Supplement-Interdisciplinary Fall Risk Prevention Policy and Procedure

Spaulding Rehabilitation Hospital (SRH) and Spaulding Rehabilitation Hospital Transitional Care Unit (TCU)

I. Standard:

The potential for falls and for patient/resident is minimized.

II. Purpose:

SRH has a system in which patients/residents are kept from harm within the hospital and TCU environment. SRH staff identifies patients/residents at risk for falls and takes appropriate interventions to provide a safe environment.

III. Policy:

SRH staff will maximize patient/resident safety and minimize patient/resident injury related to falls.

A. Patient/resident fall prevention is the responsibility of all hospital and TCU employees.

B. Patients/residents are oriented to the environment as part of the admission process. Particular attention is given to the location of the bathroom and the nurse call system.

C. The Fall Risk Assessment Tool (FRAT) is utilized upon admission to determine if a patient is at risk for falls.

1. Nursing within eight hours of admission completes the FRAT. The nurse utilizes data collected on the FRAT and clinical judgment to determine if a patient is at risk for falls. Each patient's fall risk is reassessed every week, or with any change in risk factors, or after an actual fall.

2. Nursing will complete the care plan on back of FRAT within 24 hours. The care plan must be completed for all patients regardless of level of risk.

3. Therapists review FRAT and "Risk for Injury" care plan. The care plan may be revised at any point with input from other disciplines.

D. Patient safety issues are discussed at the patient care conference (PCC).

E. All staff are responsible for implementing and reinforcing fall prevention strategies.

F. Post-Fall Procedures:

1. The staff person who observes or discovers a patient who falls, calls for help and:

a. A licensed nurse or a physician assesses for injury and sees that the patient is returned safely to the bed or chair if not contraindicated.

b. Notifies the primary/assigned nurse.

c. Completes an incident report and submits it to the nurse manager/shift supervisor.

d. Documents the fall in his/her respective progress note section of the medical record or, if not a direct caregiver, documents in the physician progress note section of the chart.

e. Writes the patient's name in red on the main schedule board followed by the date of the fall and the date of each subsequent fall.

2. After the fall, the primary/assigned nurse, nurse manager, or shift supervisor assesses the patient for any injuries.

a. Any fall that results in the patient striking his/her head will be reported immediately to the attending physician or house officer.

b. If no injuries are noted and vital signs are stable, the attending physician is notified as soon as he/she is available.

c. If an injury has been sustained, the attending physician is notified; if he/she is not available, the house officer is called to see the patient (certain types of injuries do require interventions as per Patient Care Policy #1.0.8).

3. After ensuring appropriate follow-up post-fall, the primary care nurse or designee utilizes the FRAT to reassess the patient's current risk for falls.

4. All team members are responsible for becoming familiar with the circumstances under which the patient fell and for coordinating treatment interventions to prevent further falls.

5. The primary nurse or designee presents the facts of the incident during the PCC and the patient's current risk for falls. The team discusses the action taken and determines if additional preventative measures are necessary to further reduce the risk of falls.

IV. Documentation:

A. Nursing admission assessment including patient orientation, FRAT, nursing standard care plan "Risk for Injury" with appropriate interventions.

B. Each therapy evaluation identifies discipline specific issues related to fall prevention.

C. Each discipline is responsible for documenting safety information (e.g. level of assistance patient requires) on the information board in the patient's room and in the medical record. Specifically, occupational therapy documents status of toilet transfers, and physical therapy documents weight-bearing status, bed-to-chair transfer status, and ambulation status. Speech and occupational therapy post the feeding and swallowing form at the bedside. Nursing documents restraint orders in the Cardex and the medical record.

V. Patient Teaching:

A. Orient to room and ensure patient has an appropriate call light at all times.

B. Explain the use of side rails.

C. Educate patient/family about patient level of risk and fall prevention plan.

VI. Outcome Criteria:

A. Patient/resident remains free from fall and related injury.

B. Patient/resident family verbalizes understanding of fall prevention program.

Source: Spaulding Rehabilitation Hospital, Quality Management Department, Boston.