NURSING PATIENT CARE POLICY & PROCEDURE
May 31, 2017
Amended: July 21,
Nursing Manual (Red)
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Title: Fall Prevention for Inpatients (Adult &
To identify inpatients (adult or pediatric) at greatest risk for falls, implement strategies to reduce
the risk for falls, and decrease the risk for injuries related to falls.
All patients are at higher risk for falling during hospitalization. Unfamiliar surroundings,
under-estimating weakness due to illness, and the effects of medications, treatments and
procedures are a few of the factors that increase this risk. All inpatients are considered to be
at risk for falling.
(From National Database of Nursing Quality Indicators (NDNQI):
A. Fall: A sudden, unintentional descent, with or without injury to the patient that results
in the patient coming to rest on the floor, on or against some other surface, on another
person, or on an object.
B. Assisted fall: A fall in which any staff member (whether nursing service employee or
not) was with the patient and attempted to minimize the impact of the fall by slowing
the patient’s descent.
C. Pediatric developmental fall: A fall in which an infant, toddler, or preschooler who is
learning to stand, walk, run, or pivot falls as part of the developmental process of
acquiring these skills. Generally the child will be less than 8 years old. Older children
may have developmental delays with limited ability to acquire these skills. Only falls
that occur as normal parts of this learning process are considered developmental. Falls
from a bed or a chair are not developmental falls.
D. Baby/child drop: A fall in which a newborn, infant, or child being held or carried by a
healthcare professional, parent, family member, or visitor falls or slips from that
person’s hands, arms, lap, etc. This can occur when a child is being transferred from
one person to another.
E. Falls during play: Some units such as psychiatric and pediatric have gyms or other
designated play area for patients. ‘Falls during play’ are falls that occur during normal
play activities in such areas.
F. Physiological falls: A fall attributable to one or more intrinsic, physiological factor.
Physiological falls include:
1. Anticipated physiological; Falls that we anticipate will occur due to the patient’s risk
factors, existing physiological status, history of falls, and decreased mobility upon
assessment. These falls are preventable.
a. Falls occurring due to side effects of known “culprit drugs” (e.g., central
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nervous system- active drugs and certain cardiovascular drugs)
b. Falls attributable to some aspect of the patient’s physical condition such as
delirium, intoxication, dementia, gait instability, or visual impairment.
2. Unanticipated physiological: Falls that we cannot predict, associated with unknown
falls risks. Typically, these falls are not preventable.
a. Examples: Falls caused by sudden physiologic event such as hypotension,
dysrhythmia, seizure, transient ischemic attack, or stroke.
G. Accidental fall: Falls that occur due to extrinsic environmental risk factors(ie: spills on the
floor, tripping on clutter), These falls are preventable
H. Suspected intentional fall: When a patient age 5 or older falls on purpose or falsely claims
to have fallen. Patients may fall intentionally or falsely claim to have fallen for various
reasons, including seeking attention or obtaining pain medication.
A. Assessment for hospitalized patients
1. Patients are assessed for risk of falling daily, on admission, upon transfer, with a
change in the patient’s clinical status and following a fall. Using the Hendrich II
Fall Risk Model
for adults and the GRAF- PIF for pediatric patients one year
2. Pediatric patients are screened against extrinsic factors to assess risks for falls as
the majority of pediatric inpatient falls are accidental. They are unpredictable,
and as a result, can only be prevented through increased surveillance, assessment,
3. Reassessment is indicated with changes in condition including, but are not
limited to: changes in mental status, alertness, pain level, or new weakness,
fatigue, or drowsiness. Changes to the patient’s treatment plan may also warrant
a reassessment. These include but are not limited to: anything that would affect
mental status (including procedural sedation or pain medication), change in
elimination patterns (including addition of diuretics or bowel preps), addition of
new high risk medications (including antihypertensives, benzodiazepines,
opioids, anticonvulsants or antidepressants), and any significant changes in
dosage of any high risk medications. Mobility limitations, or change from
patient’s previous nursing assessment would also indicate a need for
4. Patients may be at risk for orthostatic hypotension post operatively, post
procedure or as a result of changes to antihypertensive medications. Checking
vital signs for orthostatic changes are recommended when patients are
symptomatic or first time out of bed after surgery or procedure.
B. Risk for Injury
Some adult patients are at higher risk for injury if a fall occurs. Injurious risk factors will be
assessed and documented with each Hendrich II fall assessment. Injurious risk factors include:
1. Advanced age (85 years and older)
2. Bone issues (history of fracture, osteoporosis, bone metastases)
3. Coagulation (receiving anticoagulants or bleeding disorder)
4. Recent surgery (an incision that could dehisce with a fall).
C. Fall Risk Confirmation
1. If the patient scores 5 or greater on the Hendrich II or 2 or greater on the GRAF-PIF, the
patient is probably at high risk for falls. Using clinical judgment, confirm if this patient
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requires High Fall Risk Precautions. If the patient scores high risk on the fall assessment
tool, but the nurse indicates the patient is a standard fall risk, the nurse will document
the rationale on the flowsheet or in a progress note. If the patient scores as a standard
risk on assessment, the nurse can still make the determination to make the patient a high
fall risk (e.g., history of falls, behavior issues, fatigue or weakness in spite of a low
Hendrich II score, or a specific patient population).
2. All patients will have a standard fall risk plan of care. Only patients who warrant a
higher level of fall risk awareness will be placed on High Fall Risk precautions. Staff
will document the level of fall risk in the assessment flowsheet.
1. Standard Risk Fall Prevention Interventions (all hospitalized patients)
a. To reduce their risk for falls, all patients should minimally have the standard
fall risk plan of care Staff may individualize the standard fall risk plan of
care by selecting key interventions related to the patient’s known fall risk
factors. Fall prevention interventions tied to patient’s risk factors will be
b. After determining fall risk status, steps are taken to minimize the risk of
falling or risk of injury related to a fall. This includes education for the
patient and family about the fall risk assessment and individualized fall
c. The American Family Children’s Hospital (AFCH) staff will implement fall
precautions and family education for all patients based on Patient- and
Family-Centered Care (PFCC) model of care and fall prevention screening
d. Standard Fall Risk Interventions for All Patients:
i. Intentional hourly rounding, addressing all 5 Ps each time: pain,
personal needs (bathroom), possessions (call light, phone, etc),
position and prevention (safe environment, clutter-free, bed alarm,
etc) according to Nursing and Patient Care Policy 14.35AP,
Intentional Rounding (Adults and Pediatric).
ii. Familiarize the patient with the environment, keep free of clutter, and
assure adequate lighting.
iii. Have the patient demonstrate call light use and keep call light in
iv. Keep patient’s personal items within reach.
v. Have sturdy handrails in patient bathrooms, room and hallway.
vi. Discuss fall risk with patient during bedside report.
vii. Perform mobility assessment, utilize safe patient handling equipment
viii. Perform early and frequent mobilization: use non-slip, well-fitting
footwear on patient and assistive devices if indicated.
ix. Place hospital bed in low position and keep brakes locked.
x. Keep floor surfaces clean and dry. Clean up all spills promptly.
xi. Perform medication reviews.
xii. Measure orthostatic vital signs when patients is symptomatic or first
time out of bed after surgery or procedure.
xiii. Provide education about fall prevention for the patient and family,
using the teach back method.
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o Provide Health Facts for You (HFFY)
• HFFY 5461, Preventing Falls in the Hospital (for adult
• HFFY 7928, Partnering for Fall Prevention: My Falls
Safety Plan (for pediatric patients)
o UW Health Pediatric Fall Prevention video (on the Care
Channel on Uconnect)
o UW Health Adult Fall Prevention video (on the Care Channel
2. High Risk Fall Prevention Interventions
a. These interventions should be in place for any patient who may require a
higher level of fall risk awareness and interventions in addition to the
standard fall risk interventions.
b. High fall risk prevention interventions tied to patient’s risk factors will be
c. High Fall Risk Interventions – In addition to employing all Standard Fall
Risk Interventions, complete the following:
i. Use visual cues to communicate high fall risk patients
ii. Place yellow leaf on patient’s door
iii. Apply yellow high fall risk wristband
iv. Remain with the patient in the bathroom or shower (any staff member
v. Perform frequent safety checks, in addition to intentional rounding
vi. Review medications with healthcare team
vii. Use of a gait belt when patient is out of bed or with ambulation
viii. Utilize low bed and/or floor mats when patient is at risk for an injury
with a fall
ix. Eliminate leaving patient sitting on edge of bed
x. Adequate day and night time lighting
xi. Educate patient and family about fall and injury risk factors and
discuss patient safety plan.
xii. Provide Health Facts for You (HFFY)
o HFFY 6625, Falls and Older Adults (for adult patients)
o HFFY 7928, Partnering for Fall Prevention: My Falls Safety
Plan (for pediatric patients)
o Implement patient and family centered care (PFCC) “Culture
of Safety” handout on admission to all patients in an effort to
engage families in fall prevention.
3.Individualized Fall Precautions (to be considered in addition to above)
a. Yellow slippers as additional visual cue for high fall risk
b. Early detection alarms (chair pad, bed pad, or seat belt
c. Bed alarm – zone 2 is preferred for most patients
d. Comprehensive fall evaluation by the Acute Care for Elders (ACE) team for
patients with known history of falling or fall-related admission
e. Occupational (OT)and/or physical therapy (PT) consultations
f. Scheduled Toileting regimen
g. Elevated toilet seat or bedside commode
h. Removal of physical restraint
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i. 1:1 constant observation (Patient Safety Attendant (PSA), Patient Safety
Observer (PSO) or Video Monitor Technician (VMT), refer to UWHC
Nursing Patient Care Policy 14.40AP Constant Observation (Adult and
j. Moving patient closer to nurses station
k. Identify possible triggers for agitated, impulsive behavior and minimize them
4. Injury Risk Prevention Interventions Options (adult only)
Consider the following interventions in adult patients with the injurious risk
factors of advanced age, bone issues, osteoporosis, coagulation and/or recent
a. Education using teach-back strategies
b. Assistive devices within reach
c. Floor mats
d. Low bed (low when resting, raise bed up for transfer)
e. Determine safe exit side
f. Medication review
i. Evaluate use of anticoagulation
g. Pre-operative and Post-operative education
h. Offer toileting prior to pain medication administration
5.Injury Risk Prevention Interventions Options (pediatric only)
Consider the following interventions in pediatric patients
a. Implement high fall risk precautions
b. Appropriate bed (size, low bed, seizure bed)
c. Adequate lighting
d. Determine safe exit side of bed
e. Assistive devices in reach
f. PT/OT consults
g. Instruct patient/family to call for assistance, supervision when out of bed
h. Place patient in room close to nurses station
i. Increase frequency of intentional rounding
j. Frequent toileting
k. Accompany patient while at Bathroom
l. Ensure uncluttered environment
m. Instruct patient/family to call for assistance, supervision when out of bed
n. Evaluate and educate on the effects of patient’s medications (anti-hypertensives,
narcotics, diuretics, benzodiazepines)
o. Provide patient/family education: PFCC/HFFY/videos
p. Provide pre-operative and post-operative education
E. If a Fall Occurs
1. Identify if the patient is at risk for injury, then assess patient with careful
consideration for head injury, spinal cord injury or fracture.
2. Assist patient back to bed if there is no suspicion of injury.
3. Notify provider.
4. A post fall huddle should occur as soon as possible following the fall and after the
patient is stabilized, with the staff caring for the patient and present at the time of
the fall. This group should review the fall event and the current plan of care, and
adjust interventions as needed to decrease risk of further events.
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5. Complete a Patient Safety NetTM report in the on-line health care event reporting
system, using event type “fall.” Provide accurate and detailed information related
to the fall.
6. Notify patient's family. If a fall without injury occurs between 2300 and 0600,
notify the family at the end of the night shift.
a. Select new note and choose Fall Occurrence type.
b. Add Fall Occurrence template to RN Care.
c. Document fall occurrence event in the fall occurrence row on the Daily Care
d. Reevaluate and consider making the patient High Fall Risk. Add High Fall Risk
Template to RN Care if the patient is made High Fall Risk.
8. Use the Mobility Decision Support Tool on Uconnect to determine how to move
9. Nursing unit leadership will review all fall events.
10. The Clinical Nurse Specialist (CNS) for Nursing Quality and Safety reviews fall
events and re-evaluates level of injury after one business day to ensure accurate
11. Any fall resulting in serious injury requires immediate notification:
a. During business hours to Nurse Manager.
b. Outside business hours to Nursing Administrator on Call.
F. Fall Data Analysis
Patient falls are analyzed on a regular basis to identify trends. Appropriate actions are then
taken to further reduce the incidence of falls and fall-related injuries in the hospital setting.
V. UWHC CROSS REFERENCES
A. GRAF PIF Fall Risk Model (see Related section on U-Connect)
B. Health Facts For You 3140, Preventing Falls Packet
C. Health Facts For You 4817, Accident Prevention Birth to 12 Months (pediatric)
D. Health Facts For You 5234, Preventing Falls and Fractures
E. Health Facts For You 5461, Preventing a Fall in the Hospital (adult)
F. Health Facts For You 6200, Preventing Falls While in the Hospital -Pediatrics
G. Health Facts For You 6625, Falls and Older Adults
H. Health Facts For You 6626, Home Safety - Preventing Falls
I. Health Facts For You 6627, If You Fall
J. Health Facts For You 6976, Preventing a Fall While in the Hospital – Spanish version
K. Health Facts For You 7744, High Fall Risk
L. Health Facts For You 7594, Preventing Falls While in the Diagnostic and Therapy Center
M. Health Facts For You 7928, High Fall Risk – Pediatrics
N. Health Facts For You 7928, Partnering for Fall Prevention: My Falls Safety Plan
O. Hendrich II Fall Risk Model (see Related section on U-Connect)
P. Nursing Administrative Policy 14.40AP, Constant Observation (Adult and Pediatric)
Q. Nursing and Patient Care Policy 14.35AP, Intentional Rounding (Adult and Pediatric)
R. Safeguard Against Childhood Falls (see Related section on U-Connect)
S. UWHC Falls Nursing Practice Guideline (available on U-Connect, Nursing Practice
T. UWHC Pediatric Fall Prevention Video (available on UConnect)
U. UWHC Adult Fall Prevention Video (available on UConnect)
V. UW Health Mobility Decision Support Tool (available on Uconnect)
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L. Quigley, P. (2010). IHI expedition: reducing falls incidence and injury (Session One of seven
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VII. REVIEWED BY
Clinical Nurse Specialist, Nursing Quality and Safety Clinical
Nurse Specialist, Pediatrics
Director, Nursing Quality and Safety Director, Pediatric Nursing
American Family Children’s Hospital (AFCH) Staff Council
Nursing Patient Care Policy and Procedure Committee, May 2017
Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive