POST-FALL PROTOCOL
What are your first two steps to complete when a patient has fallen?
Assess for injury and obtain vital signs.
A patient at risk of falls has what abnormal lab value?
Patient with a low platelet count
In the event of a fall, which documentation do you update? 1., 2.
Physical Assessment (if injury is noted) and Risk Assessment
If a patient cannot shake your hand or bear any weight on their lower extremities, which BMAT level are they?
BMAT Level 1
What color signifies a fall risk?
Patient states, "I hit my head when I fell." What action do you take?
Order a STAT head CT per protocol and transport the patient down.
What scale do we use to measure fall risk?
Morse Fall Scale
If a fall occurs, it is a requirement to complete the "________" Assessment in Meditech.
Post-Fall Assessment
If a patient has upper body strength but is unable to bear weight in their legs, what BMAT level are they?
BMAT level 2
Patient's room and floor should be free of this to prevent falls
What is clutter?
Patient fall occurred; manually add a second "___" on the hill-rom system.
Gold Star
What number qualifies the patient as a high fall risk?
45 or greater
What reporting system does SJCHS utilize to report a fall incident that occurred?
RADAR
What lift equipment is commonly used for a BMAT level 3?
Ultra Move, Walker, Cane
If the patient has all 4 bedrails up, this is considered a "_____"
Restraint
Who do you notify in the event of a fall?
Family member, MD and RC/Supervisor
Elderly patients with "_____" are at a higher risk for falls.
Multiple Answers: Dementia, Altered Mental Status, Muscle Weakness, etc.
After a fall has occurred, it is required to complete a "_______" form, turn it in to the manager and debrief on the incident.
Post-Fall Huddle
How many people are required to operate a lift?
A minimum of two
List the items in the yellow fall bundle:
Non-Skid yellow socks, Yellow blanket, Wristband and gold star magnet for the door frame
If a patient has fallen, what documentation is required to complete? 1., 2., 3., 4., 5.
Post-Fall Assessment, Update Risk Assessment, Update Physical Assessment if Injury noted, RADAR and Post-Fall Huddle Form
If the patient is currently taking an "______", we want to monitor them closely in the event of a fall occurring.
Anticoagulant
A fall has occurred and you have notified the Physician, where do you document that correspondence?
Physician Notification/Critical Result
How do you determine the weight limit on a chair sling, steady aid belt and lift sheet?
It is listed on the tag and/or the color of the rim on the sling
Majority of falls occur when?