On This Page
- Falls Management Program Case Study
- Discussion Guide for Inservice #1
- Discussion Guide for Inservice #2
- Illustration of Fall Response
Falls Management Program Case Study
Mrs. P is a 93 year old white female admitted to your facility. She has had Alzheimer's disease for approximately 7 years and has been cared for by her husband and daughter at home. Her other past medical problems include: diabetes mellitus, hypertension, osteoarthritis, depression and a history of falls. Over the past several months, her family has found it increasingly difficult to care for her at home due to worsening agitation and insomnia.
Mrs. P has been at your facility for 3 days and has slept only 3 hours per night. She is extremely restless and anxious and often cries out for her husband. She constantly wants to get up from her chair or bed. Mrs. P was found on the floor by staff at 8 pm and apparently had fallen onto her buttocks; no injuries were found. Mrs. P was assisted to bed for the night. A waist restraint was placed on her and all four side rails were positioned in the upright position.
Later that evening Mrs. P was found on the floor. Her undergarments were soiled and she continued to cry out for her husband. She was assessed to have no injuries resulting from the fall. The nurse obtained an order for a sedative from the physician and Ativan 1.0 mg was given at 1 am. She was put back to bed and finally went to sleep for the night.
Discussion Guide for Inservice #1
What are Mrs. P's known fall risk factors?
Environment/equipment (extrinsic factors)
- New admission—unfamiliar surroundings.
- Physical restraint—increases risk of serious injury.
- Full side rails—increase risk of serious injury.
Medical conditions (intrinsic factors)
- History of falls at home.
- Trying to stand, transfer or walk alone unsafely.
- Tries to climb over bed rails or get out of bed alone unsafely.
What are possible fall risk factors that need further evaluation?
- Visual impairment due to aging and diabetes.
- Hypoglycemia/hyperglycemia resulting from diabetes.
- Loss of sensation in feet due to diabetic neuropathy.
- Pain, contractures or decreased ROM resulting from osteoarthritis.
- Urinary urgency and/or frequency.
- Additional gait and mobility problems.
- Postural hypotension as a result of cardiovascular medications.
- Side effects of antidepressants.
- Side effects of sedative/hypnotics.
- Possible systemic illness.
- Unlocked bed wheels or unstable furniture.
Discussion Guide for Inservice #2
What interventions to reduce Mrs. P's fall risk are important to consider?
Environmental and equipment
___ reduce clutter, keep clear pathways.
___ provide adequate lighting at night.
___ add labels/pictures to help her locate the bathroom and her room.
___ provide frequent reassurance and orientation to facility.
___ use hip protectors
Gait and mobility
___ screen resident's ability to transfer and ambulate safely to determine level of staff assistance needed and if further evaluation is necessary.
___ based on screen, order an evaluation by OT/PT.
___ ask primary care provider to review all medications, their possible interactions and side effects.
___ ask consultant pharmacist to review medications.
___ implement sleep hygiene measures immediately (no caffeine after 4 pm, limit daytime napping, provide comfort measures at bedtime, offer food or snack, begin an individualized toileting program at night, allow her to be up at night with supervision).
Anxiety, agitation and unsafe behavior
___ implement general behavior management strategies.
___ move closer to nurses station.
___ use adequate night light.
___ leave door open at night for regular checking by staff who walk past.
___ provide frequent reminders about call bell.
___ conduct trial use of a change in position/pressure alarm or a room sensor.
___ use a low bed and mat.
___ provide comfort measures; reassure frequently.
___ learn about her culture, likes and dislikes and religious preference.
___ know at least three things that bring her comfort.
___ develop a toileting schedule and include an evaluation of bathroom safety and possible beside commode use.
___ evaluate resident's pain level using appropriate pain scale for residents with dementia.
___ give a trial analgesic if appropriate.
Illustration of Fall Response
Step One—Evaluate and monitor resident for 24-72 hours after the fall.
A. Immediate evaluation of Mrs. P after each fall
Complete assessment of the resident's condition and examination for:
___ musculoskeletal injuries.
___ head and neck injuries.
___ mental changes.
___ changes in level of consciousness.
- Vital signs.
- Documentation of neurologic signs since the resident was found on floor.
- Postural vital signs since the resident is on cardiovascular medications for hypertension and has a history of frequent falls.
- Blood glucose level since the resident has a diagnosis of diabetes.
B. Sample of initial nurses note using SOAP and occurrence based documentation methods
4/1/04 11 pm
S: Mrs. P was found on the floor in her room at 8 pm this evening. Resident states "I was needing to use the restroom." It has been reported that Mrs. P has been agitated and restless off and on since admission and has been showing other signs of unsafe behavior-attempting to transfer without staff assistance, getting out of bed at night with disturbed sleeping patterns.
O: Vital signs-100/60, 66, 20, 98.6.
Blood glucose=70, given Orange Juice and two packets of sugar, blood glucose=100 ½ hour later. Pulse Ox= 98%.
Postural BP: standing at 1 minute 90/60, 80. No evidence of orthostatic hypotension at this time.
Resident in her room alone at time of incident, attempting to get up out of chair unassisted-wants to use bathroom. Gait unsteady and needs the assistance of one person for transfers. Resident ambulates in regular socks.
Dr. Roberts notified at 8:30 pm. Mrs. Mary Taylor, resident's daughter, was notified by telephone at 9 pm. Resident's status and immediate measures taken were explained to daughter. Daughter was reminded of her mother's care plan conference on Friday.
A: Sleep-rest pattern disturbance
Altered tissue perfusion
Altered anxiety level
Altered change in perception of reality.
P: To be determined based on further assessment and interdisciplinary evaluation.
4/01/04 11 pm
Example 2-Occurrence based
Mrs. P was found on the floor in her room at 8:00pm this evening. Resident states "I was needing to use the restroom." It has been reported that Mrs. P has been agitated and restless off and on since admission and has been showing signs of unsafe behavior-attempting to transfer without staff assistance, getting out of bed at night with disturbed sleeping patterns.
Vital signs-100/60, 66, 20, 98.6, Blood glucose=70, Orange juice and two packets of sugar given, blood glucose=100, ½ hour later. Pulse Ox=98%.
Postural BP: standing at 1 minute 90/60, 80. No evidence of orthostatic hypotension at this time. Resident in her room alone at time of fall, attempting to get up out of chair unassisted-wants to use bathroom. Gait slightly unsteady and needs the assistance of one person for transfers. Resident ambulates in regular socks.
Dr. Roberts notified at 8:30pm. Mrs. Mary Taylor, resident's daughter, was notified by telephone at 9:00pm. Resident's status and immediate measures taken were explained to daughter. Daughter was reminded of her mother's care plan conference on Friday.
Interventions to be determined based on further assessment and interdisciplinary evaluation.
C. Sample of documentation q shift X 72 hours or until stable using both SOAP and occurrence based documentation
S: Mrs. P has no evidence of injury resulting from her two falls on 4/1/04 at this time. Resident does not complain of pain and there is no evidence of grimacing or pain upon movement. She has had no more falls. She is restless and agitated, especially at night.
O: Vital signs-100/60, 80, 20, 98.6. Blood glucose=80
A: Sleep-rest pattern disturbance
Altered anxiety level
Altered change in perception of reality.
P: Increase staff surveillance of resident-monitor resident every 30 minutes, toilet every 2 hours or more frequently, ensure resident wears non-skid socks, use position change alarm while resident is up in chair or in bed. Other interventions to be determined based on further assessment and interdisciplinary evaluation.
Example 2—Occurrence based
Mrs. P has no evidence of injury resulting from her two falls on 4/1/04 at this time. Resident does not complain of pain and there is no evidence of grimacing or pain upon movement. She has had no more falls. She is restless and agitated, especially at night.
VS-100/60, 80, 20, 98.6. Blood glucose=80.
Falls Assessment completed and discussed with falls team and family. Staff to increase surveillance of resident-monitor patient every 30 minutes, toilet every 2 hours or more frequently, ensure resident wears non-skid socks and use position change alarm while resident is up in chair or in bed. Other interventions to be determined based on further assessment and interdisciplinary evaluation.
Step Two—Investigate Fall
Mrs. P had two falls within 24 hours after recently being admitted to the facility.
- What questions should be asked to uncover clues as to why Mrs. P is falling?
- What was the response of the staff member who found her?
- Were clues at the time of the fall observed or ignored?
Where was Mrs. P lying? What was she wearing on her feet? What clothes was she wearing? Was there anything next to her? What direction was she going? Was there enough light for her to see? Where was the call light?
Was the bed locked into stable position? Where was her chair? Were any assistive devices present? After the second fall, where was the waist restraint? Were the side rails up or down? Try to determine how she got out of the bed in spite of the restraint and bed rails.
Was she wet or soiled? Was she confused or agitated? Was she in pain? What was her agenda? What did Mrs. P say happened? When was the last time she had been taken to the bathroom? When was her last food intake?
Step Three—Record Circumstances, Patient Outcome and Staff Response
A Tracking Record for Improving Patient Safety (TRIPS) should be completed by the nurse in charge within 24 hours of Mrs. P's falls. A separate TRIPS form should be completed for each fall. See the sample TRIPS form.
Step Four—FAX Alert to Primary Care Provider
If the resident is already in the Falls Management Program, the FAX Alert should be sent to the primary care provider. See the sample FAX Alert.
If the resident is not already in the Falls Management Program, do not send a FAX Alert and enter the resident into the Falls Management Program. Communication to the resident's primary care provider will occur during the Falls Assessment process.
Step Five—Implement Immediate Intervention
Any one of the following would be appropriate as immediate interventions within the first 24 hours for Mrs. P.
- Increase staff surveillance of resident—monitor patient frequently—q 30 minutes
- Toilet q 2 hours.
- Bring resident out to station at night when she is agitated and wants to get out of the bed. Offer a snack and provide reassurance.
- Use a position change alarm while resident is up in the chair or is in the bed.
- Dress the resident with the blue canvas shoes or white slippers when she is up. Use non-skid socks when she is in bed during the night or while napping.
- Use a low bed and place a mat beside the bed at night.
Step Six—Complete Falls Assessment
A Falls Assessment should be completed by the nurse along with a Gait and Mobility Assessment and the Unsafe Behavior Worksheet. The 3-page fax should be sent to the primary care provider and the return orders should be received. The nurse should complete any orders and make the appropriate referrals.
Step Seven—Develop Plan of Care
Until a Falls Assessment is completed for Mrs. P, an interim plan of care should be used.
- Close observation and increased supervision.
- Frequent orientation to room, bathroom and facility.
- Medication review.
- Use of safe footwear.
- Staff assistance to toilet or bedside commode.
- Use of monitoring devices.
- Use of pressure, position alarm.
- Use of hip protectors.
- No physical restraint use.
- Use of ½ side rail as enabler.
Behavior management strategies will be particularly important for staff to use with Mrs. P because she has Alzheimer's disease and is confused, agitated and restless with unsafe behaviors. Particular emphasis should be on using a calm approach, simplifying the environment, using distraction when necessary, and providing comfort measures. It is important to determine at least three things that bring Mrs. P comfort. An effort should be made to talk with her daughter and husband to discover what aspects of Mrs. P's home environment, culture, spirituality and work experience may be used to enhance her adjustment to the facility. Activities staff should offer appropriate daily activities for Mrs. P.
As the Falls Assessment is completed and recommendations are received from the primary care provider, therapist and any other health care professionals, the nurse can select specific tasks on the Fall Interventions Plan. Input from direct care staff as well as family members should be used to individualize the interventions.
Step Eight—Monitor Implementation
The nurse should monitor staff implementation of the interventions checked on the Fall Interventions Plan and record their effectiveness and any changes on the Fall Interventions Monitor. The resident response should be monitored and used to determine effective approaches.
Samples Completed for Illustration
These forms have been filled out with information for the sample case study patient, Mrs. P.
- Falls Assessment
- Mobility and Transfer Assessment
- Unsafe Behavior Worksheet
- Fax Alert
- Fax Cover Sheet
- Falls Assessment Report
- Fax Back Orders
- Fall Interventions Plan
- Fall Interventions Monitor
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