Fall Prevention

SAVAHCS “Fall Prevention Program” utilizes the interventions discussed in the literature review and includes a post fall assessment (PFA). Post fall huddles (PFHs) are discussed within the Fall Prevention Program, however, they are not consistently used. The PFA currently captures information discussed in the literature including intrinsic and extrinsic factors and includes the physical attributes of the patient, and extrinsic environmental factors. In a cyclic process, patients are assessed for fall risk. If a patient is found at risk, he/she is placed on the hospital’s “Fall Prevention Protocol.” Any change in status triggers the need for a reassessment of fall risk. Once a patient is determined to be at risk for falls and is placed on the “Fall Prevention Protocol,”

This is reviewed with any change in patient status, a fall, and/or quarterly. Patients, depending on screening, might receive services from physical therapy (PT), occupational therapy (OT), nutritional services, bed/chair alarms, floor mats, medication adjustment, and change in room to closer to the nurses’ station, or other services. All at risk patients are easily identifiable by notation on wrist band, footwear, room and equipment signage, in the electronic medical record, and on any paper records. The fall rate of patients at SAVAHCS continues to be at or slightly below the benchmark, but our goal is to have zero falls. The intervention not fully utilized at this hospital, that does show promise in the literature, is the post-fall huddle. For this reason, it was proposed that this intervention be implemented, along with a fall algorithm to reduce the rate of recurrent falls,