147 / Version 1 / Page 1 of 14 / Last up-dated
September 2008
Reference: 10/06 / HCC AS 20/08 / South Central Ambulance Trust July 08 / NMC Code of Professional conduct
GSCC Code of Practice for Social Care Workers
Management of Falls in a Residential or Nursing Home
This protocol outlines the actions to be taken in the event of a resident falling. It has been developed in agreement with the Hampshire PCT, Wessex Local Medical committee and South Central Ambulance Service, and in response to an issue highlighted by a South East Area Coroner.
On admission to a residential or nursing home for long term, short term, respite or re-ablement care, all individuals must have a falls screening assessment as part of their care planning. If the screening assessment produces a score of 2 or more, a Multi-factorial falls risk assessment must be completed within 24 hours. This must be recorded in the resident’s care plan and placed on the resident’s personal file. (A Falls screening tool, risk assessment form, falls prevention action plan and incident reporting guidance are appended to these guidelines.)
Where a resident is at risk of falling, a falls protocol should be kept, discretely, in the resident’s room. The Protocol should also easily be accessible in communal areas and bathrooms.
In the event of a resident falling
· Do not move the resident and call the Duty Manager or Nurse
· the falls protocol must be followed. (a copy of the Falls Protocol, Action checklist, post fall assessment tool and Observation log are appended to these guidelines)
· Assess for injury following the Falls protocol tool and act according to level of injury
- Major First Aid and reassurance (even if
unconscious)
Call 999
Inform relatives
Inform GP
Record in resident’s personal file
Incident report and Reg 37 to CSCI
- Minor First Aid and reassurance
Move and make comfortable
Inform GP
Inform relatives
Record in resident’s personal file
Incident report and Reg 37 to CSCI
Observe and record at least 4 hourly for
24 - 48 hours
- Slight or no apparent injury
Reassurance
Move and make comfortable
Inform relative Record on resident’s personal file
Incident report
Observe at least 4 hourly for 24 hours
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FALLS SCREENING TOOL
Based on the Falls Risk Assessment Tool
Name ______Date of Birth______
Place of Residence______GP.______
Falls Screening Assessment ToolPlease complete for all clients. / YES / NO
1. / Is there a history of falls?
2. / Is there a significant fear of falling to restrict daily life?
3. / Is a person on 4 or more medications?
4. / Does the person have a diagnosis of Stroke or Parkinson Disease?
5. / Does the person have any problems with balance?
6. / Does the person have difficulty getting from sitting to standing? i.e. standing from a chair at knee height?
7. / Does the person have postural hypotension?
Score one for each positive response. Total score
If risk screening assessment score 2 or more, complete Multi-factorial Falls Risk Assessment.
Completed by (print name) ______
Job Role______Date______
Signature______
SERVICE USERS FALLS RISK ASSESSMENT
To be completed within 24hours of a positive response from falls screening tool or a fall.
Name ………………………………….. Date of Birth ………….
Rating Scale / Date / Date / Date0 / 1 / 2 / 3 / Score / Score / Score
When / On admission / Up to 7 days / 8 – 14 days / Over 14 days
Age / 0 -24 / 25 - 59 / 60 - 70 / 0ver 70
Falls / No falls in last year / Fall in last 6 months / Fall in last 3 months / Fall in last month
Balance / From chair/bed, stand and pivot with help / Needs assistive device and two people / Ambulant with assistive device and or one person / Ambulant without assistive device
Mental state / Orientated to time, place and person / Orientated to place and person / Orientated to person / Disorientated and/or impaired judgement and/or impulsive
Diet / Well nourished / Small but well balanced appetite / Poor appetite / Malnourished and weight loss
Sleep pattern / Normal sleep pattern (7hrs) / Normal sleep pattern (less than 7hrs) / Sleep disturbance / Severe sleep disturbance
Vision / Normal / Wears glasses / Blurred vision, cataract, glaucoma. / Severe visual disturbance or blindness
Hearing / Normal / Wears a hearing aid / Poor hearing / Severe hearing loss/deaf
Place of Residence ……………………
Date / Date / Date0 / 1 / 2 / 3 / Score / Score / Score
Communication / Normal speech and under -standing / Speech defect but understood / Language barrier and understanding / Severe defects, severe language barrier and understanding
Medication / None likely to affect
balance / CV Effectors such as beta-blockers, diuretics and anti-hypertensive medication / CNS Effectors such as tranquillisers, sedatives and psychotropic medications / Both CNS and CV effectors
Systemic Illness / None / 1 chronic condition / Toxic acute illness / Multiple illnesses
Incontinence / None / Increased frequency / Nocturnal,
or stress incontinence / Urge incontinence, indwelling catheter
Alcohol intake / None / 1 unit / 2 units / 3 or more units
SCORE / 10 – 14 = LOW RISK / 14 – 28 = MEDIUM RISK / 28 – 42 = HIGH RISK
Completed by (print name)______
Job Role______
Signature______
Date______
FALLS PREVENTION ACTION PLAN FOR RESIDENTIAL AND NURSING CARE
CONTROL MEASURES/ACTION PLAN / YES OR NO / ACTION / DATE / REVIEWEnvironment free of clutter
Appropriate footwear worn
Call bell is available, within reach and known how to use
Bed rail assessment completed
Lying and standing blood pressure chart
Person can get in and out of bed safely
Person can get up from a chair safely
Are all the lights bright enough for person to see
Person is able to get on and off the toilet safely
There is an accessible/sturdy grab rail
They are able to reach a light switch from bed
Chair at appropriate height
Discuss with family risk factors
Walking aids are within easy reach
Physiotherapy/OT assessment
Person assigned to a bed that allows them to access on the appropriate side
Bed at appropriate height
All staff informed that regular monitoring of service user is necessary
Service user to be supervised when mobilising
Request medication review
Regular monitoring regime in place
Telecare alarm or similar in place
FALLS PREVENTION ACTION PLAN FOR HOME CARE
CONTROL MEASURES/ACTION PLAN / YES OR NO / ACTION / DATE / REVIEWFLOORS
Walkways free of clutter.
Floor coverings are in good condition
Floor surfaces are non-slip in appropriate area
Loose mats are secure or removed
LIGHTING
The person can switch a light on easily from their bed
Lights are bright enough to see clearly
All areas lit, including outside
BATHROOM
Person can get on and off toilet
Person can get in and out of the bath
Person can get in and out of the shower
Grab rails are in place
Slip resistant mats in bathrooms etc
Toilet/commode in close proximity to bedroom
KITCHEN
Items that are regularly used at a height that the person does not have to climb, stretch or bend that might upset their balance
The person is able to carry/use trolley to transport meals/drinks from kitchen to other areas
CONTROL MEASURES/ACTION PLAN / YES OR NO / ACTION / DATE / REVIEW
STAIRS/STEPS
Indoor stairs have accessible/sturdy grab rail
Indoor stair rails extend the whole length of the stairs
Indoor stair rails on both sides of stairs
Edging of stairs are easily identified
Person can easily and safely go up and down stairs and steps. (inside or out)
Outdoor steps are in good condition
Sturdy grab rail extending full length of steps
MOBILITY
Appropriate foot wear worn
Person can get in and out of bed safely
Person can get up from a chair safely
Person is able to get on and off the toilet safely
Persons bed allows them to access on the appropriate side
Walking aids are with in easy reach
Pets can be cared for without bending over with risk of falling
Pets are not a tripping hazard
For additional advice or if falls persist refer to the local Falls Co-ordinator
Completed by (print name)______
Job role______
Signature______
Guidance for Falls Incident Report Forms
1. Specify where the person was found
2. Specify in what position
3. Was the person observed falling and by whom
4. Specify if the patient fell from standing, chair or bed and if bed rails were used
5. Describe any obvious environmental factors
6. What was the persons mental state
7. What injuries where sustained
8. What action was taken
9. And by whom
You must state fact and not opinion. The more details about circumstances of the fall can be useful when critically reviewing the individual person or the number of falls within your unit.
Following completion of the incident form you MUST review the FALLS RISK ASSESSMENT FORM and ACTION PLAN.
FALLS PROTOCOL
appendix 1
Duty Officer and Nurse Action Checklist (response to falls)
DANGER check for dangers, seek advice 999
RESPONSE unresponsive 999
AIRWAY compromised airway 999
BREATHING absent or difficulty breathing 999
· UNCONSCIOUS 999
· REDUCED LEVEL OF CONCIOUSNESS 999
· HEAD INJURY 999
· MAJOR HAEMORRHAGE 999
· CHEST PAIN 999
· OTHER SEVERE PAIN 999
· LIMB DEFORMITY (inc shortening and rotation) 999
· EXCESSIVE SWELLING AND BRUISING 999
· DIZZINESS / VOMITTING (after fall or head injury) 999
· FALL GREATER THAN 2 METRES 999
· CONDITION - causing serious concern for staff 999
ADMINISTER FIRST AID AND RESUSITATION APPROPRIATE TO NEED
Do not move the resident (except for resuscitation) and follow the emergency treatment and instructions given by Ambulance Control
IF NO REQUIREMENT FOR AN EMERGENCY AMBULANCE RESPONSE
· Administer first aid as appropriate
· Complete the post falls assessment with resident
(blood pressure and blood sugar - Nurse only)
· Assist resident to a comfortable place
(utilising a hoist and manual handling aids as required)
· Complete post falls assessment and body map documentation
· Inform relatives and document the discussion in the care plan
· Fax the completed post falls assessment to the GP Practice
· Observe resident for 24 / 48 hours using the post fall observation log (blood pressure - Nurse only)
· Complete incident form / record in accident book
IF AN AMBULANCE CLINICIAN HAS ATTENDED THE RESIDENT, THERE IS STILL A REQUIREMENT TO FULFILL THE FOLLOWING ACTIONS
· Complete post falls assessment documentation and body map
· Observe resident for 24 / 48 hours if remaining in HCC care
· Inform relatives and document the discussion in the care plan
· Complete incident form / record in accident book
IN ALL CASES WHERE THE RESIDENT REMAINS IN THE CARE OF HAMPSHIRE COUNTY COUNCIL, THE POST FALLS ASSESSMENT TOOL SHOULD BE FAXED TO THE RESIDENTS GP PRACTICE
Post Fall Assessment TOOL
(designed to aid judgement)
Name of Resident: …………………………………………………
Date/Time of Fall: …………………………………………………
Place of Residence:………………………………………………
Level of Consciousness * Responsive (verbal/other) _____
(Check for head injury) * Less responsive than usual _____ * Unresponsive/unconscious (call 999) _____
Pain/ Discomfort * No evidence of pain/discomfort _____ * Showing signs of pain (non verbal) _____ * Complaining of pain (verbal) _____
Site of Pain: ______
Injury/wounds * No evidence of bleeding _____
(check for open wounds, * Swelling/deformity _____
haemorrhage) * Bruising/bleeding
Site of Injury: ______
Movement * Able to move limbs on command
(check for shortening (within pre-fall range of movement) _____
or rotation of limb) * Able to move but with pain _____
* Unable to move limbs on command
or spontaneously _____
Observations Blood Pressure ______
(Before moving
if injury suspected) Pulse ______
Blood Sugar ______
Mobility * Able to get up and weight bear _____
* Able to assist but showing signs
of discomfort _____ * Unable to assist themselves up
and requires hoist or other handling
equipment. Major change in mobility
and condition from pre-fall status ? _____
Conclusion, Clinical assessment and judgment
(check relevant box)
Slight/Minor - Commence observations
Inform relatives and document
(FAX this form to surgery
Minor/Injury - Commence observations
Inform relatives and document
Inform GP and ask to see within
5 days (FAX this form to surgery)
Major/Injury - Suspected/confirmed injury,
Call 999
Inform relatives and document
First aid/resuscitate as appropriate
Close observation until help arrives
Provide ambulance staff with a copy
of this form
FAX the form to GP surgery
Place original of form on the
Resident’s personal file.
Time and Date completed: ______
Assessment by:
(print name)
Signature: ______
FAXED TO SURGERY
Date ______
Time ______
Body Map – Assessment of Injury
Residents Name: ______Date of Birth: ______
Place of Residence: ______Assessed by: ______
(print name)
Marks or bruising on resident’s body (describe, mark on map above with date observed)
Residents description of any pain/s or non-verbal signs of residents pain with date
Day number following fall, Date & Time / Action taken and Date / Signature24-48 Hour Post Fall Observation Log
(to be completed at least 4 hourly)
Name of Resident: ………………………. D.O.B. ………………
Place of Residence……………………..… Room No:…………...
Date and time of Fall ………………………
Date / Time / Reported Pain/ signs / Wounds/Bruises / BP &Pulse (nursing care only) / Comments / Signature
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