To promote patient safety by:

Effectively identifying patients who are at risk of falls

Providing early intervention to the patient at risk

Communicating to appropriate staff the plan of care

Staff training to increase awareness of the high risk patient and prevention strategies

To prevent further injury and/or falls by:

Effectively managing patients who fall

Analyzing fall data for trends and patterns.

Educating patients and families on measures to prevent falls and promote safety.

Step

Action

1

Patients will be assessed by a Registered Nurse at the time of admission to determine their risk for falling. Based on this assessment score (5 or above), the patient will be identified as a potential risk for falls and Fall Precaution will be initiated.

2

In initiating the Fall Precaution, the nurse will trigger problem to the MPA section of the Master Treatment Plan.

3

Reassessment of fall risk is documented in the Nursing Progress Notes at a minimal of twice daily.

4

Fall prevention strategies will be implemented for each patient based on the patients risk of falls.plan will be develop for each patient based on the patient's risk of falls. Fall Precaution, Direct Observation, and 1:1 Supervision.

5

Strategies may include

Communication of high fall risk to all disciplines

Reorient to surroundings and environment as needed

Maintain beds in low position

Place frequently used items within patient's reach

Offer assistance to bathroom before meal time, bedtime, and upon awakening regular (toileting q 2hrs or as needed)

Continue use of assistive device as appropriate (cane, walker, or wheel chair) if patient used them prior to hospitalization

Discuss benefit of continuous observation with treatment team --- 1:1 supervision

Teach patient fall prevention plan

Family education (if applicable)

Step

Action

1

If the patient falls:

Ensure patient safety. Do not move the patient until injuries are identified, and until safety of movement is assured by the licensed staff.

If no injuries that prevent movement, assist the patient to bed or chair

Get help from other staff

Take vital signs

Ask the patient about injury or pain

Assess the environment for safety issues

Notify physician

Notify Nursing Supervisor

2

The following will be completed once the patient's immediate needs are met:

Fall Variance Report

Document specific facts in the Progress Notes

Document in treatment plan the required interventions