FALL BASICS
What is a fall?
This is a sudden, unintentional descent that results in a patient coming to rest on the floor or another surface.
What is the Morse Fall Scale?
This assessment tool is used for adult inpatients.
What is the Fall T.I.P.S. Poster?
This bedside communication tool is reviewed every shift and during handoff.
Which fall risk tool is used for pediatric patients?
Humpty Dumpty Fall Risk Assessment Tool
Who should be notified immediately after a patient fall?
The licensed provider (MD/NP/PA)
What is an accidental fall?
Occur when the patient slips, trips, or some other mishap occurs. These falls are often caused by environmental factors
What is A.B.C.S.?
Age, Bones, Coagulation, and Surgery.
A Yellow wristband & Yellow non-slip socks mean...
Patient is a high fall risk
A Humpty Dumpty score of 13 is considered:
High Risk
Low risk: 7 - 11
High risk: 12
The RN should complete this assessment if head strike is suspected or unknown.
Neurological assessment
What is an assisted fall?
A fall in which any staff member (whether a nursing service employee or not) was with the patient and attempted to minimize the impact of the fall by slowing the patient’s descent.
What does a Morse score greater than 45 indicates?
High Fall Risk
0 No Risk
1 – 24 Low Fall Risk
25 – 45 Moderate Fall Risk
> 45 High Risk
Enumerate the 5 P's for purposeful rounding
Which assessment tool is used in adult Behavioral Health?
Wilson-Sims Fall Risk Assessment Tool
Following a fall, nurses repeat this risk assessment.
Morse Fall Scale
(or Wilson-Sims/Humpty Dumpty as appropriate)
What is an unanticipated physiological fall?
Factors associated with unknown fall risks that were not predicted (cannot be expected) on a fall risk scale: unexpected orthostasis; extreme hypoglycemia; stroke; heart attack; seizure.
Name two medication classes that increase fall risk.
Examples:
True or False:
Side rails should be routinely used to prevent falls.
False.
Behavioral Health patients with a Wilson-Sims score of 8 are considered
High Risk
Low Risk: 0 to 6
High Risk: 7 or above
What team meeting is conducted after every fall to determine what happened and improve prevention?
Post-Fall Huddle (Debrief)
What is a baby/child drop?
A fall in which a newborn, infant, or child being held or carried by a healthcare professional, parent, family member, or visitor falls or slips from that person’s hands, arms, lap, etc.
List three physiologic assessments nurses complete to evaluate fall risk.
Name five interventions for a patient with high fall risk.
Name four additional interventions for high-risk Behavioral Health patients.
Name four required nursing actions following a fall.