Additional Individualized Fall Safety Interventions

For individual patients who have been assessed and identified as needing additional
safety interventions select interventions as appropriate on the Fall Risk Profile or add
others in interdisciplinary notes/PCP/Kardex.
Consider consult / referrals to team members as appropriate: PT, OT, SW, Pharmacy,
Geriatrics etc.
A. Impaired Mental Status: Confusion / Agitation
 Use standardized testing as appropriate (e.g. MMSE) or review test
administered by team members
 Encourage family members/SDM, volunteers to remain with patient
 Place in room near nursing station. minimize number of room changes
 Change texture of arms of chairs or grab bars by wrapping with tape or
sheepskin to facilitate grip
 Provide increased observation and assistance during periods of peak
activity and at night as this can be a high fall risk time
 Place bed in lowest position; leave at least one side rail down and place
floor mat / cushion or mattress on the floor beside the bed if patient is
attempting to climb over the side rail
 Review need for least restraint as last resort

B. Impaired Mobility / Altered Elimination Pattern

 Provide regular toileting routine (if incontinent start q2hrs and progress)
o Routine assistance to toilet at night as this can be a high fall risk
time
 Mobilize at least 3 times / day
o Walk to bathroom
o Walk within room, then progress as appropriate
 Encourage patient to be up in chair for _____ meals / day
 Provide wheelchair mobility and encourage foot propelling as appropriate

C. Communication / Sensory / Perceptual Alteration

 Use hearing amplifier as appropriate and to confirm hearing of instructions
 Consider referral for assistance with sensory aids
 Consider Speech/language referral for assessment and interventions
 Use red tape to identify edges of sinks, toilets, tubs as necessary
D. Environmental Provide
 Assess need for ≥ 2 side rails. Note patient requirements on Kardex
 Educate patient / family that use of 4 side rails could be considered a
restraint and possibly contribute to greater injury in a potential fall
 Ask patient / family for their preference.
 Mark bathroom with pictorial sign at eye level, as appropriate
  Use monitoring devices (e.g. bed alarm, chair alarms)
E. Medication / Hypotension / Weakness / Other
 Monitor BP lying and standing for three consecutive mornings.
 Observe and report ≥ 20 mm drop between lying and standing.
 Encourage patient to sit at side of bed and count to ten before rising.
 Provide hypotension hand-out as appropriate
 Convert IV access to saline /hep- lock soon as possible