SJ-SM Patient Fall Prevention 2-10-15...Carondelet Health Policies & Procedures Page 2 of 12 DEFINITIONS: Fall: A patient fall is a sudden, unintentional descent, with or without injury

Carondelet Health Policies & Procedures Page 1 of 12

GUIDELINES/PLANS/POLICIES & PROCEDURES

CH Patient Fall Prevention Summary: Every patient presenting to the hospital will be assessed in order to determine the patient's potential for falls.

Effective Date: 6/26/2000 Revision History: 2/10/2015, 2/17/2014; 8/29/2011, 8/01/2009, 11/1/2007,

4/1/2006, 1/2/2006, 5/31/2004, 6/26/2000 Reviewed Date: 2/10/2015

Facilities: SJMC, SMMC Approved By: VP Nursing Executive

Policy Impacts: All Employees

POLICY: Every patient presenting to the hospital will be assessed in order to determine the patient’s potential for falls. For inpatients, the assessment will be performed by utilizing the Morse Fall Scale (See Addendum A). Outpatients will be assessed for fall risk by utilizing the Outpatient Fall Risk Assessment (Addendum B), or by utilizing a department specific Fall Assessment form. In addition to the Morse Fall Scale, all patients on the St. Joseph rehab unit will be assessed for compliance utilizing the 5 North Falls Protocol Compliance Scale (addendum E). FALL PREVENTION OBJECTIVES:

• To minimize the risk of patient falls without compromising the mobility and functional independence of patients.

• To delineate the characteristics that place patients at risk for falls.

• To promote proactive healthcare practices for patient care planning, which minimize the risk for fall.

• To identify the main components of an effective Fall Prevention Program which are:

o thorough assessment o appropriate intervention o appropriate documentation o regular evaluation


DEFINITIONS:

Fall: A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can). NDNQI counts only falls that occur on an eligible, reporting nursing unit. When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall. If a patient who is attempting to stand or sit falls back onto a bed, chair, or commode, this is only counted as a fall if the patient is injured. All unassisted and assisted falls are to be reported, including falls attributable to physiological factors such as fainting (known as physiological falls). Assisted Fall: A fall in which any staff member (whether a nursing service employee or not) was with the patient and attempted to minimize the impact of the fall by easing the patient’s descent to the floor or in some manner attempting to break the patient’s fall, e.g., when a patient who is ambulating becomes weak and the staff lowers the patient to the floor. In this scenario, the staff was using professional judgment to prevent injury to the patient. A fall that is reported to have been assisted by a family member or a visitor counts as a fall, but does not count as an assisted fall.. “Assisting” the patient back into a bed or chair after a fall is not an assisted fall (NDNQI, 2014).

Morse Fall Scale Patient Risk Factors:

o History of falling o Secondary diagnosis o Ambulatory aids o Intravenous therapy/IV Lock o Gait/Transferring o Mental status

Identification of patient problems such as impaired: eyesight, hearing, cognition, gait and balance are also conditions that need to be evaluated when considering the patient’s risk for falling. PROCEDURE: I. Inpatients A registered nurse will assess the inpatient immediately upon admission, every shift, and anytime the patient has a change in condition or is transferred to another level of care, by utilizing the Morse Fall Risk Model (See Addendum A), in order to determine the inpatient’s potential risk for falls. This assessment will also indicate which patients require the initiation of an appropriate fall prevention program. Inpatients identified as being at high risk for falls, which is designated by the Morse Fall Risk Score of forty five (45) or greater will be placed on the Falls Prevention Program.


All inpatients who have a Morse Fall Risk score of forty four (44) or less will be designated as a Low Fall Risk. The following intervention techniques will be implemented for all inpatients.

Place gait belt in visible area in patient room (associated with patient bed). Remove any environmental obstacle from the patient’s walking pathway Bed locked and in lowest position/chair brake on Use assistive devices as indicated (Wheelchair/Cane/Walker/Hearing

aids/Glasses) Call light and personal items within reach Fall risk communication at hand-off Hourly rounding to include the 4 Ps (Potty-Pain-Position-Possessions) Sleeping medications administered before 10 pm (2200). Fall Preventions education completed and documented with patient/family Falls agreement signed within 24 hours of admission

All inpatients who have a Morse Fall Risk score of forty five (45) or greater will be designated as a High Fall Risk. All of the following interventions will be implemented in addition to the interventions for all inpatients who are at low risk for falling. *

F= Fasten the gait belt around the patient when transferring, out of bed, or ambulating.

A= Alarms on. Ensure bed or chair alarm is activated at all times. L= Limbs identify patient as a high fall risk. Place yellow wristband on

patient. Don yellow socks when patient is out of bed. o St. Mary’s Medical Center will also place a yellow “Caution Sign” on

the outside of the door frame to the patients room. L= Letter of agreement signed by patient or representative to indicate they

have been educated on our fall prevention techniques. This should be signed by the patient or representative. If the patient is unable to sign and there are no representatives, indicate this on the form with the date, time, and your initals to validate it was addressed. Once patient is able to sign or designated representative available, the patient/family should be educated and the agreement signed.

S= Stay with the patient (at arm’s reach) when patient is toileting, showering, or ambulating.

*For all St. Joseph 5 North rehab patients, refer to the 5 North Rehab Unit Falls Protocol Compliance Scale (Addendum E)

II. General Knowledge

a) Monitor the patient’s activities and mobility. b) Discuss fall prevention in the home prior to discharge c) Use interdisciplinary team management: ** Every employee has an influence on

patient safety and fall prevention


1. Interventions for the patient at high risk for falls are to be provided by all hospital personnel, as appropriate.

2. If the patient is transported, the staff member transporting follows the CH Hand-Off Communication policy to determine the patient’s fall risk status and places the patient where he/she can be observed and monitored closely by the receiving department staff.

3. Non-clinical staff should immediately report a patient trying to get out of bed alone, standing alone, etc. to the nursing staff for assistance.

4. Staff members will immediately report any environmental hazards to housekeeping, such as slick floors or spills. The staff member finding the hazard will mark the area accordingly.

5. Any need for repairs of items/equipment/furniture etc., which are necessary for patient safety, will be requested and repaired as soon as possible.

6. If the patient is being transferred to another facility, the nurse should advise the other facility of the patient’s fall risk by documenting on the transfer form.

III. Outpatients

• At the time of registration, patients having outpatient procedures will be assessed and documentation will occur on the outpatients identified at risk for falling by utilizing the following three (3) questions: 1) Do you have dizziness or vertigo? 2) Do you need help standing or walking? 3) Have you fallen within the last three (3) months? If the patient, guardian or durable power of attorney answers “yes” to any

of these questions the patient is considered to be at high risk for falling. This process and identification of patients who are at a high risk for falls will be department specific.

• Two Outpatient Risk Assessment Forms are available; one is an individual form can be

used for a single outpatient visit (See Addendum B), and the other is available for sequential outpatient visits for the same treatment or procedure (See Addendum C).

IV. Emergency Department

Nurses will assess fall risk for the patient in the Emergency Department (ED) using the “Outpatient Risk Assessment” tool as seen in Addendum B. If any of the three questions are answered, “Yes”, the nurse will implement the below precautions to aid in preventing risk of falling for the ED patient.

1. Place a yellow wristband on patient (to help identify risk) 2. Keep call light within reach of patient 3. Use a gait belt with ambulation 4. Keep bed in lowest and locked position 5. Provide adequate lighting when ambulating 6. Remove obstacles during ambulation 7. Staff remain with fall risk patients during transportation 8. Staff escort fall risk patients to restroom and remain with the patient. 9. Gurney side rails up.


When a patient has orders to be admitted, hand-off communication to the receiving nurse will be given. The communication will include letting the receiving nurse know the patient is at risk for falling.

V. All inpatients will receive information/education regarding methods for prevention of falls. The nurse performing the initial assessment will provide the appropriate education at the time of admission and review with the patient and/or the spouse, family member or significant other. Additionally, patient or patient family will sign a “falls agreement ” (see Addendum D) to ensure compliance. Patient may refuse to sign contract, if patient is competent per RN assessment. VI. Utilizing the nursing process, the “Fall Prevention Program,” intervention will be initiated by the nurse performing the falls risk assessment. These interventions can be added to the patient's plan of care upon identification of the fall risk patient. VII. If the patient [or the guardian, patient family or durable power of attorney (DPOA) provided the patient is competent/cognitively intact] refuses to comply with suggested safety precautions as educated by a member of the care staff, the potential for injury due to a fall should be re-explained to the patient/patient family/guardian/DPOA. The re-education and/or refusal from the patient/patient family/guardian/DPOA will be documented as a patient note in the appropriate medical record. VIII. Patients identified to be at high risk for fall will have falls protocol in place until identified to be no longer at high risk for fall per completed fall risk assessment or upon exit from facility at time of discharge only. IX. Patients needing assistance with ambulation/transfer, the appropriate healthcare professional will document on the patient whiteboard. If assistance is recommended by the PT/OT, communication with nursing personnel will occur. X. If a patient experiences a fall, with or without an injury, during their hospitalization, the patient’s physician should be notified, an event report should be completed, the immediate supervisor should be notified, and the family or guardian should be notified. A “Fall Debriefing Form” must be completed after every patient fall, before the end of the shift, with the assistance of the manager, charge nurse, or nursing supervisor, regardless if the patient sustains an injury. XI. The risk of a fall and/or fall with injury is the responsibility of both the competent patient/patient family (when patient is cognitively impaired) and the caregiver. The “Generally Accepted Performance Standards” (GAPS) accountability form is a requirement for each caregiver to sign upon employment and caregivers who have not previously signed this acknowledgement.


References: AHI “A Vital Sign for Safety” Resource Guide, Fall Risk Program Using the Hendrich II Fall

Risk Model. AHInc., Clayton, Missouri. 2007. AHRQ (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency

for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nurseshdbk/

American Nurses Association-National Database for Nursing Quality Indicators. (2012). Data Collection Guideline Manual, version 9.4.

Hendrich, A., Bender, P., & Nyhuis, A. (2003). Validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients. Applied Nursing Research. 16(1): 9-21.

Bluni, R. & O’Shaughnessy, J. (2009) Words that save: Ensuring that “never events” never happen. Health Management Systems

Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D. (2008)Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement.

Lancaster, A., Ayers, A., Belbot, B., Goldner, V., Kress, L., Stanton, D., Jones, P., & Sparkman, L. (2007). Preventing falls and eliminating injury at Ascension Health. The Joint Commission Journal of Quality and Patient Safety. 33(7): 367-375.

Mets, M., Volkerts, E., Olivier, B., & Verster, J. (2010) Effect of hypnotic drugs on body balance and standing steadiness. Sleep Medicine Reviews. 14: 259-267

NDNQI- National Database of Nursing Quality Indicators (20124). Guidelines for Data Collection on theAmerican Nurses Association’s National Quality Forum Endorsed Measures. Retrieved from http://www.nursingquality.org/Content/Documents/NQF-Data-Collection-Guidelines.pdf

Spanki, M., McClosky, C., Remedio, V., et al (2012) Developing a culture of safety in the epilepsy monitoring unit: A retrospective study of safety outcomes. Epilepsy & Behavior. 25: 185-188

APPROVAL SIGNATURES:

VP of Nursing, SJMC/SMMC Date


ADDENDUM A

Item Scale Scoring History of falling; immediate or within 3 months

No 0 Yes 25 _______

Secondary diagnosis No 0 Yes 15 _______

Ambulatory aid Bedrest/nurse assist Crutches/cane/walker Furniture

0 15 30

_______

IV/Saline lock No 0 Yes 20 _______

Gait/Transferring Normal/bedrest/immobile Weak Impaired

0 10 20

_______

Mental status Oriented to own ability Forgets limitations

0 15

_______

The items in the scale are scored as follows: History of falling: This is scored as 25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the patien has not fallen, this is scored 0. Note: If a patien falls for the first time, then his or her score immediately increases by 25. Secondary diagnosis: This is scored as 15 if more than one medical diagnosis is listed on the patient’s chart; if not, score 0. Ambulatory aids: This is scored as 0 if the patient walks without a walking aid (even if accompanied by a nurse), uses a wheelchair, or is on a bedrest and does not get out of bed at all. If the patient uses crutches, a cane, or a walker, this item scores 15; if the patient ambulates clutching onto the furniture, equipment, or staff for support, score this item 30. IV Therapy/Saline Lock: This is scored as 20 if the patient has an intravenous apparatus or a saline lock inserted; if not, score 0. Gait: A normal gait is characterized by the patient walking with head erect, arms swinging freely at the side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the patient is stooped but is still able to lift the head while walking without losing balance. Steps are short and the patient may shuffle. With an impaired gait (score 20), the patient may have difficulty rising from the chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e. by using several attempts to rise). The patient’s head is down, and he or she


watches the ground. Because the patient’s balance is poor, the patient grasps onto the furniture, a support person, or walking aid for support and cannot walk without this assistance. Mental status: When using the scale, mental status is measure by checking the patient’s own self-assessment of his or hown ability ot ambulate. Ask the patient, “Are you able to go to the bathroom alone or do you need assistance?” If the patient’ reply judging his or her own ability is consistent with the ambulatory order, the patient is rated as “normal” and scored 0. If the patient’s response is not consistent with the nursing/physician/PT order or if the patient’s response is unrealistic, then the patient is considered to overestimate his or her own abilities and to be forgetful of limitations and scored as 15.


ADDENDUM B

Outpatient Fall Risk Assessment

This document is to be completed at the time of admission to the Outpatient Department. Date of Service: _______________ Outpatient Department: ________________ 1) Do you have dizziness or vertigo? _____ Yes _____ No 2) Do you need help standing or walking? _____ Yes _____ No 3) Have you fallen within the last 3 months? _____ Yes _____ No If the patient/DPOA/Guardian answers “Yes” to any of these questions, place a yellow “Fall Risk” I.D. band on the patient. ______________________________ _____________ __________ Hospital Representative Date Time


ADDENDUM C Outpatient Fall Risk Assessment Summary

This document is to be completed at the time of admission to the Outpatient Department. If the patient/DPOA/Guardian answers “Yes” to any of these questions place a yellow “Fall Risk” I.D. band on the patient. Date of Service: _________ Department _______________________ ************************************************************* 1) Do you have dizziness or vertigo? _____ Yes _____ No 2) Do you need help standing or walking? _____ Yes _____ No 3) Have you fallen within the last 3 months? _____ Yes _____ No ______________________________ _____________ _________ Hospital Representative Date Time ************************************************************* 1) Do you have dizziness or vertigo? _____ Yes _____ No 2) Do you need help standing or walking? _____ Yes _____ No 3) Have you fallen within the last 3 months? _____ Yes _____ No _____________________________ _____________ _________ Hospital Representative Date Time ************************************************************* 1) Do you have dizziness or vertigo? _____ Yes _____ No 2) Do you need help standing or walking? _____ Yes _____ No 3) Have you fallen within the last 3 months? _____ Yes _____ No ______________________________ _____________ _________ Hospital Representative Date Time ************************************************************* 1) Do you have dizziness or vertigo? _____ Yes _____ No 2) Do you need help standing or walking? _____ Yes _____ No 3) Have you fallen within the last 3 months? _____ Yes _____ No ______________________________ _____________ _________ Hospital Representative Date Time

Policy Reference: Carondelet Health Policies & Procedures Page 11 of 12

ADDENDUM D PATIENT FALLS AGREEMENT

Patient Identification

Falls Agreement-Patient Education “Calling Means No Falling”

Patient safety is very important at St. Joseph and St. Mary’s. At times, while in the hospital, patients often mistake their surroundings and ability to do everyday tasks, which can lead to harm from falling. We want you to be a part of the team that kees you safe. Things you and your family can do to help:

Notify and allow staff to assist you when you need to move. Do not turn off or unplug the bed/chair alarm. Please let the staff know if you use a cane, walker, wheelchair, crutches, or braces. Glasses and hearing aids should be brought and worn during your hospitalization. We also ask that family members and visitors notify staff when they arrive and depart. Please leave the door open for the staff to easily observe you.

Equipment that may be used in helping with transfer:

Gait belts Lifting machines Special sheets (to help move) Sliding boards

Falls Acknowledgement Our healthcare team is dedicated to your safety and comfort during your stay. Fall prevention is so important and we need your help in making sure you remain safe from falling. By signing below, you are acknowledging awareness of our fall prevention commitment. Thank you for partnering with your healthcare team to keep safety a priority. By working together to identify and eliminate fall risks, we can improve your safety while in the hospital.

_________________________________________ _________________________ Patient or Patient Representative Signature (Relationship to Patient)

_________________________________________ _________________________

(Witness) (Date and Time)

Policy Reference: Carondelet Health Policies & Procedures Page 12 of 12

Addendum E

5 North Rehab Unit Falls Protocol Compliance Scale

1. All patients on the 5 North Rehab unit will be considered a Fall risk unless they are Modified Independent with therapies.

2. Fall risk color a. Yellow-this patient is not cognitively intact to call for assistance to get up. They are

impulsive and/or lack insight into their deficits. They may be confused, disoriented, or short term memory deficits that impair ability to remember to call for help.

i. Full protocol in place including chair alarm when up, even in the dining room, and bed alarm during the day.

ii. Velcro belt must be used when in the wheelchair. iii. Rails must be up if pt is in bed, may use bedside table as 4th rail iv. bedside table should be in front of pt if up in the chair v. Patient should not be left alone in the bathroom/shower unsupervised, at any time.

b. Green-This patient is forgetful but cooperative, can’t be trusted to call for help all of the time. May have decreased spatial awareness (including phantom limb sensations). This patient may have periods of temporary confusion/disorientation secondary to meds or sundowning.

i. Velcro belt in wheelchair ii. Tray table in front of pt if up in the chair

iii. Bed alarm set if in bed iv. The patient should not be left alone in the bathroom/shower, unsupervised, at any

time. c. White-This patient is compliant, cooperative, memory is intact, and the patient is fully aware

of their deficits. We trust that this patient will call for help appropriately. This patient must continue to call for help.

i. Bed alarm set at night to either sitting or standing levels.