Page 99 - Flipbook January Board

Low Fall Risk Moderate Fall Risk High Fall Risk
Fall risk score: 0-5 Points Fall risk score: 6-13 Points Fall risk score: >13 Points

Maintain safe unit environment, Including:

Remove excess equipment/supplies/furniture from
rooms and hallways.

Coil and secure excess electrical and telephone Institute Fall Packet
wires. Yellow Fall Alert sign displayed in room
Clean all spills in patient room or in hallway Institute Fall Packet and additional identification

immediately. Place signage to indicate wet floor Yellow Slipper Socks or other non-skid footwear of fall risk as described under Moderate Fall Risk
(i.e., rubber soled shoes or slippers)
danger. Review Stay Independent Brochure.

The following are basic safety interventions: In addition to measures listed under Moderate
Orient patient to surroundings including bathroom Activate Fall Risk Additional Identification of Fall and Low Fall Risk:
Risk
location, use of bed, and location of call light. Fall alert tab/sign outside room Do not leave patient unattended during toileting

Keep bed in lowest position during use unless In addition to measures listed under Low Fall Risk: or ambulating
impractical (as in ICU nursing or specialty beds). Monitor and assist patient in following daily Frequent visual checks

Keep top 2 side rails up (excludes specialty beds). schedules. Bed/Chair alarm. Use Y-connector for chair
Secure locks on beds, stretchers, and wheelchairs. Supervise and/or assist bedside sitting, personal alarms. Alarm zone must be communicated on

Keep floors clutter/obstacle free (with the attention hygiene, and toileting as appropriate. the bedside white board
to path between bed and bathroom/commode).
Place call light and frequently needed objects within Reorient confused patients as necessary.
Establish elimination schedule, including use of
patient reach. bedside commode, if appropriate Evaluate need for the following, starting with less
Answer call light promptly. restrictive to more restrictive measures in the

Encourage patients/families to call for assistance If patient must leave the unit, notify receiving area listed order:
of fall risk via Travel Log
when needed. Ask MD for PT consults if patient has a history of fall Moving patient to room with best visual access

Display special instructions for vision and hearing. to nursing station.
Assure adequate lighting especially at night. and/or mobility impairment. Specialty fall prevention bed, if available.
Use properly fitting nonskid footwear/green slipper Evaluate need for: 24-h supervision/sitter.

socks Physical restraint/enclosed bed (only if less
Communicate Fall Risk Level on the bedside white OT consults. restrictive alternatives have been considered and

board found to be ineffective).
All Stryker beds must be plugged into the nurse call Use Gait Belt or Safe Patient Handling equipment
for ambulation or transfer.
system and must be set to “Zero” before occupied

by a patient for the first time
Fall risk status reviewed during bedside report and

hourly rounding.