Falls The Assessment, Prevention and Management of Patient Falls (Adult Services) 1.34

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1 SECTION: 1 PATIENT CARE Including Physical Healthcare POLICY /PROCEDURE: 1.34 NATURE AND SCOPE: SUBJECT (Title): POLICY AND PROCEDURE - TRUST WIDE FALLS: THE ASSESSMENT, PREVENTION AND MANAGEMENT OF PATIENT FALLS (ADULT SERVICES) The purpose of this policy is to detail the Trust s responsibility and processes for the assessment, prevention and management of patient falls within all adult services within Nottinghamshire Healthcare NHS Foundation Trust DATE OF LATEST RATIFICATION: NOVEMBER 2014 RATIFIED BY: EXECUTIVE LEADERSHIP TEAM REVIEW DATE: NOVEMBER 2017 IMPLEMENTATION DATE: NOVEMBER 2014 (REISSUED JULY 2016 & MAY 2017) ASOCIATED TRUST POLICIES AND PROCEDURES: Using Bedrails Safely and Effectively 3.06 Reporting of Accidents, Incidents and Near Miss situations including Serious Incidents Health, Safety and Welfare Preventing Slips, Trips and Falls (including falls from height) Manual Handing and Back Care Observation and Engagement of Patients 1.02 ISSUE 3 MAY 2017

2 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST FALLS: THE ASSESSMENT, PREVENTION AND MANAGEMENT OF PATIENT FALLS (ADULT SERVICES) 1.0 Introduction 2.0 Policy Principles 3.0 Definitions 4.0 Duties 5.0 Risk Assessment 6.0 Implementation 7.0 Training 8.0 Target Audience 9.0 Review Date 10.0 Consultation 11.0 Relevant Trust Policies 12.0 Monitoring Compliance 13.0 Equality Impact Assessment 14.0 Legislation Compliance 15.0 Champion & Expert Writer 16.0 References /Source Documents Appendix 1 Appendix 2 Appendix 3 Case Note Audit Post Falls Protocol Record of Changes CONTENTS ISSUE 3 MAY

3 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST FALLS: THE ASSESSMENT, PREVENTION AND MANAGEMENT OF PATIENT FALLS (ADULT SERVICES) 1.0 INTRODUCTION 1.1 The purpose of this policy is to detail the Trust s responsibility and processes for the assessment, prevention and management of patient falls within all adult services (people aged 18 and over) within Nottinghamshire Healthcare NHS Trust. 1.2 A patient falling is the most common patient safety incident reported to the National Patient Safety Agency. Falls are the leading cause of accident- related death in people over 75 years of age. Although the majority of falls are reported to result in no harm, even falls without injury can be upsetting and lead to loss of confidence, increased length of stay in hospital and increased likelihood of discharge to residential or nursing care home (NPSA, 2007). 1.3 Each year a third of people aged over 65 and half of those aged over 80 living in the community will fall each year (NICE, 2013). 1.4 The vast majority of published research into falls prevention relates to adults aged over 65, yet it is recognised that adults under the age of 65 with underlying medical conditions that increase the risk of falls also require assessment and intervention to reduce their risk of falls (NICE, 2013). 1.5 Half of those who fall will fall again within a year. 1.6 Falls are caused by multiple, diverse and interacting causes and situations and many falls are preventable and risk factors reversible. 1.7 People are often unaware of their risk of falling or unaware of the risk factors that can cause falls and opportunities to prevent falls are often overlooked with risk factors often only become evident after injury has occurred. 1.8 Preventing and managing falls however must be balanced with patients rights to dignity, privacy, independence, rehabilitation and their choices about the risks they are prepared to take. 1.9 Falls prevention involves identifying risk factors for falling and subsequently instituting targeted strategies to help reduce or eliminate the identified factors. 2.0 POLICY PRINCIPLES 2.1 The purpose of this policy is to ensure all adults in contact with services within the Trust receive safe and high-quality health care with ongoing quality improvement. 2.2 This Policy is deliberately written in broad terms so that it can be customised to different service environments and unique patient populations served by a specific Trust service. 2.3 The purpose of the policy is to guide clinical staff in identifying adult patients at risk of falling or with a history of falls and to identify the interventions required to reduce the risk of a fall or fall related injury for each individual. 3.0 DEFINITIONS ISSUE 3 MAY

4 3.1 Fall a fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level (World Health Organisation, 2012). 4.0 DUTIES 4.1 Each Director / General Manager / Head of Service has responsibility for ensuring compliance with the requirements of this Policy and that the Policy is implemented as appropriate within their services. 4.2 All clinicians within adult services provided by Nottinghamshire Healthcare NHS Foundation Trust are responsible for ensuring they comply with Trust policy with regard to reporting all falls by patients immediately via the Ulysses Incident Reporting System. This must be in line with the Trust Policy Reporting of Accidents, Incidents and Near Miss situations including Serious Incidents. The fall and subsequent interventions must be recorded in the patient s records. 4.3 All clinicians within adult services provided by Nottinghamshire Healthcare NHS Foundation Trust should ensure they are competent in identifying patients at risk of falls, assessing that risk and providing interventions to reduce that risk as far as is practicable. 5.0 RISK ASSESSMENT 5.1 It is recognised that falls risk assessment should identify risk factors of significance for the individual and targeted interventions be taken to reverse or modify those risks where possible, and where this is not possible actions taken to mitigate the risk. Scored or stratified risk assessments for falls are not considered good practice (NICE, 2013). 5.2 All patients over the age of 65 in contact with a healthcare professional will be asked if they have fallen in the last 12 months and the circumstances of the fall(s). This will be documented in the patient s record. 5.3 All patients aged 18 to 65 who are in contact with a healthcare professional, especially if they are admitted to an in-patient service, should be considered for their risk of falling if they have impaired gait and balance and/or a long term condition, mobility issues or disability, including Intellectual Disability, which increases their risk of falling. The patient record will have documented in it whether the patient is deemed at risk of falls and actions taken to reduce that risk. 5.4 Those who have fallen, are deemed at risk of falling, show abnormalities in gait and balance or are fearful of falling should have the Guide to Action for Falls Prevention Tool completed with them (and their care giver if appropriate). 5.5 The appropriate version of the Guide to Action for Falls Prevention Tool (Robertson et al 2010; 2012) should be used. The following versions are available: MHSOP - In Patient MHSOP - Community and Outpatient MHSOP - Care Home Falls Questionnaire (adapted Guide to Action Tool with symbols) Intellectual Disability - In Patient Intellectual Disability - Community Intellectual Disability - Care Home Adult Mental Health, Forensic and Substance Misuse - In Patient ISSUE 3 MAY

5 Adult Mental Health, Forensic and Substance Misuse - Community Health Partnerships Adult Community Services Community Health Partnerships Adult Community Services Care Homes County Health Partnerships Lings Bar Hospital 5.6 Risk factors for falling significant for the individual should be identified on the Guide to Action Tool by underlying or circling those which apply (paper notes) or ticked on drop down boxes (electronic notes.) 5.7 Actions and interventions should be taken and initiated to modify and reverse risk factors where possible. Where risk factors cannot be reversed or modified, then interventions to mitigate the risk should be taken. All actions should be documented within the patient s clinical records / care plan and on the Guide to Action Tool. 5.8 An appropriate care plan must be written in line with specific service requirements. 5.9 A risk enablement approach should always be adopted, acknowledging that not all falls can be prevented and mechanical restraint for the means of preventing falls should not be used Where the use of bed rails are considered, Policy Using Bedrails Safely and Effectively must be adhered to and an appropriate assessment undertaken and documented Where the use of a low bed is considered, the Guidance and Risk Assessment for the use of Ultra-Low beds included in this policy must be adhered to and the assessment undertaken and documented The Guide to Action for Falls Prevention Tool includes an assessment of fracture risk. Falls, Osteoporosis and Osteoporotic Fractures are inextricably linked and the risk of underlying osteoporotic bone disease must be considered as part of a falls risk assessment. For those patients with a history of fragility fracture (low trauma fracture following fall from standing height) an assessment of 10 year fracture risk should be undertaken using the FRAX Tool available at: (NICE, 2012) If a fall occurs within in-patient areas then the Post Falls Protocol should be implemented (NPSA, 2011). The amendment form for the Guide to Action for Falls Prevention Tool should be completed and care plan updated. The fall must be recorded as an incident on the Ulysess system. Guidance on grading the severity of the falls is included in the Appendices A Falls Incident Analysis form should be completed and included in the care plan for patients who have fallen. This is to enable clinical staff to establish any pattern to the falls in terms of time, location, nature of injury, activity at time of fall, witnessed/unwitnessed to assist in understanding the possible causes of the patient s fall(s) The initiation of 1:1 care to reduce the risk of falls may be considered in line with Policy 1.02 Observation and Engagement of Patients. 6.0 IMPLEMENTATION 6.1 Health and Safety Policy 16.6 Preventing slips, trips and falls (including falls from height) has been implemented across the Trust and should continue to be adhered to with regard to Health and Safety of staff, patients and visitors within the organisation. The purpose of this Clinical Policy is to support clinical decision making and evidence based interventions ISSUE 3 MAY

6 with regard to the assessment, prevention and management of falls in adult patients, in line with NICE Clinical Guidelines 161 and Falls and Osteoporosis assessment and intervention need to be embedded in clinical practice in all adult services caring for patients who are at risk of falls and injurious falls. 6.3 The Guide to Action for Falls Prevention Tools, Amendment Form and Falls Incident Analysis documentation needs to be available to all adult clinical areas. 6.4 The Trust Intranet requires a Falls site which should then have links to service areas so documentation is accessible. 6.5 Falls information should be accessible to all clinical staff to ensure patients are offered information and advice to reduce their risk of falls (NICE, 2013). 6.6 The inclusion of falls assessment on RIO requires consideration and would support the gathering of information in line with the five year Falls CQUIN requirement 2014/ TRAINING 7.1 Training for clinical staff in the Assessment, Prevention and Management of Falls and Osteoporosis will be provided through the Learning and Development Department. For staff within Mental Health Services for Older People this is Essential Training every 3 years. For staff in Health partnerships this is once only Essential Training, with updates available to staff provided via the Learning and Development Department. 8.0 TARGET AUDIENCE 8.1 This policy applies to all Trust clinical staff working in adult services. 9.0 REVIEW DATE 9.1 This policy will be reviewed every 3 years unless legislative or national guidance changes CONSULTATION Patient Safety and Effectiveness Committee Executive Leadership Council Falls Policy Review Task and Finish Group Clinical staff within adult services 11.0 RELEVANT TRUST POLICIES/PROCEDURES Using Bedrails Safely and Effectively 3.06 Reporting of Accidents, Incidents and Near Miss situations including Serious Incidents Health, Safety and Welfare Preventing Slips, Trips and Falls (including falls from height) Manual Handing and Back Care MONITORING COMPLIANCE 12.1 Compliance with the policy will be monitored by the Patient Safety and Effectiveness Committee and Health and Safety Committee ISSUE 3 MAY

7 12.2 Compliance monitoring will be undertaken through scheduled audits across adult services within the Trust. The method used will be an audit of randomly selected patient notes, audited for compliance with documentation and evidence of actions taken to reduce the risk of falls for the individual. An Audit Tool is included as an Appendix to this Policy It is the responsibility of a designated falls lead within each service to coordinate the audit for compliance monitoring. It is the responsibility of the General Manager / Head of Service to nominate a falls lead for each service area A 2 year rolling audit programme will be instigated A Trust wide Falls Group will be established and meet quarterly with falls leads from each service area attending. The purpose of the group will be to monitor compliance with the policy through the audit process described, identify areas of risk and concern, identify learning and development requirements for staff and to ensure compliance with national and local guidelines regarding falls and osteoporosis management A report on the outcome of the audits will be submitted to the Divisional Governance Groups for scrutiny by the Trust Falls Lead twice a year Following scrutiny by the Divisional Governance Groups the Trust Falls Lead will submit a written report to the Patient Safety and Effectiveness Committee twice a year 13.0 EQUALITY IMPACT ASSESSMENT 13.1 This policy has been assessed using the Equality Impact Assessment Screening Tool. Following the EIA screening exercise it has been concluded that this policy will have a positive impact on all Trust diverse communities. The aim of this policy is to ensure that processes are in place to assess, prevent and manage falls risk whilst highlighting the specific needs of those vulnerable groups identified above. Falls have been seen as an inevitable part of growing old, but are not synonymous with ageing, yet many falls are preventable and risk factors reversible. Osteoporosis is also treatable. The impact of falls and fractures on quality of life is significant and can cause loss of life, loss of independence and accelerate admissions to care homes. Consequently a full EIA is not required LEGISLATION COMPLIANCE 14.1 This policy has been considered in the context of relevant national Guidance and the Trust Health and Safety Policy 16.6 Preventing slips, trips and falls (including falls from height) 15.0 CHAMPION AND EXPERT WRITER 15.1 The Champion of this policy is the Executive Director of Nursing. The Expert Writer is the Trust Falls Lead (Kate Robertson, Trust Consultant Therapist in Falls Prevention) REFERENCES /SOURCE DOCUMENTS National Institute for Health and Care Excellence (2012) Clinical Guideline 146 Osteoporosis: assessing the risk of fragility fracture National Institute for Health and Care Excellence (2013) Clinical Guideline 161 The assessment and prevention of falls in older people. National Patient Safety Agency (2007) Slips, trips and falls in hospital ISSUE 3 MAY

8 National Patient Safety Agency (2011) Essential care after an in-patient fall Robertson K, Logan P, Conroy S, et al. (2010). Thinking Falls - Taking Action: A guide to action for falls prevention. British Journal of Community Nursing,15: Robertson K, Logan P, Ward M, Pollard J, Gordon A, Williams W, Watson J. (2012) Thinking Falls - Taking action: Adapting the Guide to Action for Falls Prevention Tool for Use in Care Homes. British Journal of Community Nursing, 17: World Health Organisation (2012) Fact Sheet no 344: Falls. ISSUE 3 MAY

9 APPENDIX 1 FALLS: THE ASSESSMENT, PREVENTION AND MANAGEMENT OF PATIENT FALLS (ADULT SERVICES) CASE NOTES AUDIT An annual rolling audit will be carried out within adult services to monitor compliance with Policy Ref: The assessment, prevention and management of patient falls. NICE Clinical Guideline 161 Falls: the assessment and prevention of falls in older people advises all healthcare professionals to consider the risk of falls in all patients aged 65 years and older, as well as all patients aged 50 to 64 with underlying conditions who may be at a high risk of falling while in their care. With consideration for the many patients the Trust supports who have underlying conditions making them at higher risk of falling under the age of 50, it is deemed appropriate to assess all adult patients with conditions that would increase their risk of falls for falls risk whilst in the care of the Trust. WARD / SERVICE ELECTRONIC / PAPER RECORDS? (Please circle) AUDIT COMPLETED BY (Print Name) SIGNATURE DESIGNATION DATE PLEASE ADD ANY GENERAL / SPECIFIC COMMENTS NOTED DURING THE AUDIT PROCESS ISSUE 3 MAY

10 FALLS: THE ASSESSMENT, PREVENTION AND MANAGEMENT OF PATIENT FALLS (ADULT SERVICES) CASE NOTES AUDIT AUDIT QUESTION YES/NO COMMENTS 1 Is the Guide to Action for Falls Prevention Tool included in the case notes? 2 Is it the correct version for the service? 3 Has the patient been asked whether they have fallen in the last year, are at risk of falls or are fearful of falling? If NO go to Question 4 If YES go to Question 5 4 Has the patient fallen following the initial assessment? If NO audit is complete If YES go to Question 5 5 Is the patient currently an in-patient? If NO go to Question 6 If YES is there documented evidence in the case notes that the Post Falls Protocol was followed? Give brief detail in comments column 6 Has the Guide to Action Tool been completed? 7 Have risk factors for falling been identified? 8 Have actions been taken to reduce/modify/reverse that risk factor? 9 Are these documented: 9.1 On the Guide to Action Tool 9.2 In the case notes 10 Are falls documented in the case notes in a clear and easily accessible place? 11 Has a Falls Incident Analysis form been completed? 12 Has the Guide to Action Tool been reviewed following a fall? 13 Is it documented that the patient / carer has been offered written information regarding falls risk? 14 Is it documented that the patient / carer has been offered verbal information re falls risk 15 Has the patient been referred on to other services regarding their falls? Please state service referred to in comments column 16 If the patient is over 65 and has a history of recurrent falls, have they been offered strength and balance training 17 If the patient has been treated in hospital due to a fall, have they been offered a home hazard assessment? ISSUE 3 MAY

11 POST FALLS PROTOCOL APPENDIX 2 Patient seen to fall Patient found on the floor If it is suspected that the patient may be putting themselves on the floor rather than falling, then a full assessment for any injuries, bruises, grazes etc. should be made and documented and this suspicion discussed with the MDT. It should always be assumed the person has fallen unless there is evidence to support the contrary DO NOT MOVE THE PATIENT Call for staff assistance immediately ASSESS FOR INJURY MAJOR INJURY Head Injury with loss of consciousness Patient on anticoagulants Breathing difficulties Tenderness / pain to spine Bone deformity Limb deformity DO NOT MOVE THE PATIENT CALL 999 Complete Observations Follow advice from EMAS crew if not transported HEAD INJURY With NO loss of consciousness COMPLETE AVPU / NEWS Minor injury ADMINISTER FIRST AID Complete Observations: BP, Pulse, Temp, SATS, RESPS Assist from floor: Self-help Minimal assistance Using Equipment OBSERVE FOR ANY DETERIORATION IN CONDITION Complete Body Map Repeat AVPU/NEWS every 30 mins for 2 hours Then every hour for 4 hours Then every 2 hours for 24 hours No apparent injury sustained Complete Observations: BP, Pulse, temp. SATS. RESPS Assist from floor Self-help Minimal assistance Using equipment COMPLETE INCIDENT FORM. If fracture has occurred this must be reported on IR1 and SUI INFORM RELATIVES MEDICAL REVIEW TO BE COMPLETED WITHIN 12 HOURS where acute management was not required REASSESS FALLS RISK USING GUIDE TO ACTION TOOL TAKE ACTIONS TO REDUCE FALLS RISK VERSION 4 / REVISED PROTOCOL / ISSUE 3 MAY

12 APPENDIX 3 Policy/Procedure for: Falls The Assessment, Prevention and Management of Patient Falls (Adult Services) Issue: 03 Status: Author Name and Title: APPROVED Kate Robertson, Trust Consultant Therapist in Falls Prevention Issue Date: NOVEMBER 2014 (REISSUED 13 JULY 2016 ISSUE 2) (REISSUED 02 MAY 2017 ISSUE 3) Review Date: NOVEMBER 2017 Approved by: Distribution/Access: EXECUTIVE LEADERSHIP TEAM NORMAL RECORD OF CHANGES DATE AUTHOR Kate Robertson POLICY/ PROCEDURE 1.34 DETAILS OF CHANGE Front page: Addition of Trust Observation and Engagement of Patients Policy 1.02 Jun 16 May 17 Kate Robertson Kate Robinson (amended by Policies) (Issue 2) Minor amendments including: Addition of 5.15 link to Policy 1.02 re 1:1 care Post Falls Protocol added (Appendix 2) The text in the Flow Chart in Appendix 2 was not displaying correctly. Re-converted to PDF to resolve this issue. Trust logo changed. ISSUE 3 MAY