managing-fall-prevention

# Managing Fall Prevention

Implements fall risk assessment (Morse, Hendrich) with intervention protocols for hospitalized patients.

## Why This Skill Exists

Inpatient falls are the most commonly reported adverse event in US hospitals, occurring at a rate of 3-5 per 1,000 patient-days. Approximately 30% of inpatient falls result in injury, and 2-6% result in serious injury including fractures, subdural hematomas, and death. CMS classifies falls with injury as a "never event" (Hospital-Acquired Condition) and does not provide additional reimbursement for the treatment of fall-related injuries sustained during hospitalization. This creates both a patient safety imperative and a financial one.

The Joint Commission NPSG 09.02.01 requires hospitals to implement a fall reduction program, including risk assessment on admission and reassessment at defined intervals. The Morse Fall Scale (MFS) and Hendrich II Fall Risk Model are the two most widely validated tools for inpatient fall risk stratification. Evidence-based multifactorial fall prevention programs reduce falls by 20-30%, but only when assessments are accurately completed and interventions are consistently implemented.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

Before assessing or managing fall prevention, confirm:

1. Which **fall risk assessment tool** does the institution use — Morse Fall Scale, Hendrich II, or a proprietary tool? *(Default: Morse Fall Scale)*
2. Has the patient been **assessed on admission** and at every **shift change**? *(Default: Per institutional protocol)*
3. Does the patient have a **fall history** — any falls in the past 3 months (home or hospital)? *(Default: Ask patient and review medical record)*
4. What **medications** is the patient taking that increase fall risk — sedatives, opioids, antihypertensives, diuretics, psychotropics? *(Default: Review MAR)*
5. What is the patient's **mobility status** — ambulatory, requires assistance, bed-bound? *(Default: Per PT/OT assessment and nursing evaluation)*
6. Does the patient have **cognitive impairment** — delirium, dementia, confusion? *(Default: Assess mental status; CAM screen for delirium)*
7. Are there **environmental hazards** in the patient's room — wet floors, clutter, poor lighting, bed height? *(Default: Nursing environmental assessment)*
8. Has the patient had a **previous fall during this admission**? *(Default: Check incident reports)*

### Documents to Request

- Admission fall risk assessment score (Morse or Hendrich II)
- Nursing shift assessments with fall risk scores
- Medication list flagged for fall-risk medications
- PT/OT mobility assessment and recommendations
- Incident reports for any falls during admission
- CAM (Confusion Assessment Method) screening results
- Prior hospitalization fall history
- Home fall risk assessment (if available)

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## Step 1: Calculate the Morse Fall Scale Score

The Morse Fall Scale (MFS) uses six variables:

| Variable | Criteria | Score |
|----------|----------|-------|
| **History of falling** (immediate or within past 3 months) | No = 0, Yes = 25 | 0 or 25 |
| **Secondary diagnosis** (≥ 2 medical diagnoses) | No = 0, Yes = 15 | 0 or 15 |
| **Ambulatory aid** | None / bed rest / wheelchair = 0; Crutches / cane / walker = 15; Furniture = 30 | 0, 15, or 30 |
| **IV therapy / heparin lock** | No = 0, Yes = 20 | 0 or 20 |
| **Gait** | Normal / bed rest / immobile = 0; Weak = 10; Impaired = 20 | 0, 10, or 20 |
| **Mental status** | Oriented to own ability = 0; Overestimates ability / forgets limitations = 15 | 0 or 15 |

**Total score range: 0-125**

| Risk Level | Score | Interventions |
|------------|-------|--------------|
| **No risk** | 0-24 | Standard precautions |
| **Low risk** | 25-50 | Standard fall prevention interventions |
| **High risk** | ≥ 51 | High-risk fall prevention protocol |

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## Step 2: Alternative — Hendrich II Fall Risk Model

| Variable | Score |
|----------|-------|
| Confusion / Disorientation / Impulsivity | 4 |
| Symptomatic depression | 2 |
| Altered elimination | 1 |
| Dizziness / Vertigo | 1 |
| Male gender | 1 |
| Antiepileptics administered | 7 |
| Benzodiazepines administered | 1 |
| Get Up and Go test: Unable to rise in one attempt | 4 |

**Score ≥ 5 = High risk**

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## Step 3: Implement Tiered Interventions

### Universal Precautions (All Patients)
- Bed in lowest position when unattended
- Wheels locked on bed and wheelchair
- Call bell within reach at all times
- Non-skid footwear for ambulation
- Adequate room lighting (nightlight at minimum)
- Personal belongings within reach
- Clutter-free path to bathroom
- Orientation to room and call bell on admission

### Low-Risk Interventions (Morse 25-50)
All universal precautions PLUS:
- Yellow fall-risk wristband applied
- Fall risk sign posted at bedside
- Toileting schedule (offer assistance every 2 hours)
- Medication review for fall-risk drugs (see Step 4)
- Bed alarm activated when patient is in bed unattended
- Assistive device at bedside (if used at home)

### High-Risk Interventions (Morse ≥ 51)
All low-risk interventions PLUS:
- 1:1 sitter or enhanced observation (consider before restraints)
- Room close to nursing station
- Hourly purposeful rounding (pain, position, potty, possessions)
- PT/OT consultation for safe mobility plan
- Chair alarm in addition to bed alarm
- Non-pharmacologic delirium prevention bundle (orientation board, glasses/hearing aids, sleep hygiene, early mobilization)
- Physician review of fall-risk medications with taper or discontinuation plan

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## Step 4: Medication Review for Fall Risk

Flag and review these high-risk medication classes:

| Medication Class | Risk Factor | Intervention |
|-----------------|-------------|--------------|
| **Benzodiazepines** | Sedation, ataxia, impaired balance | Taper or discontinue; use non-pharmacologic alternatives for anxiety/insomnia |
| **Opioids** | Sedation, dizziness, orthostatic hypotension | Minimize dose; use multimodal pain management |
| **Antihypertensives** | Orthostatic hypotension | Check orthostatic vitals; hold or reduce dose if symptomatic |
| **Diuretics** | Volume depletion, electrolyte imbalance, orthostatic hypotension | Monitor volume status; check electrolytes; reduce dose if over-diuresed |
| **Antipsychotics** | Sedation, extrapyramidal effects, orthostatic hypotension | Use lowest effective dose; reassess indication |
| **Anticonvulsants** | Sedation, ataxia, dizziness | Monitor levels; consider dose adjustment |
| **Hypoglycemic agents** | Hypoglycemia causing weakness, confusion | Monitor glucose closely; adjust insulin/oral agents |
| **Antihistamines** (diphenhydramine) | Sedation, anticholinergic effects, confusion | Avoid in elderly (Beers Criteria); use alternatives |

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## Step 5: Post-Fall Protocol

If a fall occurs despite prevention measures:

1. **Immediate assessment**: Vital signs, neurological exam, pain assessment, injury inspection
2. **Imaging**: If head strike or altered mental status — CT head without contrast; if extremity pain — X-ray of affected area
3. **Anticoagulation check**: If patient is on anticoagulants — obtain CT head even without symptoms (delayed intracranial hemorrhage risk)
4. **Incident report**: Complete institutional incident/event report within 24 hours
5. **Root cause analysis**: Why did the fall occur despite interventions? What was the patient doing? Were interventions in place? Were alarms functioning?
6. **Updated care plan**: Reassess Morse score, escalate interventions, notify physician and family
7. **Documentation**: Time of fall, circumstances, injuries, interventions, notification of physician and family

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## Checkpoint B: Post-Draft Alignment (Mandatory)

After implementing fall prevention measures:

1. Is the **fall risk score** documented and current (reassessed per protocol)?
2. Are **interventions** appropriate for the score level and consistently implemented?
3. Have **fall-risk medications** been reviewed with a documented plan to minimize or eliminate?
4. Is the **patient's room environment** assessed and hazard-free?
5. Has the patient/family received **fall prevention education**?

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## Quality Audit

- [ ] Fall risk assessment completed on admission
- [ ] Fall risk reassessed every shift and with clinical status changes
- [ ] Morse Fall Scale (or equivalent) score accurately calculated
- [ ] Risk-appropriate interventions implemented (universal, low-risk, high-risk)
- [ ] Fall-risk wristband applied for at-risk patients
- [ ] Bed alarm activated for at-risk patients when unattended
- [ ] Fall-risk medications reviewed and minimized
- [ ] Orthostatic vital signs checked for patients on antihypertensives/diuretics
- [ ] PT/OT consultation ordered for high-risk patients
- [ ] Patient/family education documented
- [ ] Hourly rounding implemented for high-risk patients
- [ ] Post-fall protocol followed for any fall event (assessment, imaging, incident report)
- [ ] Room environment assessed for hazards (clutter, lighting, wet floors)
- [ ] Restraint use is a last resort with documented justification and time-limited orders

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## Guidelines

- Fall risk assessment must be repeated every shift and with any change in clinical status (new medication, procedure, delirium onset)
- Bed alarms are an adjunct, not a replacement for nursing assessment — they alert, but do not prevent falls
- Restraints are the last resort and require specific physician orders with time limits and regular reassessment — restraints themselves increase injury risk
- The most effective fall prevention intervention is toileting assistance — most falls occur on the way to or from the bathroom
- Encourage early mobility with appropriate assistance rather than restricting activity — immobility increases deconditioning and long-term fall risk
- Avoid diphenhydramine (Benadryl) as a sleep aid in elderly patients — it is on the Beers Criteria list and significantly increases fall and delirium risk
- Post-fall CT head is mandatory for patients on anticoagulants, even if the patient denies head strike — subdural hematoma can be delayed
- Document fall prevention education with patient and family, including the patient's understanding of their own fall risk and what to do before getting up