28. Falls and Post Fall Assessment and Management

WHEELCHAIRS G***Disclaimer: This document will provide a generic overview of what a staff member is expected to do in a situation of a resident fall. Long Term Care Homes will have their individual internal Policies & Procedures that must be followed – please ensure that you know where to find this information within the home and understand the expectations. ***ERI-CHAIRS, COMMODES, WALKERS

All LTC homes strive to reduce falls using a preventative, multidisciplinary approach. Despite these efforts, it is understood that falls may still occur. In the event of a fall the goals are:

1. Ensure immediate resident safety is promoted. This includes assessing for and determining a treatment plan for any injuries sustained in the fall.
2. Learn from the fall so that future falls can be prevented.

Falls Assessment

Person witnessing the fall or finding the resident after a fall:

1. Assess the environment for any potential safety concerns and for any clue as to what may have caused the fall.
2. Reassure the resident that you will help them.
3. DO NOT move the resident until Registered Staff have determined it is safe to do so.
4. Call for Registered Staff to assess resident.
5. Provide support to Registered Staff as requested. This may include assisting with other nearby resident, retrieving supplies and/or equipment, or assisting with transfer of resident from floor to bed or chair.
6. If assisting with moving the resident, direction must be taken from Registered Staff. Transfer technique used prior to the fall may no longer apply and new direction is required.
7. Provide information as required to Registered Staff to facilitate completion of the Post Fall Assessment.

RN/RPN Staff

Each resident who has fallen or is suspected of having fallen must be thoroughly examined by an RN/RPN for any potential injuries. The registered staff who attends the fall will:

• Complete a physical examination, identify any injuries or suspected injuries.
• Provide any necessary or urgent nursing intervention/first aid.
• If it is determined that the resident requires a transfer to hospital, one registered staff member will phone emergency services for transport to hospital while second registered staff member stays with resident and provides any required intervention and care.
• If serious injury has been sustained or if an appropriate intervention is uncertain, the RN must be involved in the resident’s care. The RN will determine if the on-call physician must be called for direction or, if less urgent, the physician will be notified during normal working hours by leaving a message in the communication book.
• Once it is determined to be safe to do so, move the resident, ensuring that the proper lifting techniques are performed. Registered staff must direct unregulated care providers on safe transfer of fallen resident:
  • If resident can weight bear, 2 staff to assist resident up (Please note that staff are not to provide a manual lift and must abide by no-lift policy. If in doubt, use a Hoyer lift)
  • If resident is unable to weight bear, then 2 staff may use a Hoyer lift to assist resident up.

• If resident struck their head during the fall, is on anticoagulant therapy, or fall was unwitnessed, Head injury Routine must be initiated. Note: the HIR must be completed for a total of 72 hours.
• Phone SDM/POA to inform them of the fall, any injuries that were sustained, and any interventions that were provided. For serious falls resulting in transfer to hospital or emergency intervention this must be done immediately. Less urgent situations may be disclosed to the family 12-24 hours following the fall, depending on family’s stated wishes regarding communication.
• Complete the Post Falls Assessment in PCC.
• Review and update the resident’s care plan based on information gathered from the fall.
• Document an incident report in the Falls Progress Note on PCC, the following data:
  • Date and time of incident
  • Location of the incident
  • If fall was witnessed or unwitnessed
  • Status of the resident – vital signs, injuries, notification of POA, and interventions including hospital transfer

• Communicate to the oncoming shifts that the resident has fallen    and share details regarding the interventions initiated.
• If resident has had a previous fall in the past 90 days OR current fall resulted in injury, the fall must be discussed at the weekly Falls Rounds.
• If Physiotherapy intervention is required more urgently, a referral via PCC should be sent to the Physiotherapy department for assessment.
• Send a referral via PCC, to the occupational therapist if assessment required for falls prevention devices, safety equipment.
• At the weekly Falls Rounds, the RN or designate will provide an overview of the resident’s fall, actions which have been taken to address the falls risk (ie. Changes to the care plan, urgent referral to physiotherapy, transfer to hospital). Following discussion and recommendations, the RN will document the discussion, update the care plan as required, and complete any referrals resulting from meeting.
• During the annual interdisciplinary team conference, the resident’s individualized falls risk program will be reviewed with the family/POE and resident, and interventions will be evaluated with resident and or/POA/family.