KANABEC HOSPITAL - Minnesota Hospital Association



KANABEC HOSPITAL

MORA, MINNESOTA

|DATE: |September 2006 |SUPERSEDES: |11/04 | |

|Replaces Fall Risk Assessment |

|ORIGINATOR (Dept): |Nursing | |

|DESTINATION DEPARTMENTS: |Nursing | |

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FALL PREVENTION

I. PURPOSE

A. To protect patients and promote patient safety

B. To effectively identify and intervene with patients who are at risk for falling

C. 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.

III. DEFINITION

Fall – a fall is defined as an event in which there is uncontrolled, non-purposeful downward displacement of a person’s body from a standing, sitting, or lying position.

IV. 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.

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Fall Prevention

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V. OVERVIEW

Recognizing that every patient’s 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.

VI. PROCEDURE

A. Assessment

1. Inpatients will be assessed on admission and every shift thereafter. A specific process will be implemented for OB and pediatric patients.

2. 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.

3. All interventions may be documented in the medical record.

4. Family, if available, will be consulted for individualizing fall prevention interventions.

B. Upon admission

1. Complete the Fall Risk Data Collection section of the Admission Data Base.

2. If the patient’s score is ≥ 7, or at the nurse’s discretion, initiate Fall Precautions.

a. Place a smiling face sticker on white grease board in patient room.

b. Apply yellow Fall Precautions armband on patient.

c. Place Fall Precautions label on Kardex.

d. Initiate appropriate interventions to minimize the patient’s risk of falling.

e. Identify appropriate interventions on patient’s Kardex and care plan.

C. Ongoing risk assessment

1. Complete the Fall Risk Reevaluation with patient assessment every shift and with a change in patient condition.

2. Document score on A/A.

3. If patient condition/score changes, or at the nurse’s discretion, Fall Precautions may be initiated or discontinued.

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Fall Prevention

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VI. Procedure, continued

E. If a patient experiences a fall:

1. Document what occurred in the nurse’s progress notes including: patient appearance at time of discovery, patient response to event, evidence of injury, location, medical provider notification, medical/nursing actions.

2. Complete the Patient/Visitor Accident/Incident Report.

3. Complete the Post Fall Flowsheet.

4. Notify the physician if injuries are noted.

5. Notify the patient’s family.

6. Complete Post Fall Analysis.

7. Update interventions if changes are noted in the patient’s condition.

8. Communicate to all shifts that the patient has fallen and is at risk to fall again.

9. For falls with significant harm, inform Quality Director and Nursing Manager.

VII. 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.

VIII. REFERENCES:

1. Perrell KL Assessing the Risk of Falls: Guidelines for Selecting Appropriate Measures for Clinical Practice Settings.  Generations Winter 2002-2003.

2. 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.

3. 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.

4. 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.

5. Stevens JA Falls Among Older Adults-Risk Factors and Prevention Strategies 2005 NOCOA Falls Free: Promoting a National Falls Prevention Action Plan

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Fall Prevention

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VIII. References, continued

6. Cameron KA The Role of Medication Modification in Fall Prevention 2005 NCOA Falls Free: Promoting a National Falls Prevention Action Plan

7. 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.

8. Halfens R, Roll S, Dassen T. Psychometric evaluation of the Hendrich Fall Risk Model. Journal of Advanced Nursing 53(3), 327-332.

9. 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.

10. Health East Assessing Fall Risk and Determining Fall Risk Prevention Interventions

11. VA Fall Incident Reports and Assessment Tools

12. VA National Council on Patient Safety (NCPS) Tool Kit May 2004.

 

Assessment Tools Reviewed

1. St Cloud Hospital- Hospital Inpatient Flow Sheet and Fall Assessment Tool

2. Marianjoy Fall Risk Assessment- from Marianjoy Rehabilitation Hospital -Pilkington, Ruroede, Cutler  (Donna Pilkington, 1-630-462-4000)

3. Morse Fall Scale

4. Owatonna Hospital (Hendrich II)

5. Fairview Southdale Hospital Fall Prevention Tools

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