Category 1: Fall Facts
True or False: A fall only “counts” if the patient is injured.
False — all unplanned descents are falls, even without injury.
Name one intrinsic (patient-related) fall risk factor.
Examples: Muscle weakness, dizziness, medications, vision problems.
Mr. James has a yellow sign on the outside of his door. He calls for help to go to the bathroom, and you assist him there. He says, “I’ll be fine by myself.” What should you do?
Ensure he is safe on the toilet, make sure the call light is within reach, step out but stay nearby (he doesn’t need direct watching), and assist him back when done.
What does a Red status imply ?
Bed and chair alarms ON all times of the day; someone must watch patient on toilet or commode at all times. pt must have assistance every time a patient moves from point A to point B.
How can a patient falling affect their rehab progress?
A patient who falls and becomes injured may have to stop therapy for days or even weeks.
What percentage of falls result in some type of injury?
About 30–50%.
Name one extrinsic (environmental) fall risk factor.
Examples: Clutter, poor lighting, wet floors, uneven surfaces; no proper footwear or socks, improper lighting, TLSO brace that does not fit well, transfer equipment that is not appropriate for pt. etc.
Mrs. Lopez, a post-stroke patient with left-sided weakness and a red sign on her door, starts to scoot to the edge of her bed without calling. You hear her bed alarm go off. What should you do?
Go to her room immediately, assess her needs(restroom assistance, something may have fallen on the floor, altered mental status that may need redirection.) remind her to call for help before moving, assist her safely back to bed, ensure the bed and chair alarms are active, and document the event. Re-educate on using the call light.
What does a Yellow status imply?
No bed alarm during the day time but alarm needs to be on at night; patient needs assistance to the bathroom but can have there privacy when transferred on the commode safely. pt needs to be transferred safely back to bed or w/c after they are done.
After a fall, a patient may become afraid to move or walk again. how does it affect rehab?
This is when a patient has a fear of falling, which reduces confidence and independence in therapy?
What are different reasons that a patient’s fall risk may change throughout their rehab stay?
medical condition, medications, fatigue, or new weakness can alter mobility and safety levels day to day.
What time of day do most inpatient falls occur? Why?
Nighttime or early morning. Why? Improper lighting, vision, urgency to use bathroom, Feel that they can not wait on someone to make it in time so they attempt to go on there own. (Tip: this is why it is very important to try your best to answer call lights as promptly as possible as this can PREVENT A FALL. )
Ms. Patel, a green tag patient, has good balance and walks around her room freely. You notice her heading toward the hallway to visit another patient. What should you do?
Politely remind her that green-tag patients can move freely in their room but not in the hallway. Offer to assist or accompany her if she wants to go down the hall.
What does a Green status imply for how a patient can transfer?
No need for alarms at anytime of day; patient can move freely in the room but not in the hallway.
BONUS: what status does a patient need to obtain to roam around the facility without any assistance?
A patient who fractures a bone during a fall might need surgery or hospital transfer. How does this impact their stay in rehab?
This means prolonged hospitalization and delayed discharge back home?
Why is reassessing the patient’s fall risk and updating their care plan immediately very important?
More than one-third of patients who fall in the hospital will fall again during the same stay if this step is not taken after the first incident.
Which type of medication increases fall risk due to dizziness or drowsiness?
Sedatives or blood pressure medications.
A nurse walks into a pt's room and notices there is a green tag on the outside of the pt's door. The nurse walks into the room to notice that the pt is having a hard time standing up and using their walker to go to the bathroom. The nurse continues to watch and notices that the pt almost falls. The nurse helps pt from falling. what is the appropriate step for this nurse to take after stabilizing pt?
The best thing to do in this moment is downgrade the pt to a red tag until therapy can reevaluate pt.
Why?
Can a nurse down grade the pt? YES
Can the nurse upgrade the pt? NO
You have three patients: one red, one yellow, and one green. All call for assistance at once — who do you go to first?
The red tag patient first (highest fall risk, alarms active, needs supervision). Then the yellow tag (needs assistance), and lastly the green tag (independent in room). Prioritize by fall risk level.
Even if no injury occurs, every fall must be reported and investigated. Why is this important for patient outcomes and safety?
This is important due to identifying causes and preventing future falls to keep patients safe and progressing?
What is the first thing you should do after a fall occurs?
Ensure patient safety and assess for injury before moving them.
What is orthostatic hypotension, and why does it increase fall risk?
A drop in blood pressure when standing; it can cause dizziness or fainting.
What can one do to make sure that a pt is safe if they experience orthostatic hypotension?
What is the role of therapy staff in fall prevention?
Assess balance, strength, mobility, and recommend safe transfers or devices. post-therapy hand-off report to either nursing or PCT to ensure pt safety.
Are therapists the only ones that can give patients transfer status?
Why is it important to follow the tag color system consistently for patient transfers no matter what our beliefs may be regarding how a patient may transfer?
It ensures all staff understand each patient’s fall risk and provides consistent safety. Many times when a short-cut route is adopted (to possibly save time) is when a fall can most likely occur.
Preventing falls keeps patients safe and therapy on track. What is one key reason fall prevention is part of every rehab team member’s responsibility?
every fall can undo progress, delay recovery, and increase healthcare costs or complications?