Jeff Reece, RN, MSN, MBA

Chief Executive Off ice

Chesterfield General Hospital

Eliminating Harm:A Fall Prevention Program

Patient Safety Concerns- injury to patient

HAC’s became reality by the signing of the 2006 Deficit Reduction Act.

Discharges occurring on/after October 1, 2008 in which one of the HAC’s were not present on admission, hospitals will not receive additional payment for those cases.

Why is this important to us?

Purpose of the policy was to address:Targeted (Re) Assessment for identified

patients at riskTargeted Interventions to prevent falls for

patients identified as low or at risk for falls.Visually identify and effectively communicate

hospital wide which patients are at risk to fall.Reduce fallsDefine FallsReduce severity of injury related to fallsReduce repeat fallsEducate staff, patient and family.

The First Step- Policy Development

Any observed fall of patient from one surface level to another, i.e. bed to floor or chair to floor.

Any fall reported by a patient

Any patient found on the floor and there is a reason to believe the patient fell as opposed to sitting on his/her own accord.

Any patient assisted to the floor by staff.

Fall Definition

Department Managers held accountable to ensure staff compliance with the policy.

Admitting RN will perform a fall risk assessment and implement nursing interventions

The patients nurse to routinely reassess the patient for the need for appropriate intervention throughout the stay. A low risk patient is to be reassessed when there is a significant change in their mental status, gait or mobility, medications, etc not to exceed 24 hours. High risk is reassessed every shift.

Responsibility

The patient’s nurse should re-assess the patient when a change in the patient’s condition or environment changes. Interventions should be implemented, communicated and documented.

It is the responsibility of all employees to observe and monitor patients identified at risk for falls.

Responsibility

The Fall Risk Assessment Tool

Fall Risk Assessment

Fall Risk Assessment

Fall Risk Assessment

Fall Risk Assessment

An orange Leaf is placed on the door to remind staff that this patient is at risk for falls.

Orange Non-skid socks are placed on identified at risk patients.

Orange Dot is placed on patients medical record.

Orange ID band is placed on patient to help those who may be transporting patient from unit to unit identify quickly of the patients fall risk status.

Visual Reminders of Identified Risk Patients

The care plan is updated to reflect the patients fall status as well as in the nursing notes.

Documentation

Discussion?Questions?

Thank You!