Risk Assessment
Morse Fall Scale: history of falls, secondary diagnosis, ambulatory aid, IV therapy, gait, mental status. Score >=45 = high risk. Other tools: Hendrich II, Hester Davis. Assess on admission, after fall, with change in condition, at discharge. Risk factors: age >65, confusion, weakness, orthostatic hypotension, frequent toileting, medications (sedatives, diuretics, antihypertensives), sensory deficits, environmental hazards.
Intervention Bundle
High risk: yellow wristband, fall risk sign, bed alarm, low bed, mats, non-skid socks, hourly rounding. Toileting schedule. Keep call light within reach, personal items within reach. Keep bed in low position, wheels locked. Room near nursing station. Encourage use of call light before getting up. Family at bedside if possible. Review medications. Physical therapy consult. proper footwear.
Post-Fall Protocol
Assess for injury (head, spine, hip, extremities). Neuro checks if on anticoagulants or head strike (x24h). Vital signs. Notify provider. Do not move if suspected spinal injury. File incident report. Analyze: what happened, why, what can be changed. Update care plan. Reassess fall risk. Implement new interventions. Document: circumstances, assessment, interventions, notifications, patient/family education.
Important Notes
- Patients on anticoagulants who fall need neuro checks for 24 hours even if asymptomatic — intracranial bleeding can be delayed.
- Post-fall huddle: analyze contributing factors and implement targeted interventions — prevents recurrence.
Clinical Tips
- Hourly rounding (especially toileting) reduces falls by 50% — anticipate needs before patient gets up.
- Low beds and floor mats reduce injury from falls — use for high-risk patients.
Summary
Fall prevention requires risk assessment (Morse Scale), targeted interventions (alarms, hourly rounding, low beds), and post-fall analysis with neuro monitoring for anticoagulated patients.
