BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised:

Transcription

1 Page 1 of 5 PROTOCOL FOR: All trained staff PURPOSE: This protocol is designed to identify individuals at risk for falling, and to implement strategies and trainings to minimize those risks. There are many reasons for falls. A fall is any loss of balance or uncontrolled, unintended bodily contact with a surface or object. This includes the floor, furnishings, or other persons. Any individual at risk for falling must have the BAMSI Falls Risk Assessment Form filled out by the Program Nurse. This will help determine a person s fall risk potential and individual risk factors. The designated Program Nurse and Program Manger are to be notified of all falls. If a fall occurs during the off hours (5p-9a), follow the On-Call Procedures. A Falls Assessment is to be done: Upon admission Post fall With any change in condition Individuals at risk for falling: Have a past/recent history of falls Are on 4 or more prescription medications Lack awareness of or are mistaken about time, place or person Are confused Are hearing impaired Have a seizure disorder Have an unsteady balance Need physical or verbal assistance when walking or transferring Require a walking aid Are agitated (show fearful affect, make frequent moves or are anxious) Are impulsive Have poor eye vision Have low blood pressure Have medical health issues such as: cardiac, muscle weakness, arthritis, neurological disorders, osteoporosis, frequent UTI s Fatigue easily Use a wheelchair Require assistance with ADL s

2 Page 2 of 5 When an individual falls, the following must occur: Assess the individual for any injury or unstable medical condition before moving him/her. (see below) Provide immediate first aid. Check vital signs blood pressure, heart rate, respiratory rate, temperature. If an individual has diabetes, consider checking their blood sugar. Notify the Program Manager and/or Program Nurse. If off-hours, follow the On-Call Procedures. Notify PCP. If an individual refuses treatment, PCP must be notified. Falls Risk Assessment Tool do be done as soon as possible. A determination needs to be made when to call 911 for transport. Any major medical emergency requiring IMMEDIATE emergency care MUST be sent to the ER via ambulance. When a fall occurs, emergency assistance is required for any of the following conditions: The individual hits their head (regardless of injury or lack of an apparent injury). The individual is in pain. The individual is bleeding significantly. There is a change in their ambulatory ability. The individual has difficulty moving their arms or legs. When the fall is not witnessed. When any swelling is noticed. If they are on a blood thinner (e.g. Coumadin, Lovenox, Heparin, Plavix). When there is a significant change in their vital signs. The individual is unconscious. The individual has chest pain. The individual is dizzy. The individual cannot move. The individual becomes confused or lethargic. The individual has a significant bruise / hematoma ANY OTHER UNSTABLE, CRITICAL SITUATION THAT YOU FEEL WARRANTS IMMEDIATE MEDICAL ATTENTION.

3 Page 3 of 5 Determine environmental reasons for fall: Assess for: Slip rugs/scatter rugs Wet floor Slick floor Clutter Unstable furniture Low beds/high beds Low toilets Furniture obstructing walkways Poor lighting Cracks in sidewalks Leaves, snow, or ice in driveway or walkways Lack of grab bars Slippery bathtubs or showers Any other contributing factor that has been noted Attempt to identify other reasons for the fall: (Document in Note) Ask staff that were around the details of the fall that they witnessed. Ask the individual if they were dizzy. Determine if the individual slipped or tripped. Did the individual s legs give out? What was the individual doing at the time? Was a new medication started? Was the individual transferring? Is the individual resistant to using equipment, such as walker, cane, etc? Environmental reasons? (see above) Post-fall considerations to reduce an individual s risk for falling: (always start with LEAST restrictive) PT/OT assessment PT/OT assessment for a home evaluation Exit Alarm e.g., pressure sensitive alarm, pressure release alarm, clip on alarm (Supportive and Protective Device Form required and Human Rights Committee approval). Assistive devices for chairs, toilets, and walking

4 Page 4 of 5 Use chairs with arm rests to support safe transfers. Canes, walkers at right height, device being used appropriately, rubber tips not worn, device not broken. Higher bed for ease of transferring or different bed Low boy bed Floor pad Better lighting Bathroom handrails Higher toilets Slip free mats Assess wheelchair anti-tippers, footrests Transfer techniques Staff training If individual has frequent seizures, or serious head injury, consider helmet (Supportive and Protective Device Form required and Human Rights Committee approval). Apply wheelchair brakes, make sure footplates are not in the way. If appropriate, place on a toileting schedule. Non-skid shoes or other appropriate footwear. Consider chest harness (Supportive and Protective Device Form required and Human Rights Committee approval). Consider lap tray (Supportive and Protective Device Form required and Human Rights Committee approval). An Individualized Fall Protocol should address the following: Diagnosis that places individual at risk for falls Other risk factors associated with falls (see Individuals at Risk for Falling above) Individualized interventions/strategies based on identified risk factors PT/OT recommendations, if any A follow-up plan to review protocol/reassess if plan is working Date DOCUMENTATION: Document the fall in the Medical Notes, or on paperwork required by the program. Document: Vital Signs Blood glucose level (if applicable)

5 Page 5 of 5 Time and place of the fall First aid/medical interventions If able to determine, reasons for fall Post-fall interventions (if any) File Falls Risk Assessment tool in medical chart Phone call to PCP, if indicated Review of Falls Protocol Complete funding source required Incident Report After every fall, reassess/review/modify the Falls Protocol as needed.