IPSG/TT-006 Post Fall Investigation

Appendix7 to the Policy on Fall Prevention and Management (IPSG/PP-003)

IPSG/FO-006 – Appendix 8

POST FALL INVESTIGATION TOOL

Incident No.

Date of Fall 17/11/2022 Time of Fall 23:20 Unit: IPU3 MRN No. 102978

Unit Census: 14 Total Staff on duty at the time of fall: 5 Time of last rounds: 21:00

Was a fall risk assessment completed prior to fall? Yes No

If yes, how long since the last falls risk assessment? <8hrs. 12 to 24 hrs. > 24 hrs.

If Yes, What level of falls risk? Low Moderate High. Fall Risk assessed correctly Yes No

FALLS DETAILS (PLEASE TICK)

Activity Level prior to fall Bed rest to chair with assist Ambulate with assist
Ambulatory

Toileting functions: Continent Incontinent Urinary catheter/Drain Anuria

Toileting Assistance Independent Requires assisting Incontinence care only

Injury resulting from fall No injury With Injury (describe) Left arm distal radius fracture

NA/
YES NO
UNKNOWN
Was there a mental status change from baseline prior to fall (e.g. new disorientation, agitation)
✓
Was there a physiologic change prior to fall (e.g. new onset of fever, hypoxia, arrythmia)
✓
Does the patient have cognitive impairment at baseline (prior to fall)
✓
MEWS Score >1
✓
Language Barrier exists
✓
Education about falls risk provided to the patients /family/ career
✓
Patient on fall risk medications (if yes, was the recent medication taken within 6 hrs. of fall)
FALL PREVENTION INTERVENTIONS:
✓
What interventions were part of the patients fall prevention plan prior to fall and were they in place at the time of fall (select all
that apply)
Visual Communication YES NO NA ATTACHMENT YES NO NA

Sign inside the room IV tubing connected to the patient

✓ ✓
Sign outside room Infusion pump cords plugged into wall
✓ ✓
Neon pink bracelet (if high risk) Urinary catheter attached to drainage bag
✓ ✓
Specialty Equipment Gastrotomy or other drainage tubes in place
✓
Exit alarm bed set Negative pressure wound therapy
✓ ✓
Low bed Oxygen tubing/ trach collar/ ventilator
✓ ✓
Restraint
✓ Other:
Footwear

Nonskid slipper or socks/ rubber- soled shoes

✓
Assistive devices (if yes specify)
✓

IPSG/TT-006 Page 1 of 3
IPSG/TT-006 Post Fall Investigation
Appendix7 to the Policy on Fall Prevention and Management (IPSG/PP-003)
ENVIRONMENT STATUS AT TIME OF FALL
IN THE ROOM
Call bell within reach
Call bell functioning
Patient aware of how to use call bell
Floor clear and dry
Patient items within reach
Bed in lowest position
Bed wheels locked
Bed rails applied as per bed rail matrix tool
Chair/ wheelchair wheels locked
Room to move freely/ turn radius/ dominant
side is clear
Others present (staff, visitors etc.)
Why does the staff think the person fell (describe) lose his balance when he try to exit the bathroom after stepping on wet area in
the floor
YES NO NA IN THE TOILET/ WASHROOM YES NO NA
Clear path to bathroom or commode
✓ ✓
Call bell in toilet functioning
✓ ✓
Aware of use of call bell in toilet/ washroom
✓ ✓
Patient used grab bars in toilet/ washroom
✓ ✓
Bathroom clear
✓ ✓
Floor dry
✓ ✓
Adequate lighting
✓ ✓
Patient gown/ trouser length appropriate
✓ ✓ the
Others: (if fall occurs outside patient room describe
environment)
✓
✓
✓

Ask the person, what were you doing when you fell? (describe using the patient’s words) Finishing toileting and want to exit the
bathroom

Ask the person/ patient

Was he/ she aware of fall risk medication? YES NO

NA Was he/ she aware of mobility limits? YES NO

NA
Why do you think you fell (describe using the patient’s words): Wet floor

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IPSG/TT-006 Post Fall Investigation
Appendix7 to the Policy on Fall Prevention and Management (IPSG/PP-003)

Root cause(s) of this fall (to be completed by the investigator)

1. Patient has history of seizure, on home medication but stopped days before admission.
2. Attendant left the patient despite being informed by team leader to stay with the patient, but attendant
insist to go for dinner and pray, told the team leader that his father doesn’t need anything and going to
sleep.
3. Family reported that the patient has a sleep disturbance and only sleep intermittently.
4. Patient didn’t call for help, did not wait the nurse to come and went to the bathroom alone.
5. Maybe attendant just put the side rails down and forgot to close.
Recommendations / Action Taken:
1. We reinforce about the need to assess the fall risk for patients at high risk and ensure they have
attendant available at bedside.
2. Educate the patients about the call bell and the needs to wait for the nurse to help them in daily activity if
they have some deficiencies and require help.
3. Reinforce staff about the need for hourly round and apply the 5P’s.
4. Educate the staff about the call bells privilege’s (they can talk to the patients and know their needs
without attend the patient, can provide them with needed things immediately like urinals or bed pans.
5. Provide the patient at high risk of fall a urinal if they are complaining of urine urgency.

COMPLETED BY
Ahmad Bashir Al-Debyan Clinical Resource Nurse AA.1032

NAME: TITLE SIGNATURE

Report to Quality Department and attach to the OVR form.

IPSG/TT-006 Page 3 of 3