Knowledge
You have 19 seconds
What is the response time to prevent a fall
BMAT (Bedside Mobility Assessment)
What is the tool/assessment nurses use to determine patient ability and safety to mobilize?
Falls Risk Score 7-10 level of risk
What is low risk?
Fall risk indicator on arm band, gait belt used for ambulation, chair safety belt (pt can remove), room location near nurses' station, toileting plan, review meds that may contribute to falls, minimize disruptions at night, interdisciplinary care team meeting, Tele sitter, patient sitter, activate bed/chair alarms
What is Moderate/High Risk Falls Risk Interventions
The Neurology units focused Fall prevention sub measures that we strive to get 95% completion/documentation every week
What is Admit Fall Prevention Education on arrival to unit and Arrival High Fall Risk Interventions based on Hester Davis Scale?
Over 50% of falls occur due to....
What is bathroom needs?
Developed to predict anticipated falls in adult patients in a variety of settings
What is the Hester Davis Scale for Fall Risk Assessment?
Falls Risk Score 15 or greater level of risk
What is high risk?
The frequency to complete and document individualized interventions with the Hester Davis Scale
What is the within four hours of admission or transfer, once per shift, and with a change in patient condition?
Implement Standard Fall Risk Interventions for...
What is all patients?
Frequency of implementing/revising TIPS Tool and placing on communication board
What is on admission, transfer, and change in patient condition?
Last Known Fall, Mobility, Medications, Mental Status/LOC/Awareness, Toileting Needs, Volume/Electrolyte Status, Communication Sensory, Behavior
What is the information needed to complete the Hester Davis Scale (HDS)?
Falls Risk Score 11-14 level of risk
What is Moderate Risk?
Appropriate lighting, glasses/ hearing aids/ mobility aids within reach, belongings and call light within reach, bed/gurney in lowest position and wheels locked, side rails in up position as appropriate, clean/dry floor, Falls Risk identified clearly on communication board, decluttered environment-clear pathway, supportive footwear or nonskid socks, purposeful interval rounding, bedside shift report, signage in bathroom for safety
What is standard fall risk prevention interventions?
The care plan that is initiated on admit and updated q shift as needed in care connect is...
What is Safety Adult- Fall?
Steps needing to be taken after a patient falls on your shift
What are assess pt and notify charge nurse and attending physician, implement immediate measures to keep pt safe and prevent another fall, document details of fall and assessment of pt in care connect, conduct a post fall debrief while completing form, complete Safe 2 Share?
MAR, H&P, BMAT, PT notes, Neurological, Gastrointestinal, and Urinary Assessments, Daily/Safety flowsheets, I/O flowsheet, Diet, Labs, Objective behaviors
What are resources to get data to complete Hester Davis Scale?
Hester Fallsalot Hester Davis Scale score and level of risk
What is 21 High Risk
Activate bed/chair alarms, stay within arm's reach during toileting at all times, place patient in yellow gown unless contraindicated
What is High Fall Risk Interventions?
We can help decrease the sense of urgency and reassure the patients that we have time to take them to the bathroom...
What is if we offer patients assistance to the bathroom every hour?
Information about the patient that increases the chance for falls including pt history of falls, medication side effects, walking aid, IV pole or equipment, unsteady walk, may forget or choose Not to Call
What are patient risk factors for falls?
The frequency to complete and document Hester Davis Scale Score
What is within four hours of admission/ transfer, once per shift, and with a change in patient condition?
Davis Dendrite case study falls score and level of risk
What is 23 and High Risk
What is purposeful interval rounding?
A patient falls with serious injury you would call....
What is Safety Stop and provider?