1. Falls Prevention Accreditation ROP Compliance
Medicine Accreditation 2016

2. To Minimize injury from falls, a documented and coordinated approach for falls prevention is implemented and evaluated

3. Falls prevention is a safety priority
Reducing injuries from falls can increase quality of life for clients and reduce costs

4. Major Tests for Compliance
A documented and coordinated approach to falls prevention is implemented.

5. Falls @ Covenant Schmid Fall Risk Assessment Tool Post – Fall Report
Reference Document
Universal Falls Precautions (SAFE)
Ask-3
Schmid Guideline
Medication List
list of medications that may increase fall risk

6. Major Tests of Compliance
The approach identifies the populations at risk for falls

7. Major Tests of Compliance
The approach addresses the specific needs of the populations at risk for falls
Apply interventions as noted in the Schmid Tool

9. Falls @ Covenant For high risk patients, consider:
Bed and/or chair alarms
Relocate the patient in nursing unit
Consider level of observation
Frequent rounding for patients with dementia, delirium or behavioral problems
Pamphlet and patient/family education
If patient has limited or no ability to engage in fall prevention strategies, consider:
Increase level of observation
Move patient closer to nursing station
Supervise all mobilization and toileting

10. Before leaving a patient’s room ask the following questions, as appropriate: 1. Do you need to go to the toilet? 2. Do you need anything for comfort or pain? 3. Are there any personal items you need within reach before I go? Communicate – “I or someone from the team will be back in about an hour to check on you” If patient is sleeping, assess for possessions but do not wake unless clinically indicated or previously arranged.
Ask-3

11. Universal Falls Precautions (SAFE)
Safe Environment
Bottom bed rails down unless assessed otherwise
Pathways clear of clutter and tripping hazards
Bed and chair brakes are “ON”
Lights are working and “ON” as required
Assist with mobility
Safe and regular toileting
Transfer/mobility assist documented
Glasses, hearing and mobility aides within patient reach
Fall risk reduction
Call bell in patient’s reach
Bed lowered to patient’s knee height
Personal items reachable
Proper footwear available and in use
Engage patient and family
Discuss risk factors with patient and family
Mutual Falls/Injury Prevention plan developed

12. Minor Tests for Compliance
The effectiveness of the approach is evaluated regularly
Results from the evaluation are used to make improvements to the approach when needed.

13. Covenant
Follow the post fall process on reporting and patient care:
Report fall to person in charge
Document the fall on the Post-Fall Report
Follow the post-fall protocols, as appropriate
Document fall in RLS
Work collaboratively to analyze the fall and reduce the risk of similar falls reoccurring
Frequently monitor patient’s fall status
Frequently monitor environment of patient (room and unit) for new risks

15. SPLATT Tool
Symptoms Previous Falls History Location Activity at time of fall Time Trauma Treatment

16. Falls Champions in Medicine
Your falls champions provide: Education Audits Quality Improvement Projects using the PDSA cycle (Plan Do Study Act)

17. Questions?