The nurses at Med League frequently get calls from attorneys about patients who fell within a healthcare facility. The attorney is looking for a well-qualified nursing expert to review the case. Hip fractures or head injuries are often the medical consequences of these falls. The damages are often not in question. The attorney is usually asking us for a nursing expert to determine if the standard of care was followed.

The assessment of patient fall risk is the responsibility of medical, nursing, and rehabilitation staff of the nursing home. Every nursing home resident is to be evaluated with the MDS (Minimum Data Set) to identify risk factors for falls, among other things. Additionally, a facility (or chain) may have its own fall risk assessment tool and a specific policy and procedure describing its use. Most homes will have a fall assessment tool as part of its nursing or rehabilitation (physical and/or occupational) therapy admission evaluation.

Note that fall risk assessment is performed as a screening measure (primary level of prevention) for all residents admitted to a nursing home facility (to detect and modify existing risks to fall), and it is repeated as part of a post fall assessment.

Although there are numerous published fall risk assessment tools, there is no single tool that is considered “standard” in the nursing home. Although some falls may be isolated events, most residents who have fallen should have a thorough post-fall assessment. This is especially necessary for those with a history of recurrent falls, since a history of falls is identified as a major risk factor for subsequent falls.

Discovery tip related to patient falls: Does the facility have fall risk assessment tools and separate post-fall assessment tools for evaluation of the falling older adult?

Patient Falls Risk Factors

An essential aspect of any fall assessment tool is the consideration of risk factors for injurious falls. See below for a list of risk factors that should prompt a thorough evaluation and plan of care.

Circumstances of the falls

New admission to nursing home
Recent transfer from hospital or other setting
Recent transfer from another unit or room
Responding to bladder or bowel urgency
Attempting to remove a physical restraint
Climbing over or around side rails
History of recurrent falls

Intrinsic Factors

Functional
Loss of leg or arm movement
Unilateral (one-sided) weakness
Recent, rapid decline in functional status (ability to care oneself)
Musculoskeletal
Arthritis
Osteoporosis
History of fracture
Post-amputation
Neuro-muscular
Stroke
Parkinson’s disease
Neuro-sensory
Impaired vision
Impaired hearing
Dizziness
Vertigo
Polyneuropathy (reduced sensation of extremities) of diabetes, peripheral vascular disease or alcoholism
Pain, especially of joints
Psychiatric
Delirium (often indicative of underlying, acute, physical illness)
Dementia
Depression
Acute illness
Infection
Myocardial infarction

Extrinsic Factors for Patient Falls

Medications
Polypharmacy
Cardiac, antihypertensives, and diuretics
Psychoactive
Sedatives, anti-anxiety agents
Benzodiazapines
Valium
Chloral hydrate
Antidepressants
Tricyclic antidepressants
Selective serotonin-reuptake inhibitors
Trazodone
Antipsychotics
Haldol

Environmental Hazards for Patient Falls

Slippery floors, especially from urine
Glare from highly polished floors
Absence of night lights
Unstable furniture
Low chairs without armrest support or seat back
Low toilet seats without secure gab bars
Assistive devices
Wheelchair
Walker
Cane, especially if poorly maintained or not fitted properly to the individual resident’s size and needs
Physical restraints, including side rails

Patient Falls Behavioral Factors

Risk-taker personality or impulsive mobility (may be secondary to stroke or impaired cognition)
Tendency to stand quickly, especially from bed or immediately after a meal

As you can see, there are multiple risk factors that affect the risk of falling. The standard of care requires the long term care nurse to consider these when assessing risk of falls.

Med League provides expert witnesses with expertise in evaluating slip and fall cases. Call us for assistance.

This blog post comes from the Falls Handbook