Managing Fall Prevention

1. Which fall risk assessment tool does the institution use — Morse Fall Scale, Hendrich II, or a proprietary tool? (Default: Morse Fall Scale)
2. Has the patient been assessed on admission and at every shift change? (Default: Per institutional protocol)
3. Does the patient have a fall history — any falls in the past 3 months (home or hospital)? (Default: Ask patient and review medical record)
4. What medications is the patient taking that increase fall risk — sedatives, opioids, antihypertensives, diuretics, psychotropics? (Default: Review MAR)
5. What is the patient's mobility status — ambulatory, requires assistance, bed-bound? (Default: Per PT/OT assessment and nursing evaluation)
6. Does the patient have cognitive impairment — delirium, dementia, confusion? (Default: Assess mental status; CAM screen for delirium)
7. Are there environmental hazards in the patient's room — wet floors, clutter, poor lighting, bed height? (Default: Nursing environmental assessment)
8. Has the patient had a previous fall during this admission? (Default: Check incident reports)

Documents to Request

• Admission fall risk assessment score (Morse or Hendrich II)
• Nursing shift assessments with fall risk scores
• Medication list flagged for fall-risk medications
• PT/OT mobility assessment and recommendations
• Incident reports for any falls during admission
• CAM (Confusion Assessment Method) screening results
• Prior hospitalization fall history
• Home fall risk assessment (if available)

Step 1: Calculate the Morse Fall Scale Score

The Morse Fall Scale (MFS) uses six variables:

Total score range: 0-125

Step 2: Alternative — Hendrich II Fall Risk Model

Score ≥ 5 = High risk

Step 3: Implement Tiered Interventions

Universal Precautions (All Patients)

• Bed in lowest position when unattended
• Wheels locked on bed and wheelchair
• Call bell within reach at all times
• Non-skid footwear for ambulation
• Adequate room lighting (nightlight at minimum)
• Personal belongings within reach
• Clutter-free path to bathroom
• Orientation to room and call bell on admission

Low-Risk Interventions (Morse 25-50)

All universal precautions PLUS:

• Yellow fall-risk wristband applied
• Fall risk sign posted at bedside
• Toileting schedule (offer assistance every 2 hours)
• Medication review for fall-risk drugs (see Step 4)
• Bed alarm activated when patient is in bed unattended
• Assistive device at bedside (if used at home)

High-Risk Interventions (Morse ≥ 51)

All low-risk interventions PLUS:

• 1:1 sitter or enhanced observation (consider before restraints)
• Room close to nursing station
• Hourly purposeful rounding (pain, position, potty, possessions)
• PT/OT consultation for safe mobility plan
• Chair alarm in addition to bed alarm
• Non-pharmacologic delirium prevention bundle (orientation board, glasses/hearing aids, sleep hygiene, early mobilization)
• Physician review of fall-risk medications with taper or discontinuation plan

Step 4: Medication Review for Fall Risk

Flag and review these high-risk medication classes:

Step 5: Post-Fall Protocol

If a fall occurs despite prevention measures:

1. Immediate assessment: Vital signs, neurological exam, pain assessment, injury inspection
2. Imaging: If head strike or altered mental status — CT head without contrast; if extremity pain — X-ray of affected area
3. Anticoagulation check: If patient is on anticoagulants — obtain CT head even without symptoms (delayed intracranial hemorrhage risk)
4. Incident report: Complete institutional incident/event report within 24 hours
5. Root cause analysis: Why did the fall occur despite interventions? What was the patient doing? Were interventions in place? Were alarms functioning?
6. Updated care plan: Reassess Morse score, escalate interventions, notify physician and family
7. Documentation: Time of fall, circumstances, injuries, interventions, notification of physician and family

Checkpoint B: Post-Draft Alignment (Mandatory)

After implementing fall prevention measures:

1. Is the fall risk score documented and current (reassessed per protocol)?
2. Are interventions appropriate for the score level and consistently implemented?
3. Have fall-risk medications been reviewed with a documented plan to minimize or eliminate?
4. Is the patient's room environment assessed and hazard-free?
5. Has the patient/family received fall prevention education?

Quality Audit

• Fall risk assessment completed on admission
• Fall risk reassessed every shift and with clinical status changes
• Morse Fall Scale (or equivalent) score accurately calculated
• Risk-appropriate interventions implemented (universal, low-risk, high-risk)
• Fall-risk wristband applied for at-risk patients
• Bed alarm activated for at-risk patients when unattended
• Fall-risk medications reviewed and minimized
• Orthostatic vital signs checked for patients on antihypertensives/diuretics
• PT/OT consultation ordered for high-risk patients
• Patient/family education documented
• Hourly rounding implemented for high-risk patients
• Post-fall protocol followed for any fall event (assessment, imaging, incident report)
• Room environment assessed for hazards (clutter, lighting, wet floors)
• Restraint use is a last resort with documented justification and time-limited orders

Guidelines

• Fall risk assessment must be repeated every shift and with any change in clinical status (new medication, procedure, delirium onset)
• Bed alarms are an adjunct, not a replacement for nursing assessment — they alert, but do not prevent falls
• Restraints are the last resort and require specific physician orders with time limits and regular reassessment — restraints themselves increase injury risk
• The most effective fall prevention intervention is toileting assistance — most falls occur on the way to or from the bathroom
• Encourage early mobility with appropriate assistance rather than restricting activity — immobility increases deconditioning and long-term fall risk
• Avoid diphenhydramine (Benadryl) as a sleep aid in elderly patients — it is on the Beers Criteria list and significantly increases fall and delirium risk
• Post-fall CT head is mandatory for patients on anticoagulants, even if the patient denies head strike — subdural hematoma can be delayed
• Document fall prevention education with patient and family, including the patient's understanding of their own fall risk and what to do before getting up