Post Fall
A period of debriefing to determine the causes of a fall and to identify ways to prevent fall reoccurrence.
What is a Post-Fall Huddle?
Asked on admission and includes last known fall, mobility, medications, behavior, and communication
What is the Hester Davis fall risk assessment?
Gait belt, special low bed, floor mat, sitter/care companion, pharmacy consult for medication review
What are High Fall Risk Individualized interventions?
Occurs immediately following a fall or as soon as possible.
When should Post Fall Huddle occur?
Cardiovascular or central nervous system meds, diuretics, recent chemotherapy
What are medications that increase the risk of falls?
Mobility aids, non-slip footwear, lighting, cleanliness without clutter, call light within reach, bed in low position, secure wires and tubing
What are Universal Fall Precautions?
Completed and documented by the nurse when a patient falls and hits their head or when a fall is un-witnessed.
What are Post Fall Neuro Checks?
Orientation to surroundings, when to notify staff for assistance, medication side effects, how to safely get out of bed/chair, fall prevention plan.
What are critical elements of patient teaching to prevent falls?
Patient's nurse, house supervisor or manager, charge nurse, patient/family, anyone witnessing the fall
Who Participates in the post fall huddle?
A score of 11 or greater
What is a patient with a high fall risk?
Feet resting on floor prior to standing, fall arm band, sign in room, supervised, proactive toileting, Bed/chair alarm.
What are High Fall Risk Standard interventions?
A sudden, unplanned or unexpected descent, with or without injury to the patient
What is a fall?
Consider this for patients exhibiting delirium, agitation, or confusion.
What is a sitter/care companion?
Location in EPIC where the patient's current Predictive Ai Fall score is reviewed by the nurse each shift.
What is Safety Checks?
This should be done when a patient is non-compliant with fall interventions.
What is escalate and educate?
A fall that occurs when a patient stands from a sitting or lying position should trigger this type of assessment.
What are Orthostatic Vital Signs?
Commonly believed to reduce fall risk, but they actually increase the risk of patient falls.
What are restraints?
Physical assessment; review of fall risk level, patient/visitor education; description of event; any injury; updates to the care plan; notification of family, provider, and leader in the EHR; and a SAFE report
What is required documentation after a fall?
Yellow arm band, high fall risk banner in EHR, high fall risk sign in room
How are high fall risk patients identified?
A patient fell 20 days before admission. What level of fall precautions does the patient require and for how long?
What are High Fall Risk precautions for the entire patient stay?
This type of assessment is used to document the patient's ability to move and transfer and determine what safe patient handling equipment should be used to mobilize them.
What is the Nursing Mobility Assessment?
Doing this on a regular basis throughout the shift may help reduce the incidence of patient falls.
What is purposeful hourly rounding?