In addition to a documented falls risk assessment, interventions to prevent falls should be carried out and clearly documented including but not limited to: non-slip socks or footwear, appropriate mobility aides within reach and in use when ambulating, hip protectors in place, bed in low position, and call bell within reach. For those patients that are at high risk of falls, especially due to altered cognition or mental status should also have additional precautions implemented such as bed alarm, bed rails or restraints (where use is appropriate) or 1:1 supervision.
Risks and interventions need to be clearly documented every shift and passed on to the next nurse providing care so that continuity be continued. A failure to follow the nursing process including: assessment, diagnosis (i.e. at risk for falls), outcomes, planning and evaluation, along with clear documentation is a violation in the standard of care for a patient at risk of falls.
Many facilities require the reporting and documentation of a fall even if it was a “near miss”, meaning the patient almost fell or slipped. In addition, if a patient does fall, appropriate assessment, monitoring and reporting of the fall/injuries should be carried out in a timely manner and evident in documentation.
References –To read more about falls risk interventions see:
Quigley, P, Lunsford, B, et al. (2015). Focus on… Falls Prevention. American Nurse Today, 10(7), 34-37.