INDEX TAB ONE Fall Prevention and Management program TAB TWO Sample forms - Fall Risk Assessments - Side Rail Assessments - Incidents Report and Investigations - Witness forms - Post-fall Summary - Physical Restraint Assessments and Authorizations - Event, Fall, and Physical Restraint logs - QA Audit Tools TAB THREE Proposed F-tag 323 and 324 Guidance to Surveyors and Investigative protocol. Manual includes: Program CD –Fall Prevention and Management --includes entire program, protocol, and forms. Developed by Polaris Group (813) 886-6500 ii PROCEDURE How to use this manual: All systems and processes have key steps or components that are needed to achieve the desired outcome. For a clinical program, the desired outcomes include: 1. Compliance with regulations and best practices. 2. Provides for individualized assessment and care planning. 3. Monitors effectiveness of processes in achieving desired resident outcomes. The QA Committee should review all outlined key components in this manual, then perform a gap analysis comparing current systems to recommended best practices recommended. SA M PL E Steps: 1. Evaluate current systems to key components outlined in this manual. 2. Define standards and key components for the health center. 3. Review F-tag 323 Accident & Supervision survey guidelines and protocols. Access clinical resources listed in guidance as resource for developing procedures. 4. Use text from the manual provided on CD to develop center specific procedures. 5. Finalize forms. 6. Provide education and training to staff. 7. Implement systems. 8. Develop ongoing QA to monitor effectiveness. Fall Prevention Program 1 PRELIMINARY NURSING ASSESSMENT Admit Date _____________ Admit time ______________ From _______________ Via __________________ Diagnosis __________________________________________ Allergies: ______________________________ T: ___________ P: ___________ R: ___________ BP: __________ HT: __________ WT: ______________ 1. COGNITIVE (CIRCLE) ALERT / ORIENTED TO: PERSON – PLACE – TIME MEMORY PROBLEMS / ACUTE CONFUSION / LETHARGIC / SEMI COMATOSE / COMATOSE: DESCRIBE __________________________________________ CARE PLAN Y OR N 2. MOOD AND BEHAVIOR (CIRCLE) ELOPEMENT POTENTIAL: Y or N __________________________ If yes, complete full Elopement Assessment tool E (Circle One) WITHDRAWN / PACING / VERBALLY ABUSIVE / CRYING / WEEPING / ANGRY / RESISTS CARE / REPETITIVE BEHAVIORS / AGITATION/ OTHER: ____________________________________________________ PL CONDITION/DIAGNOSIS:_____________________________________________________CARE PLAN: Y OR N RECEIVING: HYPNOTIC / ANTIPSYCHOTIC / ANTIANXIETY / ANTIDEPRESSANT: If applies: SA M LIST MEDS: _______________________________________________________________________________________ BEHAVIOR MONITOR INITIATED: _____ REFERRED TO PHARMACY: _____ CONSENT SIGNED:_______SIDE EFFECT MON. STARTED:______ AIMS:__________ 3. COMMUNICATION (CIRCLE) HOH / DEAF L R B HEARING AIDE L R B / OTHER: COMMUNICATES: SPEECH / GESTURES / WRITES / OTHER APHASIC CAN BE UNDERSTOOD Y OR N UNDERSTANDS Y OR N CARE PLAN: Y OR N 4. REFER TO THERAPY: Y OR N VISION (CIRCLE) ADEQUATE Y OR N GLASSES Y OR N BLIND Y OR N – L R B LENS IMPLANTS L R B PROSTHESIS L R B GLAUCOMA / CATARACTS / FIELD CUT L R B 5. CARE PLAN: Y OR N PAIN (CIRCLE) VERBAL OR NONVERBAL EXPRESSION OF PAIN: PAIN: Yes No CARE PLAN Y OR N COMPLETE PAIN SCREEN ON ALL RESIDENTS: IF SCORE IS GREATER THAN 3, COMPLETE FULL ASSESSMENT FORM.: Pain Screen Score: _______ Pain Scale: 1-10:_______ RESIDENT:__________________________________ RM:_______MR#________ Page 1 of 4 SIDE RAIL USE PLAN AND AUTHORIZATION RESIDENT FACTORS THAT IMPACT USE OF SIDE RAILS – FALL RISK SCORE: ________ Unsafe independent transfer □ Yes □ No Comatose, semi, fluctuating Uses call light effectively Risk of seizure Waits for help □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No Immobile in bed □ Yes □ No Alteration in safety awareness □ Yes □ No Difficulty with trunk control Requires spatial awareness reminders □ Yes □ No Able to use SR for positioning □ Yes □ No □ Yes □ No RATIONALE FOR USE - circle all that apply No side rails needed □ Yes □ No Resident does not desire side rails □ Yes □ No Alert Resident prefers side rails up for feelings of safety □ Yes □ No Enhance Bed mobility with use of side rails □ Yes □ No Prevent rolling OOB: would not try to rise unassisted □ Yes □ No Provide reminder to not rise unassisted; and would try to rise unassisted (restrictive side rail-restraint) □ Yes □ No PL E POTENTIAL RISKS FROM THE USE OF SIDE RAILS: 1. Increased risk of injury from trying to climb over rails to get out of bed 2. Bruises from bumping into side rails 3. Agitation or increased agitation 4. Decreased vision by creating a visual barrier 5. Decreased physical contact from others 6. Strangulation 7. Entrapment (e.g. getting limbs or head caught in rails) 8. Death SA M POTENTIAL BENEFITS FROM THE USE OF SIDE RAILS: 1. Enable/increase independence in bed mobility 2. Enable/increase independence in transfers 3. Enable better positioning and support in bed 4. Provide tactile boundaries for vision or cognitively impaired residents SAFETY PLAN: X = Side Rail Plan (See restraint assessment if meets definition of a restraint) All down Full rails both sides up One full rail up- R or L Both half rails up at head of bed One half rail up at head of bed - R or L Both bottom rails up One bottom rail up - R or L All four rails up Mini rails up both sides only one side Side rail/mattress safety check performed Other (e.g. rise alarm, scooped mattress)______________________________________________ I have been fully informed of the above risks and benefits related to the use of side rails in care planning and agree to the plan above: Resident signature _______________________________________ Date __________ or Surrogate Decision Maker ____________________________________ Date___________ Initial Review Signature:______________________________________________Date___________ Review Dates and Signature: Date: ______ Signature:____________________________________ Date: _______ Signature: ___________________________________________________________ Date: _______ Signature_____________________________________________________________ RESIDENT’S NAME PHYSICIAN RM# MR# 1 of 1 EVENT REPORT (Quality Assurance/Confidential) Completed By Charge Nurse On Duty. Nurse/Staff: Resident: Date:_____________ Time: _________a.m. /p.m. Day of Week Resident Statement or describe Event Scene: Describe environment, position of resident, equipment, floor surface, and site of injury: Location of occurrence: Resident room Bathroom Hallway # Shower Room Nursing Station Incident: E Describe Injury and Resident Status overall (size, depth, color, pain, bleeding, limitation in ROM-results of head-to-toe assessment, VS & Neuro checks: SKIN Acquired Stage I Acquired Stage II Acquired Stage III Acquired Stage IV Skin Tear – unknown origin Skin Tear – known origin Bruise – unknown origin Bruise – known origin Burn/laceration/bite/other BEHAVIORS Resident/Resident SA M FALL Unwitnessed-found on ground During Assisted Transfer During self transfer – bed During self transfer – toilet During self transfer – chair While self-ambulating During Assisted Ambulation MISC Found in Hazardous Situation Other Risk/injury R/T equipment Front Exit Other Exit________________ Off Premises Unknown Other (specify) _______________ PL Dining Room Activity Room Therapy Room Lobby Grounds/Parking lot Elopement Resident/Visitor Resident/Staff Unaccompanied Exit Self inflicted injury MEDICATION Repeat Administration Wrong medication/wrong resident given Wrong dose/route given Omission IV Error Transcription error only, not administered. Immediate Intervention initiated to protect resident: (check all that apply): First Aid Provide immediate protection__ ________________________________ Physician orders/Tx Initiate Rise Alarm w/c / bed ER visit/Hospital admission Initiate frequent checks_______ Med error-Req. Medical care Lower bed Med error – no intervention Mat/mattress by bed Press. Reduction: Bed / chair Provide food/diversion Environmental Adjustment ____ Placed in supervised area _______________________________ Care plan updated to new interventions Oriented to call light Protective clothing-skin Toileted Put to bed Wanderguard initiated Add Enabler bar/trapeze ______________________ ______________________ Review meds PRN Med_______________ Removed S/R or restraint Added non-slip device: w/c chair Geri Initiated body pillow _______________________ _______________________ Notification of Physician: Physician notified Name:___________________ Notification of Responsible Party: Responsible Party notified No Contact. Date: Attempt Made No Contact Date:_________ Time:________ Name:_________________________________________ Date/ Time: Non Staff Witnesses to event Yes/No Name:__________________________ Phone:__________ Address:__________________ Staff Witness Yes/No Name Licensed Nurse NA assigned:____________________ Assigned: First person on scene: Page 1 of 1 PHYSICAL RESTRAINT AUTHORIZATION The following risks/benefits of ____________________________ (restraint type) use have been discussed with ________________________ (resident type), and/or __________________ (surrogate decision maker). Reason for use:__________________________________________________________________________ Duration of use: _________________________________________________________________________ he rails, tipping over E POTENTIAL RISKS: 1. Increased injury: from trying to climb over rails, out of bed, getting limbs caught in t in wheelchair 2. Incontinence or increased incontinence 3. Skin breakdown including pressure sores, skin tears, bruises 4. Agitation or increased agitation 5. Decline of functional mobility (walking) 6. Increased Confusion 7. Becoming withdrawn 8. Strangulation 9. Other SA M PL POTENTIAL BENEFITS: 1. Enable bed mobility 2. Feelings of safety 3. Enable independent wheelchair mobility 4. Enable better sitting balance, positioning or mobility 5. Treat life-threatening problems: Dehydration, electrolyte imbalance, urinary blockage, re-fracture, and severe violence to self or others. 6. Prevent removal of tube or treatment: a. Catheter c. Oxygen mask/cannula e. Gastrostomy tube b. IVs d. Nasogastric tube f. Dressings 7. Other I understand that I have the right to refuse the use of a physical restraint, and I have been fully informed of the above risks and benefits related to restraint usage and the consequences of the non-use of restraint. After careful consideration of the information provided to me, I hereby: (initial one) ______ Give my consent for the use of the restraint(s). ______ Refuse to give my consent for the use of the restraints. Date __________________ Resident ________________________________________________________ Date ___________________ Surrogate Decision Maker ___________________________________________ Date___________________ Nurse___________________________________________________________ Rev.Date______________________Rev Date___________________________Rev Date____________________________ Signature______________________Sign______________________________Sign________________________________ RESIDENT’S NAME PHYSICIAN ADMISSION NO. ROOM/BED HIGH RISK EVENT FLASH REPORT QUALITY ASSURANCE/CONFIDENTIAL MOS/YR:____________________________ FALLS BEHAVIORS Total Behaviors Resident/Resident Resident/Visitor Resident/Staff Elopement Unaccompanied Exit Self-inflicted injury MEDICATION ERRORS Total Reported Medication errors Repeat administration Wrong medication/wrong resident Wrong dose/route Omission IV Error Transcription DAY OF WEEK - FALL Sunday Monday Tuesday Wednesday Thursday Friday Saturday DAY OF WEEK - BEHAVIORS Sunday Monday Tuesday Wednesday Thursday Friday Saturday MISC. LOCATION FALLS Resident Room Bathroom Hallway Shower Room Nursing Room Activity Room Dining Room Therapy Room Lobby Grounds/parking lot Front Exit Other Exit Off-premises Unknown Other LOCATION BEHAVIORS Resident Room Resident/visitor Hallway Shower Room Nursing Station Activity Room Dining Room Therapy Room Lobby Grounds/parking lot Front Exit Other Exit Off-Premises Unknown Other FALLS TIME OF DAY 7a.m. - 9a.m. 9a.m. - 11a.m. 11a.m. - 1p.m. 1p.m. - 3p.m. 3p.m. - 5p.m. 5p.m. - 7p.m. 7p.m. - 9p.m. 9p.m. - 11p.m. 11p.m. - 1a.m. 1a.m. - 3a.m. 3a.m. - 5a.m. 5a.m. - 7a.m. Found in hazardous situation Other Risk/injury R/T equipment Alleged abuse/neglect complaint # reported to State # Substantiated SA M PL E Total Falls Unwitnessed-found on ground During assisted transfer During self transfer - bed During self transfer - toilet During self transfer - chair While self ambulating During assisted ambulation BEHAVIORS TIME OF DAY 7a.m. - 9a.m. 9a.m. - 11a.m. 11a.m. - 1p.m. 1p.m. - 3p.m. 3p.m. - 5p.m. 5p.m. - 7p.m. 7p.m. - 9p.m. 9p.m. - 11p.m. 11p.m. - 1a.m. 1a.m. - 3a.m. 3a.m. - 5a.m. 5a.m. - 7a.m. PRESSURE ULCERS ______% Acquired ______% Total Total # residents w/ acquired for month Acquired Stage I Acquired Stage II Acquired Stage III Acquired Stage IV Total # residents with Pressure Ulcer Total Stage I Total Stage II Total Stage III Total Stage IV Total Skin Tears for month Skin Tears, unknown origin Skin Tears, known origin Bruises total for month Bruise, unknown origin Bruise, known origin Burn/laceration/bite/other Grievances Lost Item Physical Restraints Restrictive side rails DEVELOPED BY POLARIS GROUP Page 1 of 2 QA Review of Incident by DON or Designee Audit at least 10 falls per month Date of Incident: Resident: Time: Location: a.m./ p.m. RM#: Type of Incident: Injury: Medical Record--Appropriate Forms/ Assessments Complete: Assessment/Nurses Notes At time of Event Alert Charting Dr. Notified Family Notified On 24 hour report Incident Report Complete Contributors Accurate IDT Review Care Plan Adjusted per contributors Meds/treatment per orders/policy Other (consent, skin flow etc) Prior to onset / Incident: Accurate and Complete Assessment with all Risk Factors Identified (Fall Risk, Skin Risk, RAPs etc per procedures) E Care Plan was based on Risk Factors? PL Care Plan was implemented? Any New Contributing Factors identified post-occurrence? SA M Care Plan updated to all old/new Risk Factors? Conclusions / further follow–up: Avoidable Yes No Action Plans/Training needs: Signature: Date:
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