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 26/01/2023 Time of Fall 10:30 Unit: IPU3 MRN No. 102879

Unit Census: 23 Total Staff on duty at the time of fall: 5 Time of last rounds: 09:00

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)

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)
✓

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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) Sudden loss of consciousness during waking
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) Ambulating with physiotherapist

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): Sudden loss of consciousness

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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 on multiple psychotropic and hypnotic medications
2. Falling down interventions were not applied to the patient by the assigned nurse
3. Fall risk assessment tool was not filled correctly
4. Patient and family were not educated about fall prevention measures
Recommendations / Action Taken:
1. Educate all staff about the correct way to fill the fall risk assessment tool and to adhere to the
interventions listed in the tool
2. Educate the patients about the call bell and the need to wait for the nurse to help them in daily
activity, especially if there is no attendant with the patient
3. Emphasize on the importance of hourly round
4. Encourage staff and team leaders to continuously check and re-educate all patient about the falling
down measurement in their rounds

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

NAME: TITLE SIGNATURE

Report to Quality Department and attach to the OVR form.

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