Transcript Falls Reduction In the Hospice Inpatient Units

Falls Reduction
In the hospice Inpatient Units
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Holly Nunemaker RNTL – Leader
Michelle Basilius, HA
Kathy Willey , RN
Deb Deuschle RNTL
Katie Perkins
Sallie Eddie, RN
Marie Wolfram, RN
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 Know
the definition of a fall
 Know
when and how to use the
Morse Falls Risk assessment
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1.They
are usually weak
2.They are on multiple medications
3.They are often confused or forgetful
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A
fall is any unplanned or
unexpected change in position
resulting in the individual landing
in a lower position.
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The
following are not considered falls and do not
need to be reported on an Incident Report. They
should be documented in the patient’s chart and
communicated to the patient’s other team
members. Clinical judgment should be used in
determining if an event is a fall.
1. When
the patient is lowered to the floor in a
controlled manner
2. The patient rolls from a High Low bed onto the
floor mats
3. When the patient stands up and quickly moves
back onto the bed, chair or commode.
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Physician:
1. Immediately
if there is patient injury
2. At the time of discovery of an unwitnessed
fall with status changes or apparent injury
3. If no status change or apparent injury
notification can be with next physician
update.
Family:
1. Anytime
there is a fall
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“The Morse Fall Scale is a rapid and simple
method of assessing a patient’s likelihood
of falling.”
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The Morse Falls Risk Scale is
completed by the direct care nurse
upon admission/transfer to the
inpatient unit and when the patient
has a fall.
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The Morse Score is documented in
Cerner as a separate profile and the
Morse Score and date of last fall are
on the patient’s Kardex to be included
in shift report.
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1.
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History of falling in the past three
months
Secondary diagnosis (patient has more
than 1 diagnosis)
Ambulatory aid needed, e.g. walker
IV or heparin lock
Gait/transfer
Mental status
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Scale
Scoring
1. History of Fall
No
Yes
0
25
2. Secondary Diagnosis
No
Yes
0
25
3. Ambulatory Aid
Bed rest/nurse assist
Crutches/Cane/Walker
Furniture
0
15
30
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Item
Scale
4. IV/Heparin Lock
No
Yes
Scoring
0
20
5. Gait/Transferring
Normal/Bedbound/Immobile
Weak
Impaired
0
10
20
6. Mental Status
Oriented to own ability
Forgets Limitations
0
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1. Foley
catheters are tripping risks, increase
potential for UTI, may increase bladder
discomfort causing urgency – all increase
fall risk
2. Oxygen tubing can cause tripping or
entanglement
3. IVs increase mobility difficulties including
tripping and entanglement as well as the IV
pole being difficult to maneuver.
4. CADD pumps are cumbersome to hold
during ambulation
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Risk Level
Morse Score
Action
No Risk
0-24
Good Basic Nursing Care
Low Risk
25-50
Implement Standard Fall
Risk Prevention
Interventions
High Risk
51 or greater
Implement High Risk Fall
Prevention Interventions
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Call light education and within reach
Items in reach, e.g. phone, remote and
water
Upper side rails for mobility
Brakes on bed, wheelchair, other DME
Family education and involvement
Rounding to ensure interventions are
effective
Whiteboards for communication
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Always continue low risk interventions and consider the
following:
Patient Centered1. Frequent, scheduled toileting
2. Assess for UTI, constipation, blocked Foley
3. Reorient and remind patient/family of availability for
assist for transfer
4. Stargazer (must use based on response of patient)
5. Team Leader/Charge Nurse notification
6. IDT referral
 Volunteer for companionship
 Massage therapy
 PT for strengthening
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Environmental
1. Room near nurse’s station
2. High Low bed if unable to walk/stand
3. Signage/Falling Star
4. Maintain calm and quiet environment
5. Involve presence of loved one
6. 1:1 staffing
7. Additional alarms:
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 TABs, 1 or 2
 Bed/chair pad alarm
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Continued
 Pharmacological – goal is to minimize hazardous
behaviors that increase risk for fall injury and
interfere with ability to care for patient
1. Review med list
2. Assess for uncontrolled symptoms including pain,
dyspnea and/or anxiety and medicate as needed.
3. Utilize antipsychotics starting with low dose and
titrate to effect
4. Lorazepam and diazepam may add to confusion and
are not the best meds for these patients unless the
symptoms are related to alcohol withdrawal or
anxiety.
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A fall is any unplanned or unexpected
change in position resulting in the
individual landing in a lower position
Use the Morse Falls Risk assessment upon
Admission/Transfer to the inpatient unit
and any time the patient falls.
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