Prevention
T/F: Mobilizing patients increases their risk of falling.
False! Early mobilization improves conditioning, balance, delirium, and reduces fear of falling!
Any patient identified as a fall risk must have this.
What is a fall risk wristband, signage outside door and at HOB?
T/F: Any patient with a FRAS >7 should have the same fall prevention interventions implemented.
False! Fall prevention interventions should be individualized and factor-focused, NOT score-focused.
Epic documentation required after fall.
Fall event documentation, VS, assessment, FRAS, provider notification
How to refill your restraint alternative box items in your unit.
What is reach out to Erica LoVan or Olivia Wulf (or Kelly Poch on weekends) to restock? You can also get the babies and cat/dogs from stores!
A common syndrome developed in the hospital setting (especially ICU) which includes sudden onset of cognitive impairment and confusion.
This score on the FRAS prompts the RN to identify this patient as a fall risk and triggers an Epic banner/icon notifying care team members of the patient's fall risk.
What is FRAS > or equal to 7?
An intervention utilized for patients who are restless and would benefit from an activity or a distraction to keep busy.
What are restraint alternatives & distraction items? (playing cards, fidget toys, coloring, breathing cat/dog, baby doll, etc.)
What is patient assessment for injury?
T/F: Floor mats should be picked up when patients are ambulating to reduce risk of falling.
True!
False! You should NOT wait to mobilize your patient on account of PT/OT. Nursing led mobility is safe when done correctly! :)
Two medication classes which increase fall risk.
What is sedatives, opioids/pain medications, benzodiazepines, psychotropics, anticonvulsants, diuretics, antihypertensives?
How to implement VMU on a patient.
What is Securechat VMU Rounder to see if there are available cameras, and assure they are monitoring patient after camera is plugged in?
Performed after a patient fall involving the interdisciplinary team where factors contributing to fall, fall event, and potential interventions to implement to prevent further falls are discussed.
What is a post fall huddle?
T/F: if the VMU camera is plugged in, it means the camera is on and there is a VMU staff member monitoring the patient.
False! At the start of your shift, you should connect with VMU to assure there is a staff member assigned to monitoring your patient.
Environmental modifications (at least two) to prevent falls due to environmental hazards.
What is decluttered room, clear walking path, personal items in reach, grab bars in bathroom, non-skid flooring in bathroom?
The best predictor for a future fall.
What is a history of falls?
Implemented when a patient is at a high risk of fall-related injury.
What are floor mats?
2 places the fall event should be documented.
What is Fall Event group in Epic and Riskonnect?
Do NOT put in Epic that a Riskonnect was submitted.
A tool utilized for patient engagement in fall prevention efforts and interventions.
What is the Fall Prevention Plan?
4 ways to mitigate delirium in the hospital setting.
All categories included in the Fall Risk Assessment Scale. Hint: There are 8.
What is elimination, mobility, medications, mental status, sensory/communication, age, history of falls, and nursing judgment?
Intervention utilized when a patient can return demonstrate ability to utilize device and allows nursing staff extra time to get to patient before getting out of bed.
What is HeadStart self-releasing belt?
Frequency of neuro checks and VS after a patient falls with head trauma or unknown.
What is q1 x4, q2 x4, q4 x4?
NOTE: this will be changed soon to q30 x4, q1x4, q2 x4, q4x4.
A current initiative that can help reinforce fall prevention interventions through addressing pain, toileting, and mobility at designated intervals.
What is purposeful rounding? 3 P's: pain, potty, positioning