Risk Factors
As this increases so does the risk of falling
What includes on environmental scan and modification?
Unobstructed, clear path to bathroom
Adequate lightning
Room free of clutter
Signage up when floor is wet
An intervention to avoid slipping can be as simple as this?
Proper footwear. Gripper socks/non skid socks
CNA should make sure pt is wearing what while walking a fall risk patient?
Gait Belt
After a patient has a fall, staff must document details related to the fall where?
Open the Communication Flowsheet. Select "Fall" from the options under Shift event Flowsheet row.
Having these occurrences in the past increase fear of falling
Previous falls
Grab a sheet or towel and clean this up quickly to avoid falls?
Spills: could be water or anything else.
How many choices can you pick under the Hester Davis Fall Risk Assessment?
All that apply
CNA's should routinely check on a patient and offer assistance. This is called?
What is rounding?
When a patient is found on the floor or they hit head during fall what should be performed?
Nurse to do neuro checks and vital signs.
A patient may attempt to get out of bed without assistance when they have
Urge or frequency of urination
This risk factor may increase for a new patient?
New environment- This may make pt confused.
Hester Davis Scoring 11-14 is what level of fall risk?
Moderate fall risk
Yellow Fall Risk socks
Fall Risk signage in room/door
Ambulate patient with gait belt
Assessing a new patient's history; medical, incontinence, and previous falls is called?
What is the fall risk assessment
When a patient is at high risk for significant injury after a fall. What assessment need to be done and how often?
Initiated a Serial Neuro Checks (Initial Q1 x 2, Q4 x 6, if indicated)
What are the following classified as: Parkinsons, stroke, CHF, DM, Hypotension, Arthritis, Visual Deficits?
Chronic health conditions that are risk factors for falls
How many people do you need to use lift equipment?
At least two staff members
Always do this prior to leaving a patient's room?
Place Call light, phone, remote, glasses, water, trash can at reach for the patient. Always ask the pt is there anything I can do for you before I leave.
A high fall risk resident that rolls out of bed should have what performed before leaving the room?
What is proper positioning?
What included on the post-fall communication measures?
Notified Charge Nurse, Provider, Completed fall debrief with Charge Nurse, Initiated/updated signage, Initiated/updated care plan, Communicate fall event at handover, Review medications with provider.
Although taken for health issues, some may increase risk by lowering BP, BS, sedation, loss of balance, and etc?
Medications
Hestor Davis score of 15 or greater means what?
Patient is a high fall risk.
Doing this every hour will help decrease patients with high fall risk and help decrease incontinence and falls?
Hourly monitoring and Bowel and Bladder management (toileting every 2hrs).
Mobility goals are documented where?
On patient's white board and on the Active Daily Management board
What interventions do we usually put in place to prevent future falls?
Bed alarm, bed in low position, hourly monitoring, toileting every 2hrs, non-skid socks.