Falls Prevention

1.

A near miss fall is a type of falls.

A.

True
B.

False

Correct Answer
A. True

Explanation
A near miss fall is an event in which a potential fall is prevented through purposeful actions.

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2.

Which of the following is a Falls Risk Assessment Tool that is used to assess for fall risks in all patients?

A.

Morse Falls Scale
B.

Stratify
C.

Hendrich II Fall Risk Model
D.

All of the above

Correct Answer
D. All of the above

Explanation
In the acute care settings (in-patients), the use of these three Falls Risk Assessment Tools is recommended due to their high sensitivity and specificity in these patient care areas.

For more information, click on the corresponding link to each tool:
1. Morse Falls Scale - https://sunnynet.ca/data/1/rec_docs/13566_Morse_Fall_Scale.pdf
2. Stratify - https://sunnynet.ca/data/1/rec_docs/13568_STRATIFY_Scale_for_Identifying_Fall_Risk_Factors.pdf
3. Hendrich II Fall Risk Modle - https://sunnynet.ca/data/1/rec_docs/13567_Hendrich_II_Fall_Risk_Model.pdf

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3.

How would you find information about a patient's fall risk? Please select all that apply.

A.

Kardex
B.

Patient Care Plan
C.

Patient Care Record
D.

Assessment of patient using Falls Risk Assessment Tools
E.

BMS falls risk icon on patient list on the TV

Correct Answer(s)
A. Kardex
B. Patient Care Plan
C. Patient Care Record
D. Assessment of patient using Falls Risk Assessment Tools
E. BMS falls risk icon on patient list on the TV

4.

How would you intervene once you find a patient who fell? Please select all that apply.

A.

Assess the patient for injury including neurological status as indicated
B.

Assist the patient to get up if safe to do so
C.

Notify most responsible physician or resident
D.

When appropriate, discuss with the patient and/or family their perception of fall incident, exploring possible causative factors that led to fall. Provide “Falls Prevention” pamphlet
E.

Notify pharmacist and/or physician to complete medication review if indicated
F.

Inform family or substitute decision maker about fall incident and proposed/revised plan of care
G.

Document event and patient condition in PCR
H.

Complete E-Safety report
I.

PCM/APN/CE to update all fall related safety reports once additional information becomes available such as injury, level of harm, contributing factors, etc.
J.

Re-assess patient for modifiable fall risk factors and collaborate with team to develop and implement individualized plan of care

Correct Answer(s)
A. Assess the patient for injury including neurological status as indicated
B. Assist the patient to get up if safe to do so
C. Notify most responsible physician or resident
D. When appropriate, discuss with the patient and/or family their perception of fall incident, exploring possible causative factors that led to fall. Provide “Falls Prevention” pamphlet
E. Notify pharmacist and/or physician to complete medication review if indicated
F. Inform family or substitute decision maker about fall incident and proposed/revised plan of care
G. Document event and patient condition in PCR
H. Complete E-Safety report
I. PCM/APN/CE to update all fall related safety reports once additional information becomes available such as injury, level of harm, contributing factors, etc.
J. Re-assess patient for modifiable fall risk factors and collaborate with team to develop and implement individualized plan of care

Explanation
You can find the Post-Fall Procedure in the Falls Risk Reduction Policy (PC-136).

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5.

What are some strategies to reduce falls risk for all patients? Please select all that apply.

A.

Clear, well lit environment
B.

Free of obstacles
C.

Use of equipment safety devices (ex. bed in lowest position, use of commode)
D.

Ensure patient personal items and amenities are within reach (ex. sensory aids and call bells)
E.

Non-slip footwear
F.

Provide education

Correct Answer(s)
A. Clear, well lit environment
B. Free of obstacles
C. Use of equipment safety devices (ex. bed in lowest position, use of commode)
D. Ensure patient personal items and amenities are within reach (ex. sensory aids and call bells)
E. Non-slip footwear
F. Provide education

Explanation
Universal Falls Risk Reduction Interventions are applied in all patients (PC-136).
Here is a link of the Fall Prevention brochure, which outlines great ideas to reduce falls risk! https://sunnynet.ca/data/1/rec_docs/13570_PR_15050_-_Fall_Prevention_Brochure_INPATIENT.pdf

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6.

What are some individualized falls risk reduction interventions? Please select all that apply.

A.

Increased observation by placing patient in room near nursing station
B.

Bed alarms, chair alarms, low beds
C.

Toileting routine
D.

Put all side rails up

Correct Answer(s)
A. Increased observation by placing patient in room near nursing station
B. Bed alarms, chair alarms, low beds
C. Toileting routine

Explanation
All side rails up is a form of restraint. Full siderails are not recommended as a fall reduction strategy.

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