Fall Interventions
What can prevent a resident from falling while reaching for things? (2 answers)
1) Keep items within reach
2) Provide resident with a reacher
How do you complete required documentation in Risk management?
Incident Report
Number one reason resident's get up unassisted.
Need to or having already used the bathroom.
Why do residents have difficulty getting around during the night?
Poor lighting
What medications are used as chemical restraints?
Ativan, Xanax, Trazadone, Haldol, Morephine, Oxycodone, Hydrocodone
How can we keep resident's with low vision from falling? (2 answers)
1) Leave on bathroom light.
2) Provide resident with night light or flashlight
How do you document injuries or lack there of?
Head to toe assessment and enter new orders for wound care.
Time. Residents wake up early and think it is time to get ready. Be sure to keep lighting conducive to sleep and keep room well lit in the day. Try to maintain a regular bedtime and rising schedule.
Name some trip and slip hazards:
slippery socks, linen in the floor, cords not out of the walking area, oxygen tubing, IV tubing, fall mats, poorly fitted shoes, clutter/ excess furniture in the room
Wheelchair and restraints- how do we use them improperly?
Locking brakes when a resident cannot release them on command.
Example: Pushing resident up to dining table and locking wheels to keep them from leaving or standing up.
What is the primary physical need that causes residents to get up unassisted and how can we keep them from falling due to this need? (2 answers)
1) Urinary/ bowel incontinence or urgency
2) Keep resident clean and dry; anticipate resident's need to use the restroom and take them timely and routinely.
Name some components of neurological checks?
(7)
Level of consciousness, mental status, ability to communicate, movement/ coordination; reflexes, change of behavior, vital signs
*I would also encourage you to watch pupil changes and reaction to light in a patient who has hit their head. *
When residents try to get in and out of bed, in and out of the wheelchair, attempt to walk unassisted, or move into another chair, they may be experiencing what?
Pain! Residents often try to change positions to relieve pain from sitting, standing, or lying too long. Assist with change of position and anticipate the residents' needs. Talk to the provider about a pain regimen. Assist resident to walk if possible and desired.
What are some bathroom hazards that cause falls?
Wet floor (especially at the new building), light not on, no toilet riser, unsteady or wrong height of toilet riser, not locking wheels on wheelchair when transferring, no grab bar
True or False
Is placing the resident's wheelchair and walker on the other side of the room a restraint?
1) Provide residents with a call light and assess resident on ability to use it.
2) Answer call lights in 2-3 minutes.
What one piece of paper is required to help ALL staff analyze the fall scene immediately after in an attempt to find the route cause of the fall?
Fall Huddle form
What is a reason residents fall out of the wheelchair?
Trying to pick up items off the floor. Try to keep items within reach and pick up trash for residents.
What items should be kept within reach to keep resident from attempting to get out of bed or chair on their own?
Call light, remote, phone, water, snacks, clock, wheelchair, walker, shoes
Can a gerichair or recliner be a restraint? If so, how?
Yes. Putting resident in a gerichair or recliner with legs elevated when the resident cannot put the legs down on command.
What is the easiest way to prevent residents from slipping?
NON SKID SOCKS!!!
What is the number one way to document what was seen and done following a fall?
Nurse's Note!! Your DETAILED narrative in a good ole fashion nurse's note is the best way to document any event during your shift and is usually required. (For PT/OT/ST to pick up there must be a note. If you don't want me to call you the next morning, write a really good note that includes lighting, footwear, environmental hazards, condition of resident, injuries, what the resident was doing just prior to the fall, what was done to prevent another fall:)
What should we watch for in residents that may warn us about future falls?
Changes in gait, strength, mental status, vision, transferring difficulties, inability to use the call light.
What hallway hazards contribute to falls?
Equipment in the hallway, med carts in hallway, wet floors, changes from one type of flooring to another (hardwood to carpet, carpet to tile). Residents with dementia and vision issues can have increased difficulty with lighting that makes the floor look shiny and appear wet, changes in tile color that look like holes, edges at changes of floor they try to step over.
What is the easiest way for a surveyor to site us for restraint/ isolation?
Not placing call light within reach or providing resident with a call light that they can physically operate.