Risk Factors
As this increased so does the risk of falling?
Age
What includes on environmental scan and modification?
Unobstructed, clear path to bathroom
Adequate lightning
Room free of clutter
Signage up when floor is wet
An intervention to avoid slipping can be as simple as this?
Proper footwear. Gripper socks/non skid socks
CNA should make sure pt is wearing what while doing restorative walking?
Gait Belt
After a patient has a fall, staff must document details related to the fall where?
Open the Communication Flowsheet. Select "Fall" from the options under Shift event Flowsheet row.
Having these past occurrences in the past increase fear of falling?
Previous falls
Grab a sheet or towel and clean this up quickly to avoid falls?
Spills: could be water or anything else.
Some residents may have self releasing seat belt attached to their wheelchair due their poor safety awareness to alert staff the resident is trying to get up or needs assistance . What should you do with this resident?
Release self releasing seat belt every 2hrs while keeping pt in close supervision, Allow pt to have range of motion,toilet pt every 2hrs.
Release self releasing seatbelt at meal times
CNA's should routinely check on a resident and offer assistance. This is called?
What is frequent visual checks?
When a resident is found on the floor or they hit head during fall these should be performed?
Nurse to do neuro checks and vital signs.
A patient may attempt to self transfer due to?
Urge or frequency of urination
This risk factor may increase for a new patient?
New environment- This may make pt confused.
Hester Davis Scoring:
Low risk: 7-10
Yellow Fall Risk socks
Fall Risk signage in room/door
Ambulate patient with gait belt
Assessing a new patient's history; medical, incontinence, and previous falls is called?
What is the fall risk assessment
When a patient is at high risk for significant injury after a fall. What assessment need to be done and how often?
Initiated a Serial Neuro Checks (Initial Q1 x 2, Q4 x 6, if indicated)
What are the following classified as: Parkinsons, stroke, CHF, DM, Hypotention, Arthritis, Visual Deficits?
Chronic health conditions that are risk factors for falls
A patient propelling backwards in a wheelchair or a patient using a walker as a cane is?
Inproper use of mobility equipment.
Always do this prior to leaving a patient's room?
Place Call light, phone, remote, glasses, water, trash can at reach for the patient. Always ask the pt is there anything I can do for you before I leave.
A high fall risk resident that rolls out of bed should have what performed before leaving the room?
What is proper positioning?
What included on the post-fall communication measures?
Notified Charge Nurse, Provider, Completed fall debrief with Charge Nurse, Initiated/updated signage, Initiated/updated care plan, Communicate fall event at handover, Review medications with provider.
Although taken for health issues, some may increase risk by lowering BP, BS, sedation, loss of balance, and etc?
Medications.
Broken bed, brakes that don't lock, alarm malfunction is?
What is improper maintenance of safety equipment?
Doing this every hour will help decrease residents with high fall risk and help decrease incontinence and falls?
Hourly monitoring and Bowel and Bladder management (toileting every 2hrs).
When a resident is trying to mobilize through a cluttered or crowed area we should do this?
What is clear the pathway?
What interventions we usually put in place to prevent future falls?
Falling star, low bed,floormats,hourly monitoring,toileting every 2hrs,hipsters,non skid socks. All interventions that nurse added should be in your task.