Fall Risk Factors
Fall Prevention Tools & Strategies
Hester Davis Risk Assessment Tool
Fact or Fiction
Post-Fall Procedures
100
Intervention that should not be used on a patient with a shuffling gait.
What are non-skid socks?
Rationale
100
What simple device can alert staff when a patient attempts to leave the bed or chair?
What is bed/chair alarm?
Rationale: These alarms alert staff when a high-risk patient attempts to get up without assistance. While not foolproof, they serve as an early warning system and help prevent unassisted ambulation.
100
When should the Hester Davis fall risk score be reassessed?
What is...per shift, transfer/admission, after any change in condition, fall event, and at discharge.
Rationale: A patient's fall risk can fluctuate quickly. Reassessing after changes or incidents ensures that prevention strategies remain appropriate and up to date.
100
Falling once doubles your chances of falling again.
What is fact?
A history of falls is one of the stronger predictors of future falls. According to statistics individuals who have fallen once are two to three times more likely to fall again.
100
This sign should be placed outside the patient's room if they are admitted for a fall, or have had a fall during the current admission/hospitalization.
What is the orange HD post-fall sign?
Rationale: A prior fall is one of the strongest predictors of future falls. According to statistics, individuals who have fallen once are two to three times more likely to fall again.
200
This medication administration method will increase a patient's risk for falls.
What is intravenous therapy?
Rationale: Being tethered to an IV pole whether continuous or intermittently increase the patient's risk for sustaining an accidental fall.
200
This strategy decreases the likelihood that patients will attempt to get up alone to use the bathroom.
What is proactive toileting?
Rationale: Many falls occur when patients attempt to toilet without waiting for assistance. Scheduled toileting addresses this need proactively, reducing urgency and unassisted ambulation.
200
Falls that occur as a result of a patient attempting to go to the bathroom should be categorized as an anticipated physiological fall.
What is fact?
Rationale: Anticipated- The risk is foreseeable based on the patient's condition of behavior.
Physiological- The fall is linked to normal body function changes, like needing to urinate or defecate urgently, and not being able to safely mobilize without help.
200
True or False: You should notify the provider, even if the patient has no visible injuries after a fall.
What is true?
Rationale: Provider notification ensures that the patient is properly evaluated for subtle or delayed-onset injuries, such as internal bleeding or head trauma, and allows timely medical decision-making.
300
This device may diminish a patient's ability to steady themself and its use at the bedside can cause the patient to experience orthostasis from standing to quickly to void. This is why it is included in toileting domain for HD scoring.
What is a urinal?
Rationale: Urinal use places the patient at risks for falls because the patient may hold the urinal diminishing their ability to steady themselves. Also they can experience orthostasis from standing too quickly to void. Patients often get up to use the urinal without calling for assistance because it is close to the bed.
300
Where in Epic can you view readily available information designed to assist with increasing accuracy in HD risk assessment scoring.
What is the Hester Davis side bar summary:
Rationale: The HD side bar summary provides current information on the patient's active medications, current diet, IV fluids, tube feeding, GI symptoms, and recent labs
300
Bed alarms alone are enough to prevent patient falls.
What is fiction?
Rationale: While they can alert staff to movement, bed alarms are only effective when paired with timely rounding and response.
300
All the documentation that must be completed after a fall.
What is... post-fall evaluation, narrative (nursing note), any relevant physical assessments if patient sustains and injury (i.e. pain, skin, etc.) and SAFETRACK event report.
Rationale: Thorough documentation is essential for legal, quality and clinical tracking purposes.
400
These should be implemented on each patient, regardless of fall risk.
What are universal precautions?
Rationale: All patients are at risk for falling, even if they do not score as high risk on formal assessments. Factors like unfamiliar environments, acute illness, medications, and temporary confusion can increase fall risk unexpectedly. I
400
Patients who refuse fall precautions can be left alone as long as they're alert and oriented x 4.
What is fiction?
Patients refusing fall precautions should still be assessed, and staff must follow protocols to mitigate risk and document interventions.
400
This key information should be discussed in the post-fall huddle.
What is... time and location of fall, what happened, who was present, any injuries, contributing factors and opportunities for improvement to prevent future falls.
Rationale: A post-fall huddle allows real-time evaluation of the incident, fosters team learning and identifies system issues or communication gaps that can be corrected quickly.
500
What is missing in this scenario? 
What is a gait belt?
Rationale: Gait belts provide a secure way for staff to control a patient's descent, reducing injury risk for both the patient and staff. Their absence during assisted falls is a common safety lapse that should be corrected and documented.
500
These six electrolytes are included in the Volume/Electrolyte domain for HD scoring.
What is Sodium, Potassium, Calcium, Magnesium, Chloride and Phosphorus?
Rationale: Na+: gait and attention impairments
K+: abnormal heart rhythms and muscle weakness
Ca+- diminished musculoskeletal function
Mg- Ost
500
A patient falls and initially reports knee pain but no visible injuries. One hour later, during reassessment, they deny pain. This should be documented as a fall with no injury.
What is fiction?
Rationale: According to NDNQI pain that resulted from a fall should be reported as a minor injury, even if it was not treated and/or resolved within 24 hours.
500
The difference between an unwitnessed fall in terms of clinical response?
What is...An unwitnessed fall requires a neurological evaluation and frequent monitoring, as injuries may not be immediately apparent.
Rationale: If no one saw the fall, there's potential for head trauma or loss of consciousness, which calls for more thorough neuro checks and documentation.