Checklist for Investigating Officers undertaking Fall Fracture Investigations

·  Did the patient have a diagnosis of dementia?

o  If yes, was a Mental Capacity Assessment undertaken?

o  When?

o  If not, why not?

·  Did the patient show signs of delirium?

o  If yes, was a formal delirium assessment undertaken?

o  What was the identified cause of the delirium?

o  Was it treated appropriately?

o  If not, why not?

·  Was the inpatient falls care plan completed within 6 hours of admission?

o  If no inpatient falls care plan in place, were the falls risks appropriately assessed on the new documentation?

o  Was the falls care plan / falls risks reviewed at any time?

o  Was a lying and standing BP undertaken?

·  If the patient was confused,

o  Were they nursed in an appropriate position on the ward?

o  Were bed/chair sensors considered?

o  Was an ultra low bed considered?

·  If the fall was from bed, were bedrails used?

o  Were the bedrails up at the time of the fall?

·  If the fall was from a chair or commode, were their mobility and their ability to transfer safely assessed?

·  Is there any indication on the Safeguard incident report about their footwear or whether their walking aid was within reach?

·  Was a medication review undertaken for culprit drugs for falls (see SHFT falls medication list)?

o  Were they prescribed any new medications just prior to the fall?

o  What was the last medication taken prior to the injurious fall? Could this be relevant?

·  Was an osteoporosis risk assessment undertaken?

o  Was the patient taking a Bisphosphonate and/or Calcium and Vitamin D?

·  Was the SHFT post fall protocol followed?

·  Was a post falls checklist completed after the fall?

·  If the patient hit their head or the fall was unwitnessed, were neurological observations undertaken as per Slips, Trips & Falls policy?

·  Was an incident form completed on Safeguard?

·  What percentage of ward staff have attended Sips, Trips & Falls training as per falls policy?

·  Have the ward staff attended Falls Scenario training?

·  At Lymington Hospital, if Arjo flat-lifting equipment was required, was it used appropriately?

o  If not, were the staff involved in using this equipment trained in its use?

Version 1. SHFT Falls prevention team 07/12/2012