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Clinical Process GuidelineClinical Process Guideline
Evaluation of Falls/Fall RiskEvaluation of Falls/Fall RiskDeborah Ayers RN-MSNDeborah Ayers RN-MSN
Learning ObjectivesLearning Objectives Following this presentation the audience will be Following this presentation the audience will be
able to: able to: Verbalize the assessment/recognition of long Verbalize the assessment/recognition of long
term care risk for falls.term care risk for falls. Verbalize possible causes of falls in long term Verbalize possible causes of falls in long term
care residents.care residents. Verbalize cause specific interventions to prevent Verbalize cause specific interventions to prevent
or minimize resident fall risk, falls and or minimize resident fall risk, falls and complications from falls.complications from falls.
Will be able to verbalize methods of monitoring Will be able to verbalize methods of monitoring the resident’s response to fall interventions.the resident’s response to fall interventions.
Fall DefinitionFall Definition
““Any unplanned descent from a Any unplanned descent from a higher elevation to a lower higher elevation to a lower
elevation.”elevation.”
Also count near- fallsAlso count near- falls
Also count roll outs from a Also count roll outs from a mattress on to themattress on to the
floorfloor
Falls Process Guidelines Falls Process Guidelines
Assessment/Problem Assessment/Problem DefinitionDefinition
Falls Process GuidelinesFalls Process Guidelines
Assessment/Problem AnalysisAssessment/Problem Analysis HistoryHistory External FactorsExternal Factors Internal FactorsInternal Factors
Falls Process GuidelinesFalls Process Guidelines
Assessment/Problem Assessment/Problem AnalysisAnalysis
Refer to the (RAPs) for Refer to the (RAPs) for possible causes of fallspossible causes of falls
Falls Process GuidelinesFalls Process Guidelines
Assessment/Problem AnalysisAssessment/Problem Analysis
Documentation of notification of Documentation of notification of physician/extender related to significance of physician/extender related to significance of falls or falls risk in the resident. falls or falls risk in the resident.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
Diagnosis/Cause Diagnosis/Cause IdentificationIdentification
Identify and document Identify and document risk factors in the RAP: risk factors in the RAP: External factorsExternal factors
Falls Process GuidelinesFalls Process Guidelines
Diagnosis/Cause IdentificationDiagnosis/Cause Identification
Identify and document risk factors in the RAP: Identify and document risk factors in the RAP: Internal factorsInternal factors
Falls Process GuidelinesFalls Process Guidelines
Diagnosis/Cause Diagnosis/Cause IdentificationIdentification
Physician or physician Physician or physician extender participates in extender participates in the evaluation of the the evaluation of the resident to identify the resident to identify the causes of falls or fall causes of falls or fall risksrisks
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
Treatment/Problem ManagementTreatment/Problem Management
Care plan should contain cause-specific Care plan should contain cause-specific interventions to prevent or minimize fall risk, interventions to prevent or minimize fall risk, falls, or complications from falls OR the care falls, or complications from falls OR the care plan is modified to accommodate the plan is modified to accommodate the expectation of continued risk.expectation of continued risk.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
Treatment/Problem Treatment/Problem ManagementManagement
Documentation of the Documentation of the physician involvement physician involvement in the development of in the development of cause-specific fall cause-specific fall interventions.interventions.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
Treatment/Problem ManagementTreatment/Problem Management
If the resident falls, (without another obvious If the resident falls, (without another obvious cause) the physician documentation should cause) the physician documentation should reflect a trail adjustment of medications or reflect a trail adjustment of medications or medication combinations.medication combinations.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
Treatment/Problem Treatment/Problem ManagementManagement
Is there evidence to Is there evidence to indicate the care plan indicate the care plan has been implemented?has been implemented?
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
MonitoringMonitoring
Document monitoring of the resident’s Document monitoring of the resident’s response to interventions.response to interventions.
Document a periodic review of approaches for Document a periodic review of approaches for applicability to the current situation.applicability to the current situation.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
MonitoringMonitoring
Care plan Care plan
documentation that documentation that reflects previously reflects previously selected interventions selected interventions were re-evaluated if were re-evaluated if falling continued.falling continued.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
MonitoringMonitoring
After a fall associated with injury occurs After a fall associated with injury occurs documentation should reflect notification of documentation should reflect notification of the physician.the physician.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
MonitoringMonitoring
Document that actual Document that actual consequences were consequences were addressed, based on addressed, based on prominence of s/s, with prominence of s/s, with re-evaluation until re-evaluation until stable.stable.
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
MonitoringMonitoring
Document observation for possible delayed Document observation for possible delayed consequences of a fall ( late evidence of consequences of a fall ( late evidence of fracture, subdural hematoma, etc.) for at least fracture, subdural hematoma, etc.) for at least 48 hours).48 hours).
Falls Clinical Process GuidelinesFalls Clinical Process Guidelines
MonitoringMonitoring
Documentation of staff Documentation of staff awareness of awareness of policy/procedures for policy/procedures for resident fallsresident falls
ReferencesReferences
American Medical Directors Association & American Medical Directors Association & American Health Care Association Falls and American Health Care Association Falls and Fall Risk Clinical Practice Guideline, 2003Fall Risk Clinical Practice Guideline, 2003
Joint Commission on Accreditation of Joint Commission on Accreditation of Healthcare Organizations, Sentinel Event Healthcare Organizations, Sentinel Event Alert, Issue 14, July 12, 2000.Alert, Issue 14, July 12, 2000.
JSC, Ink. 1999 Update MDS User’s Manual V JSC, Ink. 1999 Update MDS User’s Manual V 2.0, Watertown, Maine2.0, Watertown, Maine