Fall Prevention Bundle

Compiled by

Professional Nursing Development

March 2009

Revised November 2010, October 2011

February 2013

Falls are the leading cause of accidental deaths in the elderly & are the most common type of accident that occurs in a healthcare setting. Falls at Garden City Hospital can be minimized or prevented by identifying patients who are a "Fall Risk" by using the Morse Fall Scale and by implementing a "Fall Risk/Safety Alert" Program which utilizes an intervention based "Fall Prevention Bundle". Fall Risk assessments of all hospitalized patients are to be done by the Registered Nurse on admission, with a change in patient’s condition, upon transfer to a new nursing unit, after a fall, & at a minimum of every 4 hours by utilizing the Morse Fall Scale. Documentation of the fall risk assessment score is written on the Clinical Management Record by the Registered Nurse.

Morse Fall Scale Scoring

  1. History of Falls
  2. 0 = No falls
  3. 25 = Patient has fallen after admission or there is a current history of falls prior to admission.
  4. Secondary Diagnosis
  5. 0 = No other diagnosis
  6. 15 = More than 1 diagnosis listed on chart
  7. Ambulatory Aids
  8. 0 = Patient walks without a walking aid, uses wheelchair, or is on bedrest and does not get out of bed
  9. 15 = Patient uses crutches, cane, or walker
  10. 30 = Patient ambulates by clutching furniture for support
  11. Intravenous Therapy
  12. 0 = No IV
  13. 20 = Patient has IV/Saline Lock
  14. Gait
  15. 0 = Bedrest, immobile, or normal gait
  16. 10 = Weak gait – Stooped but able to lift head while walking without loosing balance. Short steps with shuffle.
  17. 20 = Impaired gait – Difficulty rising from chair, using arms of chair to push, or bouncing several times to rise. With head down, patient watches the ground. Poor balance using furniture, support person, or walking aid.
  18. Mental Status
  19. 0 = Knows own limits
  20. 15 = Overestimates or forgets limits
  21. Total Score: Implement the standard fall prevention interventions listed on the “Fall Prevention Bundle” for all patients. Additional interventions listed on the “Fall Prevention Bundle” are initiated for moderate to high fall risk patients when applicable.
  • If MFS is 0-24 = Low Risk
  • If MFS is 25-44 = Moderate Risk
  • If MFS is >45 = High Risk

Patients receiving any type of intravenous pain medications, benzodiazepines, sedatives, or sleeping medications are automatically a “fall risk” and are placed on Fall/Safety Alert.

Standard Fall Prevention Interventions for

All Patients (LOW Risk, MODERATE Risk, or HIGH Risk):

  • Orient to surroundings and personnel upon admission and as needed during hospital stay.
  • Instruct on use of call system.
  • Maintain placement of personal belongings, call light, phone, and water (as allowed) within patient reach.
  • Monitor patient environment for safety, e.g., floors dry and free of obstacles and clutter, night lights on in room at night.
  • Maintain bed in low position with brakes engaged when unattended.
  • Keep head-of-bed side rails up, if patient assessment indicates need.
  • Instruct patient/significant other on activity level, bathroom privileges, and repositioning as allowed/ordered. Specify any restrictions and need to request assistance.
  • Make slow, gradual position changes.
  • Use non-slip footwear.
  • Teach transfer techniques and use of assistive devices as indicated.
  • Check on patient at least every hour.
  • Answer call lights promptly.
  • Transportation will notify nursing personnel that patient has been returned to room.

Additional Fall Prevention Interventions for

Patients with a MFS Score of 25 or greater (MODERATE Risk or HIGH Risk):

  1. Implement use of yellow “FALL RISK” arm band and place on patient’s wrist.
  2. Place yellow “FALL RISK” sticker on patient’s chart.
  3. Place yellow “SAFETY ALERT” magnet to patient’s door frame.
  4. Set bed alarm.
  5. Set chair alarm when patient out of bed to chair.
  6. Identify fall risk on assignment board.
  7. “Fall Risk” is entered on the comment line of the radiology order screen.
  8. Place yellow “SAFETY ALERT” sign on wheelchair or stretcher when patient is being transported to a test/procedure.
  9. Ensure transporter is aware of Fall Risk/ Safety Alert.
  10. Bed Alarm must be set to the most sensitive setting (alarm zone 3) when patient is returned to room by Transportation and nursing personnel are not present upon patient arrival.
  11. Ambulate with assistance. Use assistive devices per protocol (e.g., gait belt) when ambulating/transferring patient.
  12. Utilize torso supports and activity aprons as needed.
  13. Establish Elimination schedule. Toilet before bedtime and offer every 2 hours while awake at night. Remind to call for assistance if needed during night.
  14. Place “STOP” sign in bathroom as a reminder to patient to get assistance.
  15. Assess behavior and orientation with changes in medication.
  16. Assign room close to nursing station for close observation, if possible.
  17. Advise visitors/family of Fall Risk Program.
  18. Enlist aid of significant other/family/friends to stay with patient if deemed appropriate.
  19. Written educational materials about fall prevention are provided to patient/family such as Hospital Fall Prevention informational handout, Fall Prevention at Homewith home assessment checklist for fall hazards, Philips Lifeline Medical Alert Service: Helping You Live Independently and Safely at Home pamphlet, and Fitness: A Key to Fall Prevention pamphlet.
  20. Have the patient and/or family view, "How to get up from a fall" on TIGR if MFS > 25.

Documentation and Handoff Communication:

  1. Document on the Patient History/Assessment the Morse Fall Score and check box if Fall Risk/Safety Alert program was implemented.
  2. The Registered Nurse initiates and updates the safety alert plan of care.
  3. At a minimum of every 4 hours, the Registered Nurse will use the Morse Fall Scale to reassess Fall Risk Score and Level and document this numerical value.
  4. Document on Nurses Notes the interventions implemented.
  5. Place Fall Risk/Safety Alert on any handoff communication such as the Walking Rounds report sheet and Team Handoff of Patient for transportation.
  6. The Registered Nurse reports the Fall Risk/Safety Alert to the oncoming Registered Nurse and Unlicensed Assistive Personnel.

In the Event of a Fall:

  1. A Quality Control Report will be completed. Attending physician/house officer will be notified.
  2. If the patient is oriented to person, place and time and does not appear injured, help the patient to get up in a chair.

3. If no additional studies are ordered by the physician the following will occur:

  • Standard physician exam by physician to include at least neurological, circulatory, respiratory and movement of all joints.
  • Results of physical exam to be documented in the medical record.
  • Night house officer to give report to responsible day house officer for follow-up.
  • The nurse will then offer to assist them with contacting the family to inform them about the fall.

4. If the patient is disorientated or confused, and there is a significant patient injury or emotional response, leave the person where they fell until the physician can examine the patient.

  • The physician will order studies (e.g. x-ray, ortho consult) if an injury is apparent.
  • Once the physician has initially examined the patient, obtain a way to get the patient to bed. (EZ Lift if candidate)
  • In the absence of an absolute final radiology reading, the physician will:
  • Immobilize the limb.
  • Do a standard physical exam to include at least neurological, circulatory,respiratory, and movement of all joints.

c. Document the results of physical exam in medical record.

  • The nurse will then notify the family.

5. The nurse will document the notification of attending physician/house officer (after initial post fall assessment and when changes in patient’s condition are noted) in the Clinical Management Record.

6. Post- fall, the nurse will document on the Clinical Management Record assessments and vital signs per unit policy or more frequently as determined by physician order. In addition to the general nursing assessment, the nurse will document a post-fall specific assessment at a minimum of every twelve (12) hours for a twenty-four (24) hour period, in the Clinical Management Record nursing notes to include:

  • Vital Signs
  • Musculoskeletal assessment
  • Circulatory assessment
  • Respiratory assessment
  • Neurological assessment
  • Skin integrity

7. Document notification of patient’s family member in the Clinical Management Record nursing notes. Include name of person notified and the date and time of notification.

KEY POINT: The patient’s family member MUST be notified of the fall.

Fall Prevention Bundle Post-Test

Name: ______Employee ID#:______

Unit: ______Date: ______

A 59 year old male was admitted to the general surgical unit with a diagnosis of small bowel obstruction, morbid obesity, and hypertension. Per protocol the Morse Fall Scale was completed on admission. The patient has no history of falls, ambulates in the room by clutching furniture for support to get to the bathroom, IVF is infusing at 125ml/hr, has difficulty rising after sitting in the chair or lying in the bed, and consistently needs reminded to use the call light to ask for assistance.

  1. The Morse Fall Score is:
  2. 70
  3. 85
  4. 100
  5. 125
  1. True or False A yellow safety alert magnet would be posted on the patient’s door frame, a yellow fall risk sticker is placed on the patient’s chart, and a yellow fall risk arm band is placed on the patient’s wrist.
  1. Listed are some interventions that would be implemented on this patient (Circle all that apply):
  2. Place patient close to nursing station
  3. Set bed alarm
  4. Provide patient and family with written literature regarding fall prevention
  5. Identify fall risk on assignment board
  1. True or False Any patient determined to be a moderate or high risk for falls must have a bed alarm set.
  1. True or False At handoff during shift report and walking rounds, the nurse will communicate with the oncoming nurse and unlicensed assistive personnel about any updates in activity level (nursing unit specific) as well as Fall Risk and Safety Alert.
  1. True or False A physicianorder is required to place the patient on Fall Risk/Safety Alert.
  1. In the event of a Fall (Circle all that apply):
  2. Complete a Quality Control Report and notify physician
  3. Document the notification of physician in CMR nurses notes
  4. Notify the family of the fall
  5. Document post –fall assessment and vital signs q 12 for 24 hours or per physician order/policy.
  6. Assist the patient to bed and no need to inform the family/physician because the patient said they were o.k.

References:

GCH Patient Care Services Protocol: Safety Alert/Fall Risk/Bed Exit Alarm.Safety/Infection Control Section, 6.0

GCH Patient Care Services Protocol: General Safety Precautions.Safety/Infection Control Section, 5.0