What Action Will the Nurse Take First

Key points in Chapter 2

Eight-step Fall Response

Past history of a fall is the single best predictor of future falls. In fact, 30-40% of those residents who fall will do so again. Thus, it is crucial for staff to respond quickly and effectively after a fall. The Fall Response (Table 3) is a comprehensive approach that forms the backbone of the Falls Management Program (FMP). It includes the following eight steps:

1. Evaluate and monitor resident for 72 hours after the fall.
2. Investigate fall circumstances.
3. Record circumstances, resident outcome and staff response.
4. FAX Alert to primary care provider.
5. Implement immediate intervention within first 24 hours.
6. Complete falls assessment.
7. Develop plan of care.
8. Monitor staff compliance and resident response.

Table 3. FMP Fall Response

The first five steps comprise an immediate response that occurs within the first 24 hours after a fall. Steps 6, 7, and 8 are long-term management strategies.

The purpose of this chapter is to present the FMP Fall Response process in outline form. As you review this chapter, it may be helpful to use the case study and materials presented in Appendix C to illustrate the Fall Response process.

1. Evaluate and Monitor Resident for 72 Hours After the Fall

Immediate evaluation by the nurse after a resident falls should include a review of the resident systems and description of injuries. Upon evaluation, the nurse should stabilize the resident and provide immediate treatment if necessary.

Evaluation of the resident's condition before, during or immediately after the fall provides clues to possible causes. Risk factors related to medical conditions or medication use may be reflected in abnormal values for any of the following:

• Vital signs (T, P, R, BP).
• Postural blood pressure and apical heart rate.
• Finger stick glucose (for diabetics).

When indicated by the resident's condition and history, laboratory tests such as CBC, urinalysis, pulse oximetry, electrolytes and EKG should be performed.

Residents should have increased monitoring for the first 72 hours after a fall. Each shift, the nurse should record in the medical record a review of systems, noting any worsening or improvement of symptoms as well as the treatment provided. Reference to the fall should be clearly documented in the nurse's note. Go to Appendix C for a sample nurse's note after a fall.

2. Investigate Fall Circumstances

If fall circumstances are not investigated at the time of the incident, it is very difficult later to piece together the event and to determine what risk factors were present. Even when a resident is found on the floor after an unwitnessed fall, direct care staff can use their experience and knowledge of the resident to make educated guesses based on the evidence. A response of "unknown" should rarely if ever be accepted by the nurse manager during the investigation of a fall.

If staff fear negative responses from their supervisors, they will not be willing to report near misses or clues that might reflect a staff error. Nurse managers should be non-blaming and skilled in problem-solving with frontline staff.

3. Record Circumstances, Resident Outcome and Staff Response

A written full description of all external fall circumstances at the time of the incident is critical. This includes factors related to the environment, equipment and staff activity. (Figure 1)

Figure 1. Fall Circumstances

Date Day of week Time Location Type of fall Likely cause Activity at time of fall Staff present Type of footwear Aids in use Restraint use Side rail use Alarm use

The Tracking Record for Improving Patient Safety (TRIPS) is the method used in the FMP to report all types of falls. (Figure 2) The Centers for Medicare and Medicaid Services' definition of a reportable fall includes the following:

1. An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall.
2. The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall.
3. When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred.
4. The distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred. If a resident rolled off a bed or mattress that was close to the floor, this is a fall.

Figure 2. Examples of falls

Found on floor (unwitnessed). Fall to floor (witnessed). Near fall (resident stabilized or lowered to floor by staff or other). Rolled or fell out of low bed onto mat or floor.

The TRIPS form is divided into two sections. Section A includes basic resident information, methods for documentation in the medical record and notification of the primary care provider and family. In section B there are questions related to 1) circumstances, 2) staff response and 3) resident and care outcomes.

The nurse manager working at the time of the fall should complete the TRIPS form. After talking with the involved direct care staff, the nurse is asked to use his/her experience and knowledge of the resident to piece together clues so that "unknown" is used sparingly, if at all. The form should next be checked by the Falls Nurse Coordinator or director of nursing and any missing information such as emergency room visits, hospital admissions, x-ray results or additional medical tests added at a later time. More information on step 3 appears in Chapter 3.

4. FAX Alert to the Primary Care Provider

When a resident falls who has already been entered into the FMP, the nurse should send a FAX Alert to the primary care provider. The purpose of this alert is to inform the physician, nurse practitioner or physician's assistant of the resident's most recent fall as well as the resident's total number of falls during the previous 180 days.

5. Implement Immediate Intervention Within First 24 Hours

An immediate response should help to reduce fall risk until more comprehensive care planning occurs. Therefore, an immediate intervention should be put in place by the nurse during the same shift that the fall occurred.

When investigation of the fall circumstances is thorough, it is usually clear what immediate action is necessary. For example, if the resident falls on the way to the bathroom because of urgency and poor balance, interventions related to toileting and staff assistance would be appropriate. However, if the resident is found on the floor between the bed and the bathroom and staff do not look for clues such as urine or footwear or ask the resident questions, immediate care planning is much more difficult.

Some examples of immediate interventions are:

• Increased toileting with specified frequency of assistance from staff.
• Increased assistance targeted for specific high-risk times.
• Increased monitoring using sensor devices or alarms.
• Increased staff supervision targeted for specific high-risk times.
• Pain management.
• Protective clothing (helmets, wrist guards, hip protectors).
• Safe footwear.
• Low bed/mat.
• Specific behavior management strategies.

Documentation of the immediate response on the medical record is important. Missing documentation leaves staff open to negative consequences through survey or litigation.

6. Complete Falls Assessment

In addition to the clues discovered during immediate resident evaluation and increased monitoring, the FMP Falls Assessment is used for a more in-depth look at fall risk. Five areas of risk accepted in the literature as being associated with falls are included. They are:

• Medications—antidepressants, antipsychotics, benzodiazepines, sedative/hypnotics and digoxin.
• Orthostatic hypotension.
• Poor vision.
• Impaired mobility.
• Unsafe behavior.

The resident's footwear and foot care as well as environmental and equipment safety concerns should also be assessed. In the FMP, these factors are part of the Living Space Inspection. (Go to Chapter 6)

Because the Falls Assessment will include referrals for further workup by the primary care provider or other health care professionals, contact with the appropriate persons should be made quickly. Automatic faxes are used to communicate with the resident's physician, nurse practitioner or physician's assistant. The Primary Care Provider FAX Report and Orders introduces the FMP, presents results of the resident's Falls Assessment and provides a form to fax back orders. The FAX Back Orders sheet and the Falls Assessment should be placed on the medical record once completed. A copy of this 3-page fax is in Appendix B. More information on step 6 appears in Chapter 4.

7. Develop Plan of Care

Results of the Falls Assessment, along with any orders and recommendations, should be used by the interdisciplinary team to develop a comprehensive falls care plan within 1-7 days after the fall. The Fall Interventions Plan should be used by the Falls Nurse Coordinator as a worksheet and to record the final interventions selected for the resident. The interventions listed on this form are grouped in the same five risk areas used for the Falls Assessment.

Often the primary care plan does not include specific enough detail to effectively reduce fall risk. Safe footwear is an example of an intervention often found on a care plan. Yet to prevent falls, staff must know which of the resident's shoes are safe. This level of detail only comes with frontline staff involvement to individualize the care plan. The Fall Interventions Plan should include this level of detail.

More information on step 7 appears in Chapter 4.

8. Monitor Staff Compliance and Resident Response

While the falls care plan may include potentially effective interventions, it is staff compliance that will reduce fall risk. A program's success or failure can only be determined if staff actually implement the recommended interventions. Thus, monitoring staff follow-through on the unit is necessary once the care plan has been developed.

Resident response must also be monitored to determine if an intervention is successful. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input.

The Fall Interventions Monitor provides a method to document staff implementation, effectiveness of selected interventions and any necessary revisions.

More information on step 8 appears in Chapter 4.

What Action Will the Nurse Take First

Source: https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html

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