Assessment Tools
This tool assesses the Mobility, Mentation, Medication, Elimination and Prior Fall History of a patient
Schmid Fall Risk Assessment Tool
This device should be present in every room and aids in mobility for patients that may have an unsteady gait
Gait Belt
This class of medications is considered a low fall risk due to side effects including: increased ambulation due to frequency, orthostasis and electrolyte imbalance
Diuretics
The post-fall nurses note can be documented in the EMR by typing this into the smart text box
"post fall"
This tool is part of the Admission Database and includes history of falls in the past 12 months
Functional Assessment
This device is strongly encouraged for fall risks of mentation and prior fall history and is designed to be an early warning sign that a fall could occur
Bed/Chair Exit Alarms
This class of medications is considered a medium fall risk due to vasodilating properties and side effects including: orthostasis, impaired celebral perfusion and syncope
Antihypertensives and/or Antiarrhythmics
This should be performed to review the fall and the circumstances surrounding the fall. Work together with staff to determine the cause of the fall and what could be done differently in the future to prevent fall events.
Post Fall Huddle
The minimum Schmid score indictating a patient is a high risk for falls
3
This phrase reminds staff to remain within sight of all patients needing assistance to the bathroom/bedside commode regardless of their fall risk status
Stay With Me
This class of medications is considered a high fall risk due to side effects including: sedation, confusion, dizziness, orthostatic hypotension, altered gait and balance and impaired cognition
Analgesics/Narcotics
This should be completed in the electronic reporting system by using a Fall Event and filling in the report as prompted. Complete by the end of the shift or within 24 hours
Incident Report
The ABCS (Age, Bones, Coagulation, Surgical) should be used to assess a patient's risk for this if a fall were to occur.
Risk for Injury
Examples of these will be initiated for all patients regardless of fall risk score and include: keeping patient care areas uncluttered, familiarizing the patient with the environment and placing the bed in a low and locked position
Standard Fall Prevention Interventions
This class of medications is considered a high fall risk due to side effects including: muscle rigidity*, impaired cognition, sedation and altered gait and balance
Antipsychotics/Anticonvulsants
This document needs to be completed by the end of the shift or within 24 hours of the fall. It includes conducting an interview with the patient and family as to possible reason for the fall. The completed form is faxed to the Quality Department with an additional copy given to the Nurse Manager
Critical Event Analysis (CEA)
The 5 times during a patient stay that fall risk should be assessed at a minimum
1. Upon admission
2. After every shift handoff
3. When the patient condition changes
4. Whenever a fall occurs
5. Every assessment/reassessment per policy
These 3 identifiers are used when a patient is determined to be a high fall risk
Fall Risk arm band (yellow)
Fall risk Icon
High Falls Risk Banner displayed in the Electronic Medical Record
This common and often over-the-counter class of medication is not labeled a fall risk, but for older adults, caution should be used due to side effects including: sedation, confusion, paradoxical agitation and loss of balance
Antihistamines
Whenever a patient fall occurs (either witnessed or unwitnessed), these 4 components make up the basic assessment that must be completed.
Vital Signs
Baseline Neurological Exam
Pain Location
Physical Assessment noting any changes from pre-fall status