CODE STAR PACK

(What to do when a patient falls)

Call for help/Page Code Star

Assess for immediate life-threatening injuries/stabilize patient
If you suspect spine/head injury
• Do NOT move the patient
• Immobilize head and neck with collar
• Position backboard and log roll patient onto board
Move patient to safe location and assess head-to-toe for all injuries and
initiate First Aid measures
Conduct Post Fall Safety Huddle – Use Post Fall Huddle Form
Enter Post Fall Documentation in Medical Record (Assessment & Progress
Note)
Vital signs and Neuro assessment every hour x2, every 2 hours x2, then
every 4 hours x6
Submit Event Report in ERS
Completed Forms to Unit Director/Administrative Supervisor
Administrative Post Fall Huddle/Completed Forms to Quality/Risk
Management

SALEM MEDICAL CENTER

 PATIENT STICKER
POST FALL HUDDLE AND CHECKLIST

Date of Fall Time of Fall Time Last Seen Prior to Fall MORSE SCORE Prior to Fall
Location of Fall Patient Room Hallway Bathroom Other (specify) Unwitnessed Witnessed
STAFFING RNs LPNs Techs Sitters Census RN/Pt Ratio Tech/Pt Ratio
AT TIME OF FALL # on unit #off unit/test #on break #covering 1:1
Vitals (at time of fall) Temp B/P HR RR SPO2 BS
Activity at time of fall?
Assistive device? Type? In Use? Yes No N/A Defective? Yes No N/A Seen by Therapy Before Fall? Yes No
Call light active at time of fall Yes No Patient Called for Help? Yes No, Why not?
Assigned RN Statement Post Fall
Assigned Tech Statement Post Fall
INTERVENTIONS PRESENT PRIOR TO FALL
Safety interventions in use at the time? Bed/Chair Alarm Fall Signage Call Light Within Reach Fall Bracelet Family Staying
Education Provided/Documented? Yes No 1:1 Personal Items Within Reach? Yes No Close to Nurse’s Station
Yellow Grip Socks or Type of Footwear Other (specify)
ENVIRONMENTAL (mark all that apply and/or may have contributed to this fall)
Floor surface (wet, uneven, slick) Furniture Cords (phone, electric, bed, IV, n/c) Poor Lighting Blankets/sheets
Clothing or shoes Room Cluttered Bed height High Low Bed Rails Up Down Unmet Needs? (specify)
MEDICATIONS
CURRENT MEDICATION TYPES ORDERED Hypoglycemic Agents Antihistamines Antipsychotics Antihypertensives Antianxiety
Cardiovascular Antiseizure Hypnotics Laxatives Anti-Depressants Narcotics Anti-Parkinson Diuretics
All new medications in the last 72 hours:
Anticoagulants: Yes No, List:
BEHAVIOR/COGNITION
Change in Sleep Pattern: Yes No, Describe
Change in Mental Status in Last 90 days? Yes No, Describe
Behavior at time of fall: Agitated Wandering Restless Sundowning Combative Hallucinations
Unknown (unwitnessed fall) Other (specify):
MEDICAL CONSIDERATIONS
Recent change: Yes No, Describe
Primary & Secondary Diagnosis:
INCONTINENT Bladder Bowel Both Does the patient need assistance with toileting? Yes No Last time toileted:
CIRCULATORY/HEART Anemia Cardiac Dysrhythmia Angina/ME/ASHD CHF/Pulmonary Edema CVA TIA
Postural Hypotension Other (specify):
NEUROMUSCULAR/FUNCTIONAL Cerebral Palsy Loss of Arm or Leg Movement Hemiplegia/Hemiparesis Parkinson’s
Traumatic Brain Injury Paraplegia Seizure D/O Multiple Sclerosis Other (specify)
PERCEPTUAL Impaired Hearing Impaired Vision Vertigo Wearing Glasses? Yes No
PSYCHIATRIC/COGNITIVE Delirium Wandering Cognitive Impairment Alzheimer’s Anxiety D/O
Manic/Depression Schizophrenia Other (specify)
ORTHOPEDIC Arthritis UE/LE Fracture Missing Limb(s) Osteoporosis Joint Pain
OTHER Infection Low level of physical activity Pain Headache Fatigue/Weakness Vit D Deficiency
Hypo/Hyperglycemia Electrolyte Imbalance Other (specify)
IMMEDIATE ACTIONS/FOLLOW-UP (check all that apply)
Physician Notified Closer to Nurse’s Station Therapy Consult Pharmacy Consult 1:1 Initiated High/Low Bed
Bed/Chair Alarm Activated Other (specify)
Family Notified: Who? Pt Refused Family Notification EHR Fall Assessment Completed – Required
FALL DRILL DOWN/HUDDLE Time Huddle Completed Name of Person Completing Form
PARTICIPANT SIGNATURES (REQUIRED)
Charge Nurse Not Present Supervisor Not Present
Assigned RN Not Present Assigned Tech Not Present
Unit RN Not Present Unit RN Not Present
Unit RN Not Present Unit RN Not Present
Unit Tech Not Present Unit Tech Not Present
Director Not Present Assigned 1:1 Not Present

Director analysis of fall:

Director action plan:

SEND/FAX FORM TO RISK MANAGEMENT 856-339-6022

NOT TO BE PART OF MEDICAL RECORD