This is an important part of maintaining safe and quality services for the client. Despite our best efforts, clients will nonetheless fall. Some may even sustain an injury. It outlines the root causes of falls and the factors contributing to them. This process outlines your role and responsibilities when a client falls.
What constitutes a fall incident?
A widely accepted definition is “an unplanned descent to the floor with or without injury to the client”. The nursing diagnosis for risk of falls is “increased susceptibility to falling that may cause physical harm". Some falls are recorded as hazards as the client was not injured. Perhaps they had poor balance on standing or stumbled on the carpet when mobilising. Other falls are recorded as an 'incident' because they caused minor or major injuries. The increase of stumbling, poor balance, or falls must be shift noted, and you may be required to complete a hazard or incident report. Whether the client experiences a fall event or an incident, their mobility confidence is eroded.
The risk factors that correlate with falls-risk clients are:
balance problems
dizziness or vertigo
Medical conditions, e.g., dehydration, diabetes, hypotension, MND, MS, cerebral palsy, Parkinson's disease, Spinocerebellar Ataxia, recent surgery, etc.
medication and drug reactions
falls history
fractures
walking or mobility problems
improper footwear
vision impairment
uneven surfaces
obstacles in walk areas in the home
pets in the home
Older people who fall suffer moderate to severe injuries such as bruises, hip and arm fractures, or head trauma. Severe fractures have been related to an increased risk of death. Falls of older people account for 25% of deaths one year after a severe fall; see related items, references and our Falls Management policy.
What are universal fall precautions?
Universal fall precautions are called "universal" because they apply to all clients regardless of fall risk. Universal fall precautions revolve around keeping the client's environment safe and comfortable. Although the choice of which precautions to emphasize may vary from client to client, a good starting list adapted from the Institute for Clinical Systems Improvement guideline is provided here:
Maintain call device within reach, i.e., battery-operated doorbell/ or handbell.
Keep the client's personal possessions within their safe reach, especially their vision glasses and hearing aids.
Familiarize the client with where you have placed objects in their environment.
Have sturdy handrails in client bathrooms.
If there is a hospital bed, place it in a low position when a client is resting; raise the bed to a comfortable height when the client is transferring in and out of bed.
Keep hospital bed brakes locked.
Keep wheelchair wheel locks in the "locked" position when stationary.
Keep nonslip, comfortable, well-fitting footwear on the client.
Use night lights or supplemental lighting.
Keep floor surfaces clean and dry. Clean up all spills promptly.
Keep client care areas uncluttered.
Follow safe manual handling practices
Separate the client and pets during mobilisations.
Research shows that increasing balance and strength in lower limbs helps to prevent falls in people over 65 years of age.
Our Processes
What is a Falls Risk Plan?
A fall prevention program is developed by a physiotherapist or an occupational therapist following fall risk assessments and considering specific factors related to the client. The fall risk assessment scores influence the Falls Risk Plan, which aims to reduce the incidence and severity of falls among older people and/or those with disabilities.
Each client has a unique risk profile that is individualized to fit the client's needs and is integrated into the care instructions to ensure the continuity of support by all staff members.
The client's care instructions indicate specific support actions that should or should not, be performed.
A Falls Risk Plan is an active document updated regularly by a physiotherapist or occupational therapist, stored in the client's basecamp project>assessments folder and linked to the Care Instructions.
Support workers to read and follow the support strategies identified in the Falls Risk Plan.
The CCM completes and maintains the Work Health & Safety document.
A review of a Falls Risk Plan is completed after a client falls or experiences a significant change in their health or medical condition.
What is contained in Falls Risk Plan?
Many interventions are available to prevent falls and fall-related injuries that you can implement based on the client's specific risk factors. Each risk factor should have a corresponding plan for fall prevention. Below are some of the major risk factors that should be considered in the client's fall prevention program.
Our Responsibilities related to risk factors.
Altered Mental Status
Some clients with dementia experience delirium, a disturbed state of mind or consciousness, especially an acute, transient condition associated with infections, fever, electrolyte imbalances, or a medication side effect. It is characterized by confusion, disorientation, agitation, and hallucinations. Delirium can cause people to leave their bed or chair when the support worker leaves the room; they may wander or refuse care services. Their agitation and delirium may cause a fall, especially if they have impaired mobility.
Support workers must ensure they attend to the client when mobilising.
Impaired Gait or Mobility
Clients with impaired gait or mobility will always need assistance with mobility. All clients with impaired gait or mobility should have mobility equipment, such as canes or walkers, at the bedside or chair and within safe reach.
Even with this equipment, clients will need help from staff for transfers to the bathroom, between furniture and when mobilising in and around the home, or the community.
Frequent Toileting Needs
Clients with frequent toileting needs will require support to use the bathroom.
Support workers should regularly take the client to the toilet using their mobility equipment.
Visual Impairment Clients with visual impairment should have their corrective lenses easily within reach.
Support workers to ensure the client has access to their glasses at all times, particularly when mobilising.
High-Risk Medications Falls often occur due to multiple risks, making it difficult to identify a "smoking gun." For example, a new medication may interact with a client's underlying cognitive or mobility limitations to precipitate a fall, or the polypharmacy of several medications may have a cumulative effect on the client.
Clients on high-risk medications, such as psychotropic medications that cause orthostatic hypotension or polypharmacy (multiple medications), should have their medications reviewed by a pharmacist with fall risk in mind. If a pharmacist is not immediately available, the treating doctor should review the medication. The medication review may sometimes indicate that the client needs to stay on a medication that increases the risk of falls because the benefits outweigh the risks. Still, the important point is that fall risk was considered.
The CCM can recommend discontinuation, substitution, or dose adjustment to the treating provider.
The CCM completes care instructions and reporting guidance that identifies what and when the client's vital sign measurements will be taken and where they will be recorded.
The support worker takes regular measurements of the client's vital signs.
The support worker provides supervision and support during transfers and mobilisation.
Finally, the CCM should alert and educate the client, and the client's family about fall risks and steps to prevent falls when taking these medications.
Frequent Falls and Incident Reports Clients with frequent falls should have their injury risk assessed. This assessment should include checking for a history of osteoporosis, including prior low-trauma fractures or osteoporosis noted on a bone mineral density test. Although the effects are long-term, treatment for osteoporosis should be considered if the patient is not already on treatment. Also, the client's physical environment should be reviewed to reduce the risk of injury (e.g., making sure the client's bed is set low when resting in bed).
Completing incident reports fully and in detail is important for these reasons:
Communication is critical for the safety of our clients, and incident reports help us discover new risk factors for our clients.
It provides a post-fall clinical review, which is useful for the CCM, physiotherapist or occupational therapist.
Falls can be unwitnessed, and the client may be unable to provide accurate information about what occurred, so look around the environment where the fall occurred and describe it in detail.
It creates an understanding of the events surrounding a fall and a root cause analysis of the fall.
It can inform the care instructions and a fresh fall prevention plan for the client who fell,
and it provides information that may help prevent the next fall in this client or future clients.
It provides ongoing guidance to continuous improvement efforts for the company in quality client care.
What to do if a client falls?
Stay with the client and call for help if someone else is there with you.
If you are alone with the client, follow this process;
Check the client's breathing, pulse, and blood pressure.
If the client is unconscious, not breathing, or has no pulse, call an ambulance 000 and start CPR if there is no DNR - (do not resuscitate).
If the client is conscious and unsure if they are injured, systematically ask the client to move their body parts and then carefully assess the client for any injuries, such as cuts, scrapes, bruises, and potential broken bones. If you can see the client is injured, complete Step 4 above and Step 7 below.
If the client is conscious and complains of acute pain, complete Step 4 above, and Step 7 below.
As soon as possible, verbally notify the CCM of the fall emergency; if it is after office hours, call the 24/7 number -1800 717 590
Complete a hazard or an incident report as directed.
Conduct regular observations of the client as directed by the CCM.
Special Note: Whilst it is common practice to call an ambulance when a client falls, it is inappropriate to call an ambulance if the client states they are not injured and you have checked their ability to move their joints. The appropriate response in this instance is to use a fall recovery manoeuvre. You are NOT to lift the client; they must be capable of performing one of these techniques with verbal and light physical guidance from you. If a client cannot perform these manoeuvres and is confirmed as not injured, you can call 000 and ask for Fire and Rescue NSW. They would consider the person trapped in their home and needing assistance to get the person into a chair so they can mobilise to safety in emergency.
Verbally notify the CCM of the client's fall and your urgent 000 phone call to Fire and Rescue NSW; if it is after office hours, call the 24/7 number -1800 717 590
Complete a hazard or an incident report as directed.
How long after the fall does the pain start?
At first, the client may only be slightly bruised or shaken up, but pain and aches can occur later. In the following days and/or even after a week or two, they might start or continue to experience pain in their joints, knees, back or hips. They may complain of headaches and other symptoms. If the client complains of pain or other injury symptoms, record them in your shift notes and verbally request from the CCM additional medications to manage the client's symptoms.
Depending on the list of symptoms, the CCM will direct you to make an appointment with the client's GP for a physical evaluation. Follow the CCM's directions closely and record your actions in the shift notes and the additional medication signing sheet.