(Universal Falls Precautions) Maintain safe unit environment : Maintain safe unit environment : Maintain safe unit environment : Remove excess equipment/supplies/ Remove excess equipment/supplies/ Remove excess equipment/supplies/ furniture from rooms & hallways. furniture from rooms & hallways. furniture from rooms & hallways. Coil and secure excess electrical and Coil and secure excess electrical and Coil and secure excess electrical and telephone wires/cords. telephone wires/cords. telephone wires/cords. Clean all spills in patient room or in Clean all spills in patient room or in hallway Clean all spills in patient room or in hallway hallway immediately. immediately. immediately. Place a signage to indicate wet floor Place a signage to indicate wet floor danger. Place a signage to indicate wet floor danger danger. Institute flagging system: Institute flagging system: Follow the following safety interventions: 1. Apply falls risk arm band 1. Apply falls risk arm band 2. Falling star (yellow) outside the patient’s door 2. Falling star (red) outside the patient’s door Orient the patient to surroundings, 3. Falls risk sticker on the medical record. 3. Falls risk sticker on the medical record. including bathroom location, use of call light. Follow low falls risk interventions plus: Follow low & moderate falls risk interventions Keep bed in lowest position during use plus: unless impractical (when doing a Monitor & assist patient in following daily REMAIN WITH PATIENT WHILE procedure on a patient) schedules: TOILETING Keep the top 2 side rails up Observe q 60 minutes unless patient is on Secure locks on beds, stretcher, & wheel Supervise/assist bedside sitting, personal activated bed or chair alarm. chair. hygiene and toileting as appropriate. When necessary transport throughout Keep floors clutter/obstacle free Reorient confused patient as necessary. hospital with assistance of staff or trained (especially the path between bed and Establish elimination schedule and use of care givers. Consider bedside procedure. bathroom/commode). bedside commode if appropriate. Place call light & frequently needed Evaluate need for following measure going from objects within patient reach. Evaluate need for: less restrictive to more restrictive: Answer call light promptly. PT consult if patient has history of falls Moving patient to room with best visual Encourage patient/family to call for and /or mobility impairment. access to nursing station. assistance as needed. OT consult. Activated bed/chair alarm. Assure adequate lightening especially at 24 hour supervision/sitter/1:1 night. Physical restraint- only with authorized Use proper fitting non-skid footwear. Prescriber order.