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ditor’s note: The first part of this article, covering the first 3 steps of a post-fall assessment, appeared in the May ECPN and can be accessed at www.extendedcarenews.com/article/5626.

Step 4: Assess the Environment

       Check for and modify any environmental factors or hazards that may have contributed to the fall. This assessment should focus on both the location of the fall and activity the resident was undertaking at the time. For example, if the resident fell out of bed while transferring, inspect the bed and surrounding area. If the patient fell from his or her wheelchair, inspect the chair. If the patient fell while using his or her walker, inspect it for problems, and so on. Examples of environmental hazards to examine include:
• Lighting (dim, night lights working?)
• Flooring (wet or slippery, cluttered?)
• Footwear (slippery?)
• Cane/walker (appropriate use and fit and good working condition?)
• Wheelchair (appropriate use and fit and working condition, especially the brakes?)
• Bathroom grab bars (present and appropriate use?)
• Bed (height appropriate, wheels locked?)
• Call light (within reach?).

Step 5: Assess Risk for Future Falls

       If the resident was at risk before the fall, reassess his or her risk to see if he or she has any new risk factors that may have contributed to the fall. If the resident was not at a risk for fall prior to falling, assess his or her risk to identify the presence of risk factors. When assessing the resident’s status of fall risk, it is important to consider the following:
• Has the resident’s medication regime changed?
• Has the resident’s physical and/or mental status changed?
• Has the resident’s coordination and balance changed?
• Has the resident’s mobility changed?

Step 6: Analyze the Fall and Create a Post-Fall Action Plan

       One of the goals of post-fall assessment is to decide which urgent interventions need to be put in place to reduce the probability of another fall. Using the information obtained from steps 2–5, staff should try to determine probable causes or reasons for the fall and which interventions can have an immediate benefit in preventing recurrence. For example, if a resident’s fall occurred from bed and he or she is acutely confused, the use of a low bed, bed exit alarm and/or one-to-one supervision to guard against unsafe bed exits, and physician referral to evaluate the underlying cause(s) of confusion should occur.
       If a resident fell out of his or her wheelchair while attempting to transfer and the cause of the fall is due to faulty chair brakes, either a quick fix of the brakes or a working replacement chair for the resident may be an appropriate strategy. If a resident fell while he or she was hurrying to reach the bathroom in the middle of the night, a bedside commode or assisted toileting can be considered. When thinking about the precipitating factors of a resident’s fall and which interventions to apply, always consider the resident’s health conditions (eg, diseases, mental status, medications, and functional or mobility status), the specific activity the resident was engaged in at the time (eg, walking, transferring, reaching for something, hurrying, etc.), and any contributing environmental and equipment factors.

Step 7: Complete an Incident Report

       Every time a resident falls, staff is required to complete a fall investigation or incident report. The purpose of an incident report is to communicate the causes or factors responsible for the resident’s fall and immediate plan of action (ie, steps 2–6 of the post-fall assessment). This information can then be used to determine whether additional or modified care plan interventions are needed when the resident’s care plan is reviewed. To ensure that all details of the fall and subsequent assessments are captured, the incident report should include the circumstances of the fall or fall history and the results of the environmental, fall-risk, and mobility assessments as well as the post-fall action plan.

Step 8: Communicate Risk Status

       It is crucial for everyone involved in the resident’s care (eg, nurses, nursing assistants, occupational and physical therapists, physicians, other relevant staff members and family members, as appropriate) to be aware that the resident has fallen and is at risk of falling again. It is also important to communicate any changes in the resident’s fall-risk status and which strategies have been put in place to reduce falls. Post-fall communication of risk can be achieved by means of:
• Visibly identifying at-risk residents (eg, a colorful identification wristband and/or sticker affixed by the resident’s room, above the bed, and to his or her ambulation device). In this way, everyone in the facility knows that residents wearing a colored wristband, for example, are “at risk of falling” or have “potential for injury”
• Utilizing daily shift reports that indicate the resident’s risk factors, ambulatory status, and care plans.

Step 9: Review the Plan of Care

       Soon after the fall, the resident’s interdisciplinary team members should meet and review the individual’s care plan and implement appropriate fall and injury-prevention strategies as needed. Since falls are often due to multiple factors, it is crucial for the entire interdisciplinary team (eg, physicians, nurses, therapists, etc.) to be involved in the process. Sometimes, depending on whether external factors contributed to the fall, housekeeping and maintenance staff may be involved as well.

Step 10: Monitor Post-Fall Activity

       Finally, observing the resident for several days after a fall is helpful in detecting:
• Any change in the resident’s condition that might precipitate another fall
• Any change in the resident’s gait, balance, and/or transfer abilities that may indicate a new health problem and/or a potential problem with his or her surrounding environment
• Any distress or post-fall injuries that might occur (ie, in the days following a fall, delayed appearance of fracture or injury is common).

Monitoring Tip

       Having an insufficient number of nurses and aides available to watch over and anticipate the needs of residents at fall risk during the hours and days following a fall can undermine the best of plans to prevent falls. One solution to help monitor residents after a fall is to utilize a bed and/or chair exit alarm (ie, devices designed to warn nurses that patients who should not be getting up unassisted are doing so).

Summary

       A fall is one of the most important risk factors for future falls (ie, once a resident has a fall, it often leads to more falls). A comprehensive post-fall assessment can be extremely valuable in identifying treatable causes of falls and reducing the risk of subsequent falls (ie, the timely correction of precipitating and predisposing factors will help prevent further falls).

       For more fall-related information, visit www.fallsaver.net. The website of FallSaver, a new device shown in clinical trials to significantly reduce falls and related injuries, maintains a library of informative articles.