nightlight on
Patient and family education available to parents and patient
Document fall prevention teaching and include in plan of care
High Risk Standard Protocol (score 12 and above)
Inpatients will receive an armband with a yellow disk
Peds ED patients will receive a yellow band
Educate patient/parents of falls protocol precautions
Check patient minimum every 1 hour
Accompany patient with ambulation
Developmentally place patient in appropriate bed
Consider moving patient closer to nurses station
Assess need for 1:1 supervision
Evaluate medication administration times
Remove all unused equipment out of room
Protective barriers to close off spaces, gaps in bed
Keep door open at all times unless specified isolation precautions are in use
Keep bed in lowest position, unless patient is directly attended
Document in EMR
Document teaching and plan of care

_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928

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