FALLS

Nursing Standard of Practice Protocol: Fall Prevention

Deanna Gray-Micelli

Evidence-based Content - Updated January 2008

The information in this "Want to know more" section is organized according to the
following major components of the NURSING PROCESS:

Goals
Overview
Background and Statement of the Problem
Parameters of Assessment Tools
Nursing Care Strategies
Evaluation/Expected Outcomes
Follow-up Monitoring of Condition
Relevant Practice Guidelines
References

Goals

A. Prevent falls and serious injury outcomes in hospitalized older adults. B. Recognize
multifactorial risks and causes of falls in older adults. C. Institute recommendations for
falls prevention and management consistent with clinical practice guidelines and
standards of care.

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Overview

Falls among older adults are not a normal consequence of aging; rather, they are
considered a geriatric syndrome most often due to discrete multifactorial and interacting,
predisposing (intrinsic and extrinsic risks), and precipitating (dizziness, syncope) causes.
1, 2
Fall epidemiology varies according to clinical setting. In acute care, fall incidence among
elderly inpatients in one study, were highest on the Medicine and neurology units. 3
Nearly one-third of older adults living in the community fall each year in their home. The
highest fall incidence occurs in the institutional long-term-care setting (i.e., nursing
home), where 50% to 75% of the 1.63 million nursing-home residents experience a fall
yearly. Falls rank as the eighth leading cause of unintentional injury for older Americans
and were responsible for more than 16,000 deaths in 2006. 4

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Background and Statement of the Problem

A. Definition

1. Fall: A fall is an unexpected event in which the participant comes to rest on the
ground, floor, or lower level. 5

B. Fall Etiology

1. Fall risk factors include intrinsic risks of cognitive, vision, gait or balance impairment,
high-risk/contraindicated medications, and/or the extrinsic risks of assistive devices,
inappropriate footwear, restraint, use of nonsturdy furniture or equipment, poor lighting,
uneven or slippery surfaces.6

2. Fall causes include, among others, orthostatic hypotension, arrhythmia, infection,

generalized or focal muscular weakness, syncope, seizure, hypoglycemia, neuropathy,
and medication.

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Parameters of Assessment

A. Assess and document all older adult patients for intrinsic risk factors to fall:

1. Advancing age, especially if older than 75

2. History of a recent fall

3. Specific co-morbidities: dementia, hip fracture, Type II diabetes, Parkinson's disease,

arthritis, and depression

4. Functional disability: use of assistive device

5. Alteration in level of consciousness or cognitive impairment

6. Gait, balance, or visual impairment

7. Use of high-risk medications 6

8. Urge urinary incontinence 7

9. Physical restraint use 8

10. Bare feet or inappropriate footwear

11. Identify risks for significant injury due to current use of anticoagulants such as
Coumadin, Plavix, or aspirin and/or those with osteoporosis or risks for osteoporosis 9

B. Assess and document patient-care environment routinely for extrinsic risk factors to
fall and institute corrective action:

1. Floor surfaces for spills, wet areas, unevenness

2. Proper level of illumination and functioning of lights (night light works)

3. Table tops, furniture, beds are sturdy and are in good repair

4. Grabrails and grab bars are in place in the bathroom

5. Use of adaptive aides work properly and are in good repair

6. Bedrails do not collapse when used for transitioning or support

7. Patient gowns/clothing do not cause tripping

8. IV poles are sturdy if used during ambulation and tubing does not cause tripping.

C. Perform a PFA following a patient fall to identify possible fall causes (if possible,
begin the identification of possible causes within 24 hours of a fall) as determined during
the immediate, interim, and longitudinal post-fall intervals. Because of known incidences
of delayed complication of falls, including fractures, observe all patients for about 48
hours after an observed or suspected fall. 2, 10, 11,12

1. Perform a physical assessment of the patient at the time of the fall, including vital signs
(which may include orthostatic blood pressure readings), neurological assessment, and
evaluation for head, neck, spine, and/or extremity injuries.

2. Once the assessment rules out any significant injury:

a. obtain a history of the fall by the patient or witness description and document

b. note the circumstances of the fall: location, activity, time of day, and any significant
symptoms

c. review of underlying illness and problems

d. review medications

e. assess functional, sensory, and psychological status

f. evaluate environmental conditions g. review risk factors for falling 9, 10, 11, 13, 14
D. In the acute-care setting, an integrated multidisciplinary team (consisting of the
physician, nurse, health care provider, risk manager, physical therapist, and other
designated staff) plans care for the older adult, at risk for falls or who has fallen, hinged
on findings from an individualized assessment. 11, 15

E. The process approach to an individualized PFA includes use of standardized

measurement tools of patient risk in combination with a fall-focused history and physical
examination, functional assessment, and review of
medications. 9, 10, 13, 14
When plans of care are targeted to likely causes, individualized interventions are likely to
be identified. If falling continues despite attempts at individualized interventions, the
standard of care warrants a reexamination of the older adult and their falls

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Nursing Care Strategies

A. General safety precaution and fall prevention measures that apply to all patients,
especially older adults:

1. Assess the patient care environment routinely for extrinsic risk factors and institute
appropriate corrective action.

a. Use standardized environmental checklists to screen; document findings.

b. Communicate findings to risk managers, housekeeping, maintenance department, all

staff and hospital administration, if needed.

c. Re-evaluate environment for safety. 11

2. On admission, assess/screen older adult patient for multifactorial risk factors to fall,
following a change in condition, on transfer to a new unit, and following a fall. 11

a. Use standardized or empirically tested fall-risk tools in conjunction with other

assessment tools to evaluate risk for falling (e.g. Tinetti Performance Oriented Mobility,
The Timed Get Up and Go Test) 1 (Click here).

b. Document findings in nursing notes, interdisciplinary progress notes, and the problem
list.

c. Communicate and discuss findings with interdisciplinary team members.

d. In the interdisciplinary discussion, include review and reduction or elimination of high-

risk medications associated with falling.
e. As part of falls protocol in the facility, flag the chart or use graphic or color display of
the patient's risk potential to fall.

f. Communicate to the patient and the family caregiver identified risk to fall and specific
interventions chosen to minimize the patient’s risk.

g. Include patient and family members in the interdisciplinary plan of care and discussion
about fall-prevention measures.

h. Promote early mobility and incorporate measures to increase mobility, such as daily
walking, if medically stable and not otherwise contraindicated.

i. Upon transfer to another unit, communicate the risk assessment and interventions
chosen and their effectiveness in fall prevention.

j. Upon discharge, review with the older patient and or family caregiver the fall risk
factors and measures to prevent falls in the home. Provide patient literature/brochures if
available. If not readily available, refer to the Internet for appropriate Web sites and
resources.

k. Explore with the older patient and/or family caregiver avenues to maintain mobility
and functional status; consider referral to home-based exercise or group exercises at
community senior centers. If discharge is planned to a subacute or rehabilitation unit,
label the older adult's mobility status, functional status, and other forms of activity in the
home to increase gait or balance on the transfer form.

3. Institute general safety precautions according to facility protocol, which may include:

a. Referral to a falls prevention program

b. Use of a low-rise bed that measures 14 inches from floor

c. Use of floor mats if patient is at risk for serious injury, such as osteoporosis

d. Easy access to call light

e. Minimization and/or avoidance of physical restraints

f. Use of personal or pressure sensors alarms

g. Increased observation and surveillance

h. Use of rubber-soled healed shoes or nonskid slippers

i. Regular toileting at set intervals and/or continence program; provide easy access to
urinals and bedpans
j. Observation during walking rounds or safety rounds

k. Use of corrective glasses for walking

l. Reduction of clutter in traffic areas

m. Early mobility program 11

4. Provide staff with clear, written procedures describing what to do when a patient fall
occurs.

B. Identify specific patients requiring additional safety precautions and/or evaluation by a

specialist, or:

1. those with impaired judgment or thinking due to acute or chronic illness (delirium,
mental illness)

2. those with osteoporosis, at risk for fracture

3. those with current hip fracture

4. those with current head or brain injury (standard of care)

C. Review and discuss with interdisciplinary team findings from the individualized
assessment and develop a multidisciplinary plan of care to prevent falls 6

1. Communicate to the physician or advance practice nurse important PFA findings 11

2. Monitor the effectiveness of the falls prevention interventions instituted.

3. Following a patient's fall, observe for serious injury due to a fall and follow facility
protocols for management (standard of care).

4. Following a patient's fall, monitor vital signs, level of consciousness, neurological

checks, and functional status per facility protocol. If significant changes in patient's
condition occurs, consider further diagnostic tests such as plain film x-rays, CT scan of
the head/spine/extremity, neurological consultation, and /or transfer to a specialty unit for
further evaluation (standard of care).

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Evaluation/Expected Outcomes

A. Patients:

1. Safety will be maintained.

2. Falls will be avoided.
3. Will not develop serious injury outcomes from a fall if it occurs.
4. Will know their risks for falling.
5. Will be prepared on discharge to prevent falls in their homes.
6. Prehospitalization level of mobility will continue.
7. Who develops fall-related complications such as injury or change in cognitive function
will be promptly assessed and treated to prevent adverse outcomes.

B. Nursing Staff:

1. Will be able to accurately detect, refer, and manage older adults at risk for falling or
who have experienced a fall.
2. Will integrate into their practice comprehensive assessment and management
approaches for falls prevention in the institution.
3. Will gain appreciation for older adults’ unique experience of falling and how it
influences their daily living, functional, physical, and emotional status.
4. Educate older adult patients anticipating discharge about falls prevention strategies.

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Follow-up Monitoring of Condition

A. Monitor fall incidence and incidences of patient injury due to a fall, comparing rates
on the same unit over time.

B. Compare falls per patient month against national benchmarks available in the National
Database of Nursing Quality Indicators.

C. Incorporate continuous quality improvement criteria into falls prevention program.

D. Identify falls team members and roles of clinical and nonclinical staff . 11

E. Educate patient and family caregivers about falls prevention strategies so they are
prepared for discharge. 8, 14

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Relevant Practice Guidelines

A. American Geriatrics Society, British Geriatrics Society, American Academy of

Orthopedic Surgeons (AGS/BGS/AAOS) Guidelines for the Prevention of Falls in Older
Persons (2001). Journal of American Geriatrics Society, 49, 664–672. Evidence Level
VI: Expert Opinion. 10

B. American Medical Directors Association (AMDA). Falls and fall risk. Columbia, MD:
American Medical Directors Association. Evidence Level VI: Expert Opinion. 13
C. University of Iowa Gerontological Nursing Interventions Research Center (UIGN).
(2004). Falls prevention for older adults. Iowa City, IA: University of Iowa
Gerontological Nursing Interventions Research Center, Research Dissemination Core.
Evidence Level VI: Expert Opinion. 14

D. ECRI Institute: Falls Prevention Strategies in Healthcare Settings (2006). Plymouth

Meeting, PA. Evidence Level VI: Expert Opinion. 8

E. Resnick, B. (2003). Preventing falls in acute care. In: M. Mezey, T. Fulmer, I.

Abraham (Eds.) & D. Zwicker (Managing Ed.), Geriatric nursing protocols for best
practice (2nd ed., pp. 141–164). New York: Springer Publishing Company, Inc. Evidence
Level VI: Expert Opinion.8

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Gray-Miceli, D. (2008).

Preventing falls in acute care. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.)
Evidence-based geriatric nursing protocols for best Practice (3rd ed.), New York:
Springer Publishing Company, Inc.

References

For definition of Levels of Quantitative Evidence click here.

1. Rubenstein, L. Z., & Josephson, K. R. (2006). Falls and their prevention in the elderly:
What does the evidence show? Medical Clinics of North American, 90 (5), 807–824.
Evidence Level I: Systematic Integrative.

2. Gray-Miceli, D., Johnson, J. C., & Strumpf, N. E. (2005). A step-wise approach to a

comprehensive post-fall assessment. Annals of Long-Term Care: Clinical Care and
Aging, 13(12), 16–24. Evidence Level VI: Expert Opinion.

3. Hitcho, E. B., Krauss, M. J. Birge, S., Dunagan, W. C., Fischer, I., Johnson, S., et al.
(2004). Characteristics and Circumstances of Falls in a Hospital Setting: A Prospective
Analysis. Journal of General Internal Medicine. 19(7), 732-739.

4. Centers for Disease Control and Prevention (CDC), National Center for Injury
Prevention and Control (NCIPC) (2007). Preventing falls among older adults.
RetrievedMay 29, 2007, from cdc.gov/ncipc/duip/preventadultfalls.htm. Evidence Level
VI: Expert Opinion.

5. Prevention of Falls Network Europe (ProFaNE) (2006). Retrieved April 19, 2007, from
http://www.profane.eu.org. Evidence Level VI: Expert Opinion.
6. Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp,
M. J., et al. (2004). Interventions for the prevention of falls in older adults: Systematic
review and meta-analysis of randomized controlled trials. British Medical Journal,
328(7441), 680. Evidence Level I: Systematic Meta-analysis Review.

7. Brown, J. S., Vittinghoff, E., & Wyman, J. F. (2000). The study of osteoporotic
fractures research group. Urinary incontinence: Does it increase risk for falls and
fractures? Journal of the American Geriatric Society, 48, 721–725. Evidence Level III:
Quasi-experimental Study.

8. Capezuti, E., Maislin, G., Strumpf, N., & Evans, L. K. (2002). Side-rail use and bed-
related fall outcomes among nursing-home residents. Journal of the American Geriatrics
Society, 50(1), 90–96. Evidence Level III: Quasi-experimental Study.

9. Resnick, B. (2003). Preventing falls in acute care. In M. Mezey, T. Fulmer, I. Abraham

(Eds.) & D. Zwicker (Managing Ed.), Geriatric Nursing Protocols for Best Practice (2nd
Ed., pp. 141–164). New York: Springer Publishing Company, Inc. Evidence Level VI:
Expert Opinion.

10. American Geriatrics Society, British Geriatrics Society, American Academy of

Orthopedic Surgeons Panel on Falls Prevention (AGS, BGS, AAOS) (2001). Guidelines
for the prevention of falls in older persons. Journal of the American Geriatrics Society,
49(5), 664–681. Evidence Level VI: Expert Opinion.

11. ECRI Institute (2006). Falls Prevention Strategies in Healthcare Settings Guide.
Plymouth Meeting, PA: ECRI Publishers. Evidence Level VI: Expert Opinion.

12. Gray-Miceli, D., Strumpf, N. E., Johnson, J. C., Dragascu, M., & Ratcliffe, S. (2006).
Psychometric properties of the post-fall index. Clinical Nursing Research, 15(3), 157–
176. Evidence Level III: Quasi-experimental Study.

13. American Medical Directors Association (AMDA). (1998). Falls and fall risk.
Columbia, MD: AMDA. Evidence Level VI: Expert Opinion.

14. University of Iowa Gerontological Nursing Interventions Research Center (UIGN).

(2004). Fall prevention for older adults. Iowa City, Iowa: University of Iowa
Gerontological Nursing Interventions Research Center, Research Dissemination Core.
http://www.nursing.uiowa.edu/consumerspatients/evidencebased.htm. Evidence Level
VI: Expert Opinion.

15. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2006).

Root causes of patient falls. Joint Commission on Accreditation of Healthcare
Organizations. Retrieved on March 31, 2007, from
http://www.jointcommission.org/NR/rdonlyres/FA5A080F-C259-47CC-AAC8-
BAC3F5C. Evidence Level V: Case Report.