Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Falls and Fall Risk" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details.
Does the patient have a history of falls?
A history of falls is a strong predictor of future falls. Review the patient's record for evidence of previous falls. Ask the patient and the patient's caregiver or family if the patient has a history of falling. A history of one or more recent falls, for any reason, within 6 months should be listed as a problem in the patient's record. The potential for further falling should be addressed in the patient's care plan, either separately or in conjunction with care plans related to other risk factors associated with increased fall risk.
Is the patient at risk of falling?
Many risk factors are associated with falls (see Table 1 in the original guideline document). Multiple factors are often involved in a given patient. Some classes of medications impair alertness and balance or cause orthostatic hypotension (see Table 2 in the original guideline document).
Document risk factors for falling in the patient’s record and discuss the patient's fall risk in care conferences. Table 3 in the original guideline document lists items that may need to be reviewed when assessing a patient's fall risk, including the following risk categories:
- Fall history
- Underlying conditions
- Functional status
- Neurological status
- Psychological factors
- Environmental factors
Has the patient just fallen?
Provide staff with a clear, written procedure that describes what to do when a patient falls. When a patient has just fallen or is found on the floor without a witness to the fall, a nurse should record vital signs and evaluate the patient for possible injuries to the head, neck, spine, and extremities. If there is evidence of a significant injury, such as a fracture or bleeding, provide appropriate first aid, notify the practitioner and family, and get emergency assistance if necessary.
Transfer of the patient to a hospital emergency room is appropriate if he or she exhibits the following injuries or signs after a fall:
- Uncontrolled bleeding
- Major fracture or fracture likely to require surgical intervention
- Deformity of limbs
- Acute change in neurological status or cognition (see Table 4 in the original guideline document)
Evaluate the factors associated with the fall.
It is insufficient to say simply that a patient has a "fall risk" or a "problem with falling." After an observed or probable fall, or after a fall risk has been identified, a more detailed analysis of the patient's falling or fall risk should take place.
Identifying the Causes of a Fall
Identifying and correcting the causes of falls can often reduce the risk of falling. For patients who have recurrent falls, continue to collect and evaluate information until either (1) the cause of the falling is identified or (2) it is determined that the cause cannot be found or that finding a cause would not change the outcome or the patient's management. If possible, document how it was concluded that certain factors contributed to or caused falling whereas others were not relevant. No further evaluation may be necessary if the fall is clearly the result of an obvious extrinsic factor that can be corrected.
Performing a Post-Fall Evaluation
After a fall, obtain relevant history regarding the circumstances (see Table 5 in the original guideline document). The patient's current medications, especially any recent changes, should also be reviewed. A postural blood pressure and pulse should be obtained along with a gait and balance evaluation. (Box 1 in the original guideline describes the steps for assessing for orthostatic hypotension.)
Identify the patient's actual and potential complications of falls.
Some falls may result in significant complications (see Table 7 in the original guideline document). It is important to define complications of falls and significant potential complications of falling for each patient. For example, different types of falls carry different risks of injury. Direction of falling affects risk—there is an increased risk of fracture if the resident falls sideways. Energy and speed of the fall also increase the risk of injury. Posterolateral falls carry the highest risk of hip injury.
Develop a plan for managing falls and fall risks.
Care goals should include prevention of falls when possible, a decrease in the number of falls, and a decrease in the risk and severity of injury. It is unrealistic to expect to eliminate all falls, but an appropriate goal for many patients may be to reduce the number of falls and the risk of injury. The management of falls and fall risk may involve one or several measures.
Manage the cause(s) of falling.
Managing falls can be complicated because many falls result not from a single cause but from the interaction of several factors. Successful fall management uses a systematic approach that may require repeated reassessment and adjustment.
Cause-specific interventions are only sometimes available and effective. At other times, the best that can be done is to try various interventions until falling is reduced or stops or until an uncorrectable reason is identified for its continuation.
Refer to the original guideline document for suggested interventions for:
- Falls caused by disturbances of gait or balance
- Falls caused by orthostatic hypotension
- Falls associated with medications
- Falls associated with specific conditions (vitamin D deficiency, anemia, urinary incontinence, diabetes)
Implement relevant general measures to address falling and fall risks.
Various generic approaches (i.e., those that are not directed at specific causes) can have an impact on the prevention and management of falls (see table below). Coordinate clinical initiatives to prevent and manage falls with initiatives of the interdisciplinary team (IDT) and facility safety committee, reviews of falls by the quality improvement committee, and efforts to ensure a safe environment for wanderers.
|Table. Examples of Facility Approaches to Try to Reduce Falls or Consequences of Falls
- Activities program
- Function-focused care philosophies (e.g., restorative care, exercise programs)
- Patient education about safe sitting and standing
- Program to help patients and families cope with and adapt to nonmodifiable risk factors for falling
- Programs for patients who wander
- Reduction in the use of physical restraints
- Rehabilitation program (e.g., balance training, strengthening, gait training, assistive devices)
- Staff education about fall risks and potentially helpful interventions
- Toileting and continence programs or a timed voiding schedule
- Hip protectors
Monitor falling in patients with a fall risk or fall history.
Monitor and document the patient’s response to interventions intended to reduce falling or the risk of falling. It may be helpful for the pharmacy consultant to conduct a medication review after a fall to evaluate and rule out any medication risk factors. If interventions have been successful in preventing falling, continue with current approaches or reconsider whether those measures are still needed if the problem that required the intervention (e.g., dizziness, joint pain) has resolved or been corrected.
If the patient continues to fall, re-evaluate the situation and reconsider current interventions. Amend the care plan as necessary to reflect the addition of new interventions and the need for continued monitoring. Document the presence of irreversible risk factors. Also, consider relevant interventions to try to minimize fall-related injuries (e.g., using hip protectors, treating osteoporosis).
If falls continue despite initial interventions, the reason could be that different or additional causes exist, the underlying causes are not readily correctable, the cause cannot be identified, or the interventions are insufficient. Consider other possible reasons for the patient's falling besides those that have already been identified, or document why a further search for causes is unlikely to be helpful.
Establish quality improvement activities related to fall risk and falling.
Include analysis of falls in the facility's quality improvement studies. Track accidents and falls by (at a minimum) time, location, and identified categories of causes. The total number of falls will fluctuate from month to month.
Evaluate the process associated with fall prevention or interventions that are implemented; interventions need to be implemented as intended in order for them to be optimally effective. Indicators that fall prevention processes and interventions are being implemented might include evidence that post-fall assessment of patients is completed and identified causes have been addressed (e.g., removal or replacement of unsafe assistive devices, discontinuation of medications that cause orthostatic hypotension) and that patients are participating in a muscle-strengthening exercise class. Relate these data to care processes to ensure that everything reasonable is being done to identify risk factors for falling and take appropriate preventive measures (see "Performance Measures" in the original guideline document). Table 10 in the original guideline document lists additional sample performance measurement indicators.
The medical director can play a pivotal role in fall prevention and management, including:
- Setting the expectation of all facility staff that fall risk assessment and fall prevention are facility priorities as they relate to both patient safety and facility liability
- Helping to develop and use appropriate policies and procedures on falls and fall risk
- Providing education and information about potential medical causes of falling
- Ensuring appropriate and timely practitioner assessment and intervention when medications or medical conditions may be causing or contributing to falls when falls occur