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Fall Risk Assessment
Fall Prevention Resources
Select the category of resources from the menu above or browse this list for available resources
Bed Safety Checklist
Fall Risk Assessment
Fall Prevention Program Guideline
Fall Risk Level Tool
The High Fall Risk Room Set Up
Facts About Fall Risk Assessment
To be effective, assessment tools need to be sensitive (correctly identify high risk patients/residents) and specific (correctly identify patients/residents not at risk) and, perhaps most importantly, be easy for nurses to use (embedding the fall risk
assessment tool into existing nursing assessments helps with “buy-in” and acceptance of the tool/process).
Download a printable copy of the
Fall Risk Assessment Poster
This reference correlates to the online continuing education course
Managing Falls In the Nursing Home: Who, Why, and What Next?
.
Purpose of Fall Risk Assessment
Identify patient/resident problems (rational basis for deciding whether risk exists)
Identify those patients/residents most likely to fall
Trigger further fall-related assessments (multidisciplinary)
Identify interventions (guide patient/resident care planning)
Raise staff awareness of fall/injury risk.
When to Conduct Fall Risk Assessments
Upon admission
Post-fall
Upon change of health condition (including medication changes)
Daily/every shift (confused patients/residents; patients/residents taking sedatives, recent fall, etc.)
COMPONENTS
FALL RISK FACTORS
Diseases/Conditions
History of falls
Impaired vision/hearing
Urinary problems (toileting needs)
Muscle weakness
Gait/balance impairment
Dizziness
Orthostatic hypotension
Mobility impairment (impaired bed, chair and/or toilet transfers)
Uses cane/walker
Medications
Polypharmacy (>5 medications)
Psychotropics
Diuretics
Antihypertensives
Antiseizure
Benzodiazepines
Hypoglycemics
Sedative/hypnotics
Mental Status
Dementia
Depression
Delirium
Impaired 'safety' judgment
Disruptive behaviors
Non-English speaking
Exhibits unsafe behavior
Lacks understanding of mobility limitations
Situational Conditions
New admission
Floor-to-floor transfer
Post-fall
Change of condition and/or starting fall risk medication
Tideiksaar, R. Falls in Older People: Prevention and Management. 4th Edition.
Health Professions Press, Baltimore, MD 2010
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