ࡱ> ac`#` Hbjbj5G5G 7NW-W- 8,(|:4g1i1i1i191858:$;hQ>^6:96:o:xxxg1xg1xxC./ 6S.0:0:.>6>(/>/x6:6:^: KANABEC HOSPITAL MORA, MINNESOTA DATE:September 2006SUPERSEDES:11/04Replaces Fall Risk AssessmentORIGINATOR (Dept):NursingDESTINATION DEPARTMENTS:Nursing FALL PREVENTION I. PURPOSE To protect patients and promote patient safety To effectively identify and intervene with patients who are at risk for falling To educate patients/families on measures to prevent falls and promote safety. II. POLICY All patients will be assessed for risk of falling upon admission, with reassessments routinely performed to determine ongoing need for fall prevention precautions. Any patients determined to be at risk for a fall will be placed on fall prevention precautions. Those patients who do fall will be appropriately managed. DEFINITION Fall a fall is defined as an event in which there is uncontrolled, non-purposeful downward displacement of a persons body from a standing, sitting, or lying position. RESPONSIBILITY All staff members are responsible for implementing the intent and directives contained within this policy, and for creating a safe environment of care. Any staff member, physician, or family member may request that a patient be placed on Fall Precautions. Continued Fall Prevention Page 2 OVERVIEW Recognizing that every patients safety status may potentially be compromised by the nature of their illness or by their treatment, basic safety issues will be addressed for all patients, and for those patients identified as a higher level of risk, more in-depth prevention interventions will be implemented. PROCEDURE Assessment Inpatients will be assessed on admission and every shift thereafter. A specific process will be implemented for OB and pediatric patients. Fall risk screening will be completed by an RN or LPN. The RN is responsible for establishing and updating the individual plan of care related to safety and fall prevention. All interventions may be documented in the medical record. Family, if available, will be consulted for individualizing fall prevention interventions. Upon admission Complete the Fall Risk Data Collection section of the Admission Data Base. If the patient s score is e" 7, or at the nurse s discretion, initiate Fall Precautions. Place a smiling face sticker on white grease board in patient room. Apply yellow Fall Precautions armband on patient. Place Fall Precautions label on Kardex. Initiate appropriate interventions to minimize the patients risk of falling. Identify appropriate interventions on patients Kardex and care plan. Ongoing risk assessment Complete the Fall Risk Reevaluation with patient assessment every shift and with a change in patient condition. Document score on A/A. If patient condition/score changes, or at the nurses discretion, Fall Precautions may be initiated or discontinued. Continued Fall Prevention Page 3 VI. Procedure, continued E. If a patient experiences a fall: Document what occurred in the nurses progress notes including: patient appearance at time of discovery, patient response to event, evidence of injury, location, medical provider notification, medical/nursing actions. Complete the Patient/Visitor Accident/Incident Report. Complete the Post Fall Flowsheet. Notify the physician if injuries are noted. Notify the patients family. Complete Post Fall Analysis. Update interventions if changes are noted in the patients condition. Communicate to all shifts that the patient has fallen and is at risk to fall again. For falls with significant harm, inform Quality Director and Nursing Manager. FALL PREVENTION PROGRAM EVALUATION: The Fall Prevention Team will analyze Incident reports, post fall flow sheet and post fall analysis form to determine patterns/concerns and determine need for action plans. REFERENCES: Perrell KL Assessing the Risk of Falls: Guidelines for Selecting Appropriate Measures for Clinical Practice Settings. Generations Winter 2002-2003. Perrell KL, Nelson A. Goldman RL, Luther SL, et al. Fall Risk Assessment Measure: An Analytic Review. Journal of Gerontology 2001 vol 56A, No 12 M761-M766. Oliver D, Britton M, Seed P, et al. Development and Evaluation of Evidence- based Risk assessment Tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ 1997; 315: 1049-1053. Oliver D, Daly F, Martin F, et al. Risk Factors and risk assessment tools for falls in hospital in-patients: a systematic review. British Geriatrics Society 2004 33: 122-130. Stevens JA Falls Among Older Adults-Risk Factors and Prevention Strategies 2005 NOCOA Falls Free: Promoting a National Falls Prevention Action Plan (Continued) Fall Prevention Page 4 VIII. References, continued Cameron KA The Role of Medication Modification in Fall Prevention 2005 NCOA Falls Free: Promoting a National Falls Prevention Action Plan Hendrich AL, Bender PS, Nyhuis. Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients. Applied Nursing Research Vol 16 No 1 (Feb) 2003. p 9-21. Halfens R, Roll S, Dassen T. Psychometric evaluation of the Hendrich Fall Risk Model. Journal of Advanced Nursing 53(3), 327-332. Gray-Miceli, Deanna Fall Risk Assessment: Hendrich II Scale Try This: Best Practices in Nursing Care to Older adults. Harford Institute for Geriatric Nursing. 8 (winter) 2006. Health East Assessing Fall Risk and Determining Fall Risk Prevention Interventions VA Fall Incident Reports and Assessment Tools VA National Council on Patient Safety (NCPS) Tool Kit May 2004. 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