Clinical Process Guideline

1. Clinical Process Guideline Evaluation of Falls/Fall Risk Deborah Ayers RN-MSN

2. Learning Objectives • Following this presentation the audience will be able to: • Verbalize the assessment/recognition of long term care risk for falls. • Verbalize possible causes of falls in long term care residents. • Verbalize cause specific interventions to prevent or minimize resident fall risk, falls and complications from falls. • Will be able to verbalize methods of monitoring the resident’s response to fall interventions.

3. Fall Definition • “Any unplanned descent from a higher elevation to a lower elevation.” • Also count near- falls • Also count roll outs from a mattress on to the • floor

4. Falls Process Guidelines • Assessment/Problem Definition

5. Falls Process Guidelines • Assessment/Problem Analysis • History • External Factors • Internal Factors

6. Falls Process Guidelines • Assessment/Problem Analysis • Refer to the (RAPs) for possible causes of falls

7. Falls Process Guidelines • Assessment/Problem Analysis • Documentation of notification of physician/extender related to significance of falls or falls risk in the resident.

8. Falls Clinical Process Guidelines • Diagnosis/Cause Identification • Identify and document risk factors in the RAP: External factors

9. Falls Process Guidelines • Diagnosis/Cause Identification • Identify and document risk factors in the RAP: Internal factors

10. Falls Process Guidelines • Diagnosis/Cause Identification • Physician or physician extender participates in the evaluation of the resident to identify the causes of falls or fall risks

11. Falls Clinical Process Guidelines • Treatment/Problem Management • Care plan should contain cause-specific interventions to prevent or minimize fall risk, falls, or complications from falls OR the care plan is modified to accommodate the expectation of continued risk.

12. Falls Clinical Process Guidelines • Treatment/Problem Management • Documentation of the physician involvement in the development of cause-specific fall interventions.

13. Falls Clinical Process Guidelines • Treatment/Problem Management • If the resident falls, (without another obvious cause) the physician documentation should reflect a trail adjustment of medications or medication combinations.

14. Falls Clinical Process Guidelines • Treatment/Problem Management • Is there evidence to indicate the care plan has been implemented?

15. Falls Clinical Process Guidelines • Monitoring • Document monitoring of the resident’s response to interventions. • Document a periodic review of approaches for applicability to the current situation.

16. Falls Clinical Process Guidelines • Monitoring • Care plan documentation that reflects previously selected interventions were re-evaluated if falling continued.

17. Falls Clinical Process Guidelines • Monitoring • After a fall associated with injury occurs documentation should reflect notification of the physician.

18. Falls Clinical Process Guidelines • Monitoring • Document that actual consequences were addressed, based on prominence of s/s, with re-evaluation until stable.

19. Falls Clinical Process Guidelines • Monitoring • Document observation for possible delayed consequences of a fall ( late evidence of fracture, subdural hematoma, etc.) for at least 48 hours).

20. Falls Clinical Process Guidelines • Monitoring • Documentation of staff awareness of policy/procedures for resident falls

21. References • American Medical Directors Association & American Health Care Association Falls and Fall Risk Clinical Practice Guideline, 2003 • Joint Commission on Accreditation of Healthcare Organizations, Sentinel Event Alert, Issue 14, July 12, 2000. • JSC, Ink. 1999 Update MDS User’s Manual V 2.0, Watertown, Maine