Fall precautions - page 2

Hi, my name is Laura Jones. I am a RN pursuing my BSN through University of South Alabama. I am working on one of my final projects for my degree and would appreciate your help. I am to have a... Read More

  1. by   SixFive
    on admission, we use the FAST (tool) which stand for Fall Assessment Screening Tool. That gives you a number, and if it is over 60, then that patient is a high risk for falling. That means bed and wheelchair alarms. Other patients who might not score 60 but have fallen recently in the hospital or at home, have periods of confusion, family reports they are unsafe, etc. we bump them up to a high fall risk.

    High fall risk patients have a red sticker at the door, above their bed, and on their wheelchair. They can not be left alone in their room unless they are in bed (or with a competent family member who knows not to leave them in the room unattended). They can not be left in the bathroom unattended. They are rounded on q 30 minutes at minimum and more if that is needed. All patients must have some sort of non-skid footware when transferring. All patients must have the gait belt used on transfers.

    We are not a restraint free facility, but they are only used in the rarest of circumstances (both physical and chemical). SR up x 4 is also considered a restraint. We also do not utilize 1:1 staffing. We do encourage and sometimes mandate that the family provide 1:1 supervision either by the patient's family/friends or with a Home Instead type service.

    If a patient is made a red tag or high falls risk, and they are not confused or have shown no unsafe acts, the nurse can make the judgement and per medically approved protocol write an order and decrease the patient to a moderate risk.
  2. by   RedWeasel
    all of our seatbelts must be able to be released by the patient or it is considered a restraint. Siderails x4 is a restraint and needs to be reviewed q24 hours at our hospital. Thing is no matter what you can't prevent them all....which is hard to swallow if it is your patient on your shift...
  3. by   GRANNAS4
    Our hospital is revising our Fall precautions policies. We use Hendrick11 risk assessments with hourly rounding. My problem is how to document this hourly rounding. We chart electronically, however access to computers leads to summary charting. Paper charting in the room good, but not an electronic record. What are you doing in your facilities?
  4. by   Rehabme
    Hi All

    I use similar stratergies to manage falls on my unit. One of the major challenges that we face is patients falling from wheel chairs. Most of them are when they slideboard transfer or reach for the things that they drop on the floor. Tried to attach reachers to wheel chairs but have had not much luck at all. Any suggestions would be more than welcome.
  5. by   Seasoned
    to grannas4,

    re: hourly fall status electronic charting
    remember on any given documentation you can right click for the "comment" menu to appear as you document the hourly status of sleep, so during the night shift you can insert it there that way.

    during the day and evening shift hours (7a-11p) the hourly attention to fall can be done in the same way in the "ad hoc" systems listing each hour. please, don't forget about consulting with your informatics dept who direct you for consistency at your facility.

    but ... also consider you may be defeating the purpose of electronic charting. for example, the q 15 min check sheets routinely used on patients in a psychiatric facility are purposely not used in electronic charting. the sheets are a "work sheet" so you can "summarize" the hour, the shift, or the time of say the unusual observation. a hourly record on eemr (electronic medical record) is not mathematically accurate / possible, i.e. "will not hold up in court" in the event of an incident. the reason is it is not humanely possible for one person to really observe more than one person q hour or q 15 min at the same time and provide other care necessities for other patient, do unit tasks, go to personal or patient bathroom breaks / or off unit trips, attend to crisis, admissions ... etc. and swear all the patients on that specific time slot were actually under the same observation on those same time slots. yet that is what the hourly documentation is stating with out a qualifying narrative.

    it's the imperfection of the eemr that does not accommodate the subjective. it ends up being for your legal protection, if you think outside the box.

    i strongly suggest that you contact your informatics dept and do what they say. opinions from other nurses from other facilities might create liabilities at your facility. - seasoned
  6. by   hollierncrrn
    Hello I have worked in an acute rehab faclilty for the last eight years. We consider all of our patients to be at a risk for falls secondary to mobility impairment. We have fall risk screening assessment that is completed on each pt when they are admitted that scores them as a low, med, or high risk for falls. Each category has appropriate interventions listed based on what level they are. Our physiatrist also orders alarms for all incoming patients until they have proven that they will call for assistance, (even those that are alert and oriented) as the change in surroundings can sometimes trigger confusion. We utilize personal (clip on alarms), and bed alarms. Our bed alarms include the pressure pads where the pt has to be out of bed for it to alarm, or actual alarm beds. The alarm beds have a zone setting that can be set so that it alarms if a patient just sits up in bed. Also, any patient that has alarms is automatically a "Do not leave alone in the bathroom". Room assignments are made so that the patients that are the most confused are closest to the nurses station. We also occasionally do one on one nursing for those patients that are very confused and impulsive. I believe that the only restraints that we have used in the last year are mits to keep patients from pulling out their tubes, IVs, trachs, etc... We do not use hip pads as there have been studies that document that they are not very effective in preventing fractures. Of course we also utilize gait belts, proper footwear, keep the rooms free from clutter, etc... We also use orientation boards hung where they are in clear view of the patient that help orient them to place, date, and include a reminder to call the nurse for assistance. Hope this helps!
  7. by   scholarshipboy
    Quote from MS._Jen_RN
    Hi, I'm in Michigan. I work in a 40 bed acute rehab unit. We use the following to prevent falls and other injuries:
    Bed rails up X's 4
    Lap belt restraints
    Pelvic restraints
    Net beds (that's what we call them- I think you said Vail-that's a brand name)
    Bed and chair alarms
    Soft wrist restraints (at times to prevent untying the lap belts)
    Moving the patient to a room near the RN's station
    Signs in the room to remind the patient to call for help
    Appropiate foot wear at all times (no-skid booties, shoes etc)
    A personal companion (sitter)

    It all depends on the patient and why they are a fall risk. If you have any further questions post here or PM me.

    thanks jen good stuff
  8. by   MAIDEN25
    I was reading everyones post and am shocked to see how many people still use RESTRAINTS!!! I believe they just make the situation worse. I work in a rehab with TBI (traumatic brain injuries) spinal cords, strokes, ortho. We have NO restraints. Its a 89 bed facility and we average about 5 falls a month at the most. We use a sign outside the door that says LAMP(look at me please), we use low beds, floor mats, some rooms are monitored by cameras, call light in reach, fall risk assessment done every week, the pt.s use non skid socks, we have cradel beds. Im not trying to say what works best but i notice when i worked at the trauma center and they restrained pts it just made them madder. What ever happened to pts rights????