FALL PREVENTION

PROGRAM

Dr. Fathi Mohamed Ali

TQM,AUC - CPHQ
 LECTURE OBJECTIVES
At the end of this lecture the
participants will be able to:

1. Know the policies and procedures

regarding Prevention & Management
of Fall.
2. Ensure the implementation of these
policies and procedures in their
wards/units.
3. Be proficient with the use of the new
fall risk assessment forms.
4. Improve the standards of practice
and nursing care particularly in fall,
thereby promoting quality and
patient safety.
Alert Codes
 JC I A Standards for Hospitals
7th Edition | Effective 1 January 2021
Intent of IPSG.6 and IPSG.6.1: Added information about high-risk areas for
falls and fall risk screening
Measurable Elements of IPSG.6
1. The hospital implements a process for assessing all inpatients for fall risk and uses
assessment tools/ methods appropriate for the patients being served.
2. The hospital implements a process for the reassessment of inpatients who may become at risk
for falls due to a change in condition or are already at risk for falls based on the documented
assessment.
3. Measures and/or interventions to reduce fall risk are implemented for those identified
inpatients, situations, and locations within the hospital assessed to be at risk. Patient
interventions are documented.
Measurable Elements of IPSG.6.1
4. The hospital implements a process for screening outpatients whose condition, diagnosis,
situation, or location may put them at risk for falls and uses screening tools/methods
appropriate for the patients being served.
5. When fall risk is identified from the screening process, measures and/or interventions are
implemented to reduce fall risk for those outpatients identified to be at risk, and the screening
and interventions are documented.
6. Measures and/or interventions to reduce fall risk are implemented in situations and locations
in the outpatient department(s) assessed to be a risk for falls.
 IPSG # 6
REDUCE THE RISK OF PATIENT
HARM RESULTING FROM FALLS
 DEFINITION
1. Fall = An unplanned descent to the floor (or extension of
the floor, e.g., trash can or other equipment) with or without
injury. All types of falls are included, whether they result
from physiological or environmental reasons (ANA-NDNQI =
American Nurses Association-National Database of Nursing Quality Indicators ).
• Fall = is defined as any unintentional positional change that
results in the patient coming to rest on the ground, floor, or
other lower surface. Those at highest risk are likely to have
other “geriatric syndromes,” such as depression, cognitive
impairment, polypharmacy, orthostatic hypotension, gait
abnormalities, sensory impairment, and social isolation
 DEFINITION

• All nursing home patients should be considered at high risk

for falls.
• Older hospitalized patients also should
undergo a fall risk evaluation with a fall
prevention plan as part of their discharge
care.
 DEFINITION
1. Causes of fall
2.1. Accidental Falls = Occur when patient fall unintentionally, for
example, they may trip, slip or fall because of equipment or by
environmental factors such as spilled water or urine on the
floor.
2.2. Unanticipated Physiologic Falls = Occur when physical cause of
fall is not reflected in the patient’s risk factors for fall. It can be
caused by physical conditions that cannot be predicted until
the patient falls. For example, the fall may be due to a fainting,
a seizure, or a pathologic fracture of hip.
2.3. Anticipated Physiologic Falls = Occurs in patients whose score
on risk assessment scale indicates that they are at risk for
falling, e.g. a prior fall, weak or impaired gait, use of a walking
aid, intravenous access, or impaired mental status.
 DEFINITION
3. Morse Fall Scale Assessment = Is a rapid
and simple method of assessing a patient’s
likelihood of falling. It consists of six
variables that are easy to score, and it has
been shown to have predictive validity and
reliability.
 FALL PREVENTION PROGRAM

Comprehensive Interdisciplinary Approach

FALL ASSESSMENT/REASSESSMENT

1. Fall Risk Assessment by the attending physician

within 12 hours of admission
2. Fall Risk Re-assessment by the attending physician
during fall incident or change in health status within
30 minutes
3. Fall Risk Assessment by the Staff Nurses within 1
hour upon patient entry to the unit/ward.
4. Fall Risk Re-assessment by the Staff Nurses within
30 minutes of fall incident or change in health
status.
ASSESSING/SCREENING OF FALL RISK
FACTORS
1. Intrinsic Risk Factors = Integral to the patient’s system.
Patient characteristics and general physical functioning
Patient diagnosis and/or physical changes
Medications and drug interactions
Mental condition/cognition and alcohol use

2. Extrinsic Risk Factors = external to the system and relating

to the physical environment.
Lighting levels that cause glare or limit visibility
Floor surfaces/treatments that promote
slips/trips/stumbling
Bed locks/brakes that are unlocked
 Morse Fall Risk Assessment Tool
INITIAL
ASSESSME REASSESSMENT
NT
VARIABLES SCALE
DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE

SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE
1. History of falling NO 0
YES 25
2. Secondary Diagnosis NO 0
YES 15
3. Ambulatory Aid 0
 None/bed rest/nurse
assist
 Crutches/cane/walker 15
 Furniture 30
4. IV or IV access NO 0
YES 20
5. Gait 0
5.1. Normal/bed
rest/wheelchair
5.2. Weak 10
5.3. Impaired 20
6. Mental Status 0
6.1. Oriented to own ability
6.2. Overestimates or
forgets 15
limitations

TOTAL SCORE

RISK LEVEL
NURSE’S NAME/SIGNATURE
 Morse Fall Risk Assessment Tool

RISK LEVEL SCORE ACTION

NO RISK 0 Implement Standard Fall Prevention

Interventions

LOW RISK 0 - 24 Implement Standard + Low Risk Fall

Prevention Interventions

MODERAT 25 - 44 Implement Standard + Low + Moderate

E RISK Risk Fall Prevention Interventions

HIGH RISK 45 AND Implement Standard + Low + Moderate

MORE + High Risk Fall Prevention Interventions
 FALL RISK ASSESSMENT GUIDELINES SUMMARY
VARIABLE SCALE SCORING INTERPRETATION

1. History of No 0 No history of fall.

falling
(immediate Yes 25 If the patient has fallen during the present hospital admission or if there was an
or within 3 immediate history of physiological falls, such as from seizures or an impaired gait
months) prior to admission.

2. Secondary No 0 Only one medical diagnosis.

Diagnosis Yes 15 If more than one medical diagnosis is listed on the patient’s chart.
3. Ambulatory 3.1. Bed rest/nurse 0 Walks without a walking aid (even is assisted by a nurse), uses a wheelchair, or is on
aid assist bed rest and does not get out of bed at all.
3.2. 15 If patient uses these aids to ambulate
Crutches/cane/walker

3.3. Furniture 30 If patient ambulates clutching onto the furniture for support.
4. IV/Heparin No 0 No IV inserted.
Lock Yes 20 Patient has an intravenous apparatus or a heparin lock inserted.
5. 5.1. Normal/bed 0 Walking with head erect, arms swinging freely at the side, and striding without
Gait/Transferr rest/immobile hesitation.
ing 5.2. Weak 10 The patient is stooped but is able to lift the head while walking without losing balance.
Steps are short and the patient may shuffle.
5.3. Impaired 20 The patient may have difficulty rising from the chair, attempting to get up by pushing
on the arms of the chair/or by bouncing. The patient’s head is down, and he or she
watches the ground. Because the patient’s balance is poor, the patient grasps onto the
furniture, a support person, or a walking aid for support and cannot walk without this
assistance.

6. Mental 6.1. Oriented to own 0 Ask the patient, “Are you able to go to the bathroom alone or do you need assistance?
Status ability If the patient’s reply judging his or her own ability is consistent with the ambulatory
order on the Kardex.

6.2. Forgets 15 If the patient’s response is not consistent with the nursing orders or if the patient’s
limitations response is unrealistic, then the patient is considered to overestimate his or her own
abilities.
 FALL POLICY
All patients in should be assessed for risk of falls regularly
and during the following situations:
1. On admission(ED-OPD)
2. In ED
3. In OPD
4. When a patient is transferred to another unit.
5. After a fall.
6. On a regular basis if indicated
Example: When a patient’s condition changes or there
has been a change in the patient’s medication
regimen that could put the patient at risk for
fall.
 FALL PROCEDURES
1. If the patient is discovered to be at high risk for fall
based on the risk assessment, daily monitoring
should be done until the high risk status will be
changed to no risk.

2. Implement Standard Fall Prevention Interventions

as a routine standard of care for all patients who are
not identified to be at low, moderate or high risk for
fall based on the fall risk assessment.
 FALL PROCEDURES
3. Inform all members of the healthcare team who have
direct patient contact when a patient is assessed to be at
moderate or high risk for falls with the use of flagging
using the designated color coding assigned for fall.
4. Yellow Fall Risk Tag will be posted in the following
locations:
4.1. Patient’s door tag
4.2. Patient’s file cover
4.3. At the head part of the patient’s bed
4.4. ID band with Fall Risk label
 FALL PROCEDURES

7. OVR should be accomplished/completed for

patients who will suffer from fall in any ward/unit.
ASSESSING/RE-ASSESSING PATIENT

INJURY

INJURY SEVERITY
 PATIENT INJURY ASSESSMENT

Injury status or severity of injury can be coded

according to a scale
0 None – No adverse result
1 Minor- Contusion, abrasion, small skin tear, or
laceration involving little or no care or observation
2 Moderate-Sprain, large or deep laceration, skin tear,
or minor contusion requiring medical and/or nursing
interventions
3 Significant- Fracture, loss of consciousness, change
in mental or physical status requiring medical
intervention and/or consultation
4 Mortality- Fall results in death
 STANDARD FALL
PREVENTION
INTERVENTIONS
= Are general guidelines applicable for all
patients to protect them from harm resulting
from falls and enhance patient safety.
Include but are not limited to:
1. Assessment
2. Education
3. Creation of a safe patient room environment
LEVEL/CATEGORY OF
RISK INTERVENTIONS

Low Risk Interventions

Moderate Risk Interventions

High Risk Interventions

 LOW FALL RISK INTERVENTIONS

= Are interventions designed to be implemented for patients

assessed to be at low risk for fall after performing the fall risk
assessment.
Include but are not limited to:
1. Implement the Standard Fall Prevention Interventions .
2. Verbally inform patient and family of fall prevention interventions.
3. Communicate the patient’s “at risk” status.
4. Collaborate with multidisciplinary team members in planning care.
5. Implement bowel and bladder program.
6. Discuss needs with patient.
7. Evaluate medications for potential side effects.
 MODERATE FALL RISK
INTERVENTIONS
= Are interventions designed to be implemented for patients discovered/assessed
to be at moderate risk for fall after performing the fall risk assessment.
Include but are not limited to the following:
1. Follows the Standard Fall Prevention including low risk Interventions as stated in the
policy.
2. Initiate fall risk communication system to alert all the staff involved in patient care.
3. Rectangular orange tag should be posted in all designated areas as stated in the
policy.
4. Re-orient confused patients if possible.
5. Assess patient’s bowel and bladder elimination needs and provide a plan of care to
address frequency, urgency, and incontinence.
6. Supervise elimination and provide assistance as needed.
7. Establish an individualized toileting plan as appropriate.
8. Provide a bedside commode, as appropriate.
9. Supervise and assist with personal hygiene, and consider use of a shower chair.
10. Encourage use of assistive devices and mobility aids.
 HIGH FALL RISK
INTERVENTIONS
= These interventions are designed to be implemented for patients
who are discovered to be at high risk for fall and with multiple fall risk
factors and those who have fallen. These interventions are designed to
reduce severity of injuries due to falls as well as to prevent falls from
reoccurring, supplementing standard fall prevention interventions.
Include but are not limited to the following:
1. Implement all Standard, Low and Moderate Fall Prevention
Interventions.
2. Remain with patient while toileting.
3. Consider moving the patient to a room with best visual access from the
nursing station.
4. Consider the use of bed alarms.
5. Consider a rehabilitation therapy consult.
6. Consider the use of patient observer (family or sitter)
 POST FALL MANAGEMENT
IMPORTANT POINTS:
1. Assess for injury and notify physician.
2. Obtain and record sitting/standing vital signs.
3. Use the Fall Risk Assessment Tool to reassess for change in patient’s risk
of fall.
4. Document circumstances in the patient’s medical record.
5. Complete the (OVR Form) and follow the procedure of Hospital Event
Reporting Program.
6. Fall Incidence Monitoring should be completed monthly by the Quality
Coordinators if there is a case of fall in their ward/unit to be submitted
to Nursing Patient Safety Department.
 SUMMARY

Identify risk factors

Communicate Risk Factors

Perform Fall Risk Interventions

Monitor Patients Regularly

Post Fall Management

POST FALL MANAGEMENT
 Measuring/Monitoring Fall Rates
• Measuring falls
– Patient fall rate
– Patient fall injury rate
• Calculation of rates
• Stratification approaches to analyze falls
• Comparison rates

STEP 6
 Calculating Fall Rates

• Fall Rate = Number of eligible falls X 1000

Number of eligible patient days

• Fall Injury Rate =Number of fall injuries X 1000

Number of eligible patient days
 CASE 1 SCENARIO
Khadra, 59 y.o. MRN 465758 was admitted in
FMW as a case of DKA with hypertension
and old MI. The watcher verbalized that the
patient suffered from fall at home 1 month
back and suffered a minor injury. Khadra is
restless during admission with impaired gait
and unable to respond comprehensively to
verbal stimuli. When patient was admitted
from ER, an IV line with heparin lock was in
place.

How will you know if the patient is at risk for

fall?
 FALL RISK ASSESSMENT
(MORSE FALL SCALE)
PATIENT NAME: Khadra Saed Mohd Sofiani MRN: 465758 Date: 1/3/1434

INITIAL
ASSESSMENT REASSESSMENT

VARIABLES SCALE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE

SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE
1. History of falling NO 0
YES 25 25
2. Secondary Diagnosis NO 0
YES 15 15
3. Ambulatory Aid 0
 None/bed rest/nurse assist

 Crutches/cane/walker 15 30
 Furniture 30

4. IV or IV access NO 0
YES 20 20
5. Gait 0
5.1. Normal/bed rest/wheelchair

5.2. Weak 10 20
5.3. Impaired 20

6. Mental Status 0
6.1. Oriented to own ability

6.2. Overestimates or forgets 15

limitations 15

TOTAL SCORE 125

RISK LEVEL High Risk

NURSE’S NAME/SIGNATURE CCK

 CASE 2 SCENARIO
Fatma, 56 y.o. MRN 231452 was admitted in
ICU as a case of RTA with Head Injury &
Fracture Femur. She was admitted
unconscious with Glasgow Coma Scale of 7
(comatose). Patient is a known case of
Hypertension and DM. In ER, an IV line was
inserted with Heparin Lock. Initial assessment
was done in ER.

When the patient was transferred to ICU, Staff

Nurse Molly received the case and started to
assess the patient for pressure ulcer and fall.
 FALL RISK ASSESSMENT
(MORSE FALL SCALE)
PATIENT NAME: Fatma Salem Saed Al Harthi MRN: 231452 Date: 1/3/1434

INITIAL
ASSESSMENT REASSESSMENT

VARIABLES SCALE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE

SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE
1. History of falling NO 0
YES 25
2. Secondary Diagnosis NO 0
YES 15
3. Ambulatory Aid 0
 None/bed rest/nurse assist

 Crutches/cane/walker 15
 Furniture 30

4. IV or IV access NO 0
YES 20
5. Gait 0
5.1. Normal/bed rest/wheelchair

5.2. Weak 10

5.3. Impaired 20

6. Mental Status 0
6.1. Oriented to own ability

6.2. Overestimates or forgets

limitations 15

TOTAL SCORE

RISK LEVEL

NURSE’S NAME/SIGNATURE
 Figure

The American Journal of Medicine 2007 120, 493.e1-493.e6DOI: (10.1016/j.amjmed.2006.07.022)

Copyright © 2007 Elsevier Inc. Terms and Conditions
Table 1 Medical Conditions Associated with Falls
Neurological disorders Stroke
Parkinsonism and other movement disorders
Gait disorders
Vestibular disorders
Dementia
Delirium

Musculoskeletal disorders Osteoarthritis

Joint deformities
Kyphosis
Muscle weakness
Podiatric conditions

Sensory abnormalities Visual impairment

Hearing impairment
Peripheral neuropathy

Cardiovascular disease Orthostatic hypotension

Sinoatrial dysfunction
Arrhythmias
Syncope

Chronic medical conditions Anemia

Diabetes mellitus
Lung disease
Sleep disorders
Depression

Medications See Table 2

Polypharmacy (≥4 medications)

Miscellaneous Conditions Alcohol Use

Recent hospitalization
Acute medical illness
Table 2 Medications Frequently Associated with Falls by Class

Class Specific Agents

Benzodiazepines Chlordiazepoxide, diazepam, alprazolam

Antidepressants Amitriptyline, nortriptyline, fluoxetine

Anitpsychotics Fluphenazine, chlorpromazine, haloperidol,

risperidone

Antiepileptics Phenytoin, phenobarbital

Anticholinergics Diphenhydramine, hyoscyamine, tolterodine,

oxybutynin

Sedative hypnotics All barbiturates, zolpidem, zaleplon

Muscle relaxants Cyclobenzaprine, metaxalone, methocarbamol

Cardiovascular medications Diuretics, doxazosin, terazosin, clonidine, digoxin

 Patient Fall Investigation Form
Ward/ Unit:
File no: Name: Age: Gender: ⃝ M ⃝ F Diagnosis:
Consultant in-charge:

Date of Fall: Time of Fall: ⃝AM ⃝ PM

Location: ⃝ Bedroom ⃝ Toilet ⃝ Corridor/Hallway ⃝ Diagnostic Area ⃝ Other
Type of Fall: ⃝ From Bed ⃝ From Chair ⃝ From Commode ⃝ Trapped in the bed rail
⃝ Near Fall ⃝ First Fall ⃝ Repeated Fall ⃝ From wheel chair ⃝ Baby Child dropped
Assisted: ⃝ Yes ⃝ No
Witnessed: ⃝ Yes ⃝ No The Patient Has a sitter: ⃝Yes ⃝ No
Witness/s Relationship: Sitter Around the Patient During the Fall:
⃝ Another Patient ⃝ Visitor ⃝ Staff ⃝Yes ⃝ No
⃝ Sitter

Fall Risk Assessment Before the Fall: ⃝ High Risk ⃝ Standard

Brief description of the Fall:

Activity at Time of Fall:

Was the patient using assisting device such : ⃝ High Risk ⃝ Standard
Harm Post Fall: Intervention Done by Physician:
Medication Received with the last 72 hours:
⃝ Antihypertensive ⃝ Antiseizure
⃝ Diuretics ⃝ Laxatives
⃝ Narcotics ⃝ Antipsychotics
⃝ Hypoglycemic ⃝ Antidepressants
⃝ Antihistamine ⃝ Cardiovascular

Patient/Sitter Received Falls Prevention Education on admission:

⃝ Yes ⃝ No
High Risk for Fall Signage is there: The Patient/Sitter Understands the Falls Signage:
⃝ Yes ⃝ No ⃝ Yes ⃝ No
Causes of Fall:

Recommendations:

Name of Investigator:
Date: Signature:
 MAHC 10 - Fall Risk Assessment Tool
Click here to review the Validation Study of the Missouri Alliance for Home Care’s fall risk assessment

Conduct a fall risk assessment on each patient at start of care and re-certification.

Patient Name: (Circle one) SOC or

Re-certification Date:

Required Core Elements

Assess one point for each core element “yes”. Points
Information may be gathered from medical record, assessment and if applicable, the patient/caregiver.
Beyond protocols listed below, scoring should be based on your clinical judgment.

Age 65+

Diagnosis (3 or more co-existing)

Includes only documented medical diagnosis
Prior history of falls within 3 months
An unintentional change in position resulting in coming to rest on the ground or at a lower level

Incontinence
Inability to make it to the bathroom or commode in timely manner
Includes frequency, urgency, and/or nocturia.
 MAHC 10 - Fall Risk Assessment Tool
Click here to review the Validation Study of the Missouri Alliance for Home Care’s fall risk assessment

Visual impairment
Includes but not limited to, macular degeneration, diabetic retinopathies, visual field
loss, age related changes, decline in visual acuity, accommodation, glare tolerance,
depth perception, and night vision or not wearing prescribed glasses or having the
correct prescription.

Impaired functional mobility

May include patients who need help with IADLS or ADLS or have gait or transfer
problems, arthritis, pain, fear of falling, foot problems, impaired sensation, impaired
coordination or improper use of assistive devices.

Environmental hazards
May include but not limited to, poor illumination, equipment tubing, inappropriate
footwear, pets, hard to reach items, floor surfaces that are uneven or cluttered, or
outdoor entry and exits.

Poly Pharmacy (4 or more prescriptions

– any type)
All PRESCRIPTIONS including prescriptions for OTC meds. Drugs highly
associated with fall risk include but not limited to, sedatives, anti-depressants,
tranquilizers, narcotics, antihypertensives, cardiac meds, corticosteroids, anti-
anxiety drugs, anticholinergic drugs, and hypoglycemic drugs.
OTC meds You can buy many medicines for minor problems at the store without a prescription (over-
the-counter).
 MAHC 10 - Fall Risk Assessment Tool
Click here to review the Validation Study of the Missouri Alliance for Home Care’s fall risk assessment

Pain affecting level of function

Pain often affects an individual’s desire or ability to move or pain can be a factor in
depression or compliance with safety recommendations.

Cognitive impairment
Could include patients with dementia, Alzheimer’s or stroke patients or patients
who are confused, use poor judgment, have decreased comprehension,
impulsivity, memory deficits. Consider patients ability to adhere to the plan of
care.

A score of 4 or more is considered at risk for falling

Total
Clinician’s signature
 Patient Fall Investigation Form
Ward/ Unit:
File no: Name:
Age: Gender: ⃝ M ⃝ F Diagnosis:
Consultant in-charge:

Date of Fall: Time of Fall: ⃝AM ⃝ PM

Location:⃝ Bedroom ⃝ Toilet ⃝ Corridor/Hallway ⃝ Diagnostic Area ⃝ Other
Type of Fall: ⃝ From Bed ⃝ From Chair ⃝ From Commode ⃝ Trapped in the bed rail
⃝ Near Fall ⃝ First Fall ⃝ Repeated Fall ⃝ From wheel chair ⃝ Baby Child dropped
Assisted: ⃝ Yes ⃝ No
Witnessed: ⃝ Yes ⃝ No The Patient Has a sitter: ⃝Yes ⃝ No
Witness/s Relationship: Sitter Around the Patient During the Fall:
⃝ Another Patient ⃝ Visitor ⃝ Staff ⃝Yes ⃝ No
⃝ Sitter

Fall Risk Assessment Before the Fall: ⃝ High Risk ⃝ Standard

Brief description of the Fall:
Activity at Time of Fall:
Was the patient using assisting device such : ⃝ High Risk ⃝ Standard
Harm Post Fall: Intervention Done by Physician:
 Patient Fall Investigation Form
Ward/ Unit:
Medication Received within the last 72 hours:
⃝ Antihypertensive ⃝ Antiseizure
⃝ Diuretics ⃝ Laxatives
⃝ Narcotics ⃝ Antipsychotics
⃝ Hypoglycemic ⃝ Antidepressants
⃝ Antihistamine ⃝ Cardiovascular

Patient/Sitter Received Falls Prevention Education on admission: ⃝ Yes ⃝ No

High Risk for Fall Signage is there: The Patient/Sitter Understands the Falls
⃝ Yes ⃝ No Signage: ⃝ Yes ⃝ No
Causes of Fall:

Recommendations:

Name of Investigator:
Date: Signature:
THANK YOU!