BACKGROUND/STATEMENT OF THE PROBLEM

A.  Definition

1. A fall is an unexpected event in which the participant comes to rest on the ground, floor, or lower level (Prevention of Falls Network Europe, 2006).

B.  Fall etiology

1. Fall risk factors include intrinsic risks of cognitive, vision, gait, or balance impairment, high-risk/contraindicated medications, and/or the extrinsic risks of assistive devices, inappropriate footwear, restraint, use of unsteady furniture or equipment, poor lighting, and uneven or slippery surfaces.
2. Fall causes include, among others, orthostatic hypotension, arrhythmia, infection, generalized or focal muscular weakness, syncope, seizure, hypoglycemia, neuropathy, and medication.

PARAMETERS OF ASSESSMENT

A.  Assess and document all older adult patients for intrinsic risk factors to fall.

1. Advancing age, especially if older than 75
2. History of a recent fall, repeat falls, or fall-related injury (Panel on Prevention of Falls in Older Persons et al., 2011)
3. Specific comorbidities: dementia, hip fracture, type 2 diabetes, Parkinson’s disease, arthritis, and depression
4. Functional disability: use of assistive device
5. Alteration in level of consciousness or cognitive impairment
6. Gait, balance, or visual impairment
7. Use of high-risk medications (Chang et al., 2004)
8. Urge urinary incontinence (Brown et al., 2000)
9. Physical restraint use (Capezuti, Maislin, Strumpf, & Evans, 2002)
10. Bare feet or inappropriate footwear
11. Identify risks for significant injury resulting from current use of anticoagulants, such as Coumadin, Plavix, or aspirin, and/or those with osteoporosis or risks for osteoporosis (Resnick, 2003).

B.  Assess and document patient-care environment routinely for extrinsic risk factors for fall, and institute corrective action:

1. Floor surfaces for spills, wet areas, and unevenness
2. Proper level of illumination and functioning of lights (night-light works)
3. Tabletops, furniture, and beds are sturdy and in good repair
4. Grab rails and bars are in place in the bathroom
5. Adaptive aids work properly and are in good repair
6. Bed rails do not collapse when used for transitioning or support
7. Patient gowns/clothing do not cause tripping
8. IV poles are sturdy if used during mobility, and tubing does not pose a safety hazard for tripping

C.  Perform PFH and a comprehensive PFA following a patient fall to identify possible fall causes (if possible, begin the identification of possible causes within 24 hours of a fall) as determined during the immediate, interim, and longitudinal post-fall intervals. Because of known incidences of delayed complication of falls, including fractures, observe all patients for about 48 hours after an observed or suspected fall (ECRI Institute, 2006; Gray-Miceli et al., 2006; Panel on Prevention of Falls in Older Persons et al., 2011).

D.  Perform a physical assessment of the patient at the time of the fall, including vital signs (which may include orthostatic blood pressure readings); neurological assessment; and evaluation for head, neck, spine, and/or extremity injuries.

1. Once the assessment rules out any significant injury:
   • Obtain a history of the fall by the patient or witness description and document
   • Note the circumstances of the fall, location, activity, time of day, and any significant symptoms
   • Review underlying illness and problems
   • Review medications
   • Assess functional, sensory, and psychological status
   • Evaluate environmental conditions
   • Review risk factors for falling (American Medical Directors Association, 2003; ECRI Institute, 2006; Panel on Prevention of Falls in Older Persons et al., 2011; Resnick, 2003).

E.  In the acute care setting, an integrated multidisciplinary team (comprised of the physician, nurse, healthcare provider, risk manager, physical therapist, and other designated staff) plans care for the older adult at risk for falls or who has fallen, hinged on findings from an individualized assessment (ECRI Institute, 2006; The Joint Commission, 2007).

F.   The process approach to an individualized PFA includes use of standardized measurement tools of patient risk in combination with a fall-focused history and physical examination, functional assessment, and review of medications (American Medical Directors Association, 2003; Panel on Prevention of Falls in Older Persons et al., 2011; Resnick, 2003). When plans of care are targeted to likely causes, individualized interventions are likely to be identified. If falling continues despite attempts at individualized interventions, the standard of care warrants a reexamination of the older adult and his or her fall.

NURSING CARE STRATEGIES

A.  General safety precaution and fall-prevention measures that apply to all patients, especially older adults, include:

1. 1.  Assess the patient-care environment routinely for extrinsic risk factors, and institute appropriate corrective action.
   • Use standardized environmental checklists to screen; document findings.
   • Communicate findings to risk managers, housekeeping, maintenance department, all staff, and hospital administration if needed.
   • Reevaluate environment for safety (ECRI Institute, 2006).
2. Screen/assess older adult patient for multifactorial risk factors for fall on admission, following a change in condition, on transfer to a new unit, and following a fall (ECRI Institute, 2006; NCPS, 2014):
   • Use standardized or empirically tested fall risk tools in conjunction with other assessment tools to evaluate risk of falling (Panel on Prevention of Falls in Older Persons et al., 2011; Tinetti, Williams, & Mayewski, 1986).
   • Document findings in nursing notes, interprofessional progress notes, and the problem list.
   • Communicate and discuss findings with interprofessional team members.
   • In the interprofessional discussion, include review and reduction or elimination of high-risk medications associated with falling.
   • As part of fall protocol in the facility, flag the chart or use graphic or color display of the patient’s risk potential to fall.
   • Communicate to the patient and the family caregiver the identified risk to fall, and specific interventions chosen to minimize the patient’s risk.
   • Include patient and family members in the interprofessional plan of care and discussion about fall-prevention measures.
   • Promote early mobility and incorporate measures to increase mobility, such as daily walking, if medically stable and not otherwise contraindicated.
   • On transfer to another unit, communicate the risk assessment and interventions chosen and their effectiveness in fall prevention.
   • On discharge, review fall risk factors and measures to prevent falls in the home with the older patient and/or family caregiver. Provide patient literature/brochures, if available. If not readily available, refer to the Internet for appropriate websites/resources.
   • Explore with the older patient and/or family caregiver avenues to maintain mobility and functional status; consider referral to home-based exercise or group exercises at community senior centers. If discharge is planned to a subacute or rehabilitation unit, label the older adult’s mobility status at the time of discharge on the transfer, or indicate other types of physical activity in the home to strengthen lower extremities or assist with gait/balance problems.
3. Institute general safety precautions according to the facility protocol, which may include:
   • Referral to a fall-prevention program
   • Use of a low-rise bed that measures 14 inches from the floor
   • Use of floor mats if patient is at risk of serious injury such as osteoporosis
   • Easy access to call light
   • Minimization and/or avoidance of physical restraints
   • Initiate patient-engaged video surveillance
   • Use proper footwear
   • Regular toileting at set intervals and/or continence program; provide easy access to urinals and bedpans
   • Observation during walking rounds or safety rounds
   • Use of corrective glasses for walking
   • Reduction of clutter in traffic areas
   • Early mobility program (ECRI Institute, 2006)
4. Provide staff with clear, written procedures describing what to do when a patient fall occurs.

B.  Identify specific patients requiring additional safety precautions and/or evaluation by a specialist or:

1. Those with impaired judgment or thinking caused by acute or chronic illness (delirium and mental illness)
2. Those with osteoporosis, at risk of fracture
3. Those with current hip fracture
4. Those with current head or brain injury (standard of care)

C.  Review and discuss with the interprofessional team the findings from the individualized assessment, and develop a multidisciplinary plan of care to prevent falls (Chang et al., 2004).

1. Communicate to the physician significant PFA findings (ECRI Institute, 2006).
2. Monitor the effectiveness of the fall-prevention interventions instituted.
3. Following a patient fall, observe for serious injury resulting from a fall, and follow facility protocols for management (standard of care).
4. Following a patient fall, monitor vital signs, level of consciousness, neurological checks, and functional status as per facility protocol. If significant changes in patient condition occur, consider further diagnostic tests, such as plain film x-rays, and CT scan of the head/spine/extremity, and provide a neurological consultation and/or transfer to a specialty unit for further evaluation (standard of care).

EVALUATED/EXPECTED OUTCOMES

A.  Patients will:

1. Maintain their safety.
2. Avoid preventable falls.
3. Not develop serious injury from a fall if it occurs.
4. Know their risks of falling.
5. Be prepared on discharge to prevent falls in their homes.
6. Continue prehospitalization level of mobility.
7. Those who develop fall-related complications, such as injury or change in cognitive function, will be promptly assessed and treated appropriately should fall-related complications, injury, or cognitive decline occur.
8. Be fully engaged as a partner in the fall-prevention plan of care.

B.  Nursing staff will:

1. Accurately detect, refer, and manage older adults at risk of falling or who have experienced a fall
2. Integrate into their practice comprehensive assessment and management approaches for fall prevention in the institution
3. Gain appreciation for older adults’ unique experience of falling and how it influences their daily living and functional, physical, and emotional status
4. Educate older adult patients anticipating discharge about fall-prevention strategies
5. Collaborate and coordinate fall prevention as members of interprofessional teams

C.  Family caregivers will:

1. Benefit from added knowledge about fall prevention to become sensitized and more aware of simple strategies to prevent falls
2. Be fully engaged in patient safety efforts

D.  Healthcare organizations will

1. Realize reduced fall and injurious fall rates
2. Realize the benefits of fall-prevention programs that minimize liability
3. Support budgetary lines for fall-prevention interventions directed to patients and healthcare staff

FOLLOW-UP MONITORING OF CONDITION

1. Monitor fall incidence and incidences of patient injury caused by a fall, comparing overall fall rates, rates by type of fall, and root causes of fall events, within and across units over time.
2. Compare falls, falls with injury, and percentage of falls with major injury per quarter against national benchmarks available in the National Database of Nursing Quality Indicators.
3. Incorporate continuous quality-improvement criteria into fall-prevention program.
4. Identify fall team members and roles of clinical and nonclinical staff (ECRI Institute, 2006).
5. Educate patient and family caregivers about fall-prevention strategies so they are prepared for discharge.

RELEVANT PRACTICE GUIDELINES

1. Panel on Prevention of Falls in Older Persons, AGS, BGS (2011)
2. American Medical Directors Association (2003)
3. University of Iowa Gerontological Nursing Interventions Research Center (UIGN, 2004)
4. ECRI Institute (2006)

ABBREVIATIONS

PFA             Post-fall assessment

PFH             Post-fall huddle

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 23:  Gray-Miceli, D. & Quigley, P. (2021) Assessing, Managing, and Preventing Falls in Acute Care. In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 375-408).  New York: Springer.