A patient fall in a healthcare setting demands an immediate, systematic, and calm response to ensure patient safety and prevent further harm. The first priority is to stabilize the situation and assess the patient’s condition while minimizing movement, as an unseen injury could be worsened by a hurried response. A methodical approach, starting with scene security and followed by a focused physical assessment, is required before any attempt to move the individual is made. This protocol addresses life-threatening issues first and then manages potential injuries sustained during the fall.
Securing the Scene and Calling for Assistance
The first action upon discovering a fallen patient is to perform a rapid environmental scan to identify and remove any immediate hazards, such as spilled liquids or equipment. The healthcare provider must then approach the patient and immediately instruct them to remain still, especially if they are conscious, to protect against potential spinal injury. This instruction prevents the patient from reflexively moving or trying to get up before a proper assessment can be completed.
Simultaneously, the facility’s emergency response system must be activated by calling for nursing or medical assistance, often referred to as a “Code Fall.” This ensures that necessary personnel, equipment, and resources, including a registered nurse and physician, are mobilized to the scene. The initial healthcare provider should not attempt to move the patient alone unless there is an immediate, life-threatening environmental danger, such as a fire or an unstable structure. Stabilizing the patient on the floor is preferred over risking further injury through unsupported movement.
Performing the Focused Injury Assessment
While waiting for assistance to arrive, the initial healthcare provider must perform a focused physical assessment, which begins with checking the patient’s airway, breathing, and circulation (ABCs). This rapid check determines if immediate cardiopulmonary resuscitation or emergency intervention is necessary. If the patient is unconscious or unresponsive, emergency medical services must be contacted immediately, treating the situation as a trauma until proven otherwise.
Neurological and Trauma Assessment
The assessment continues by checking the patient’s level of consciousness (LOC) and pupillary response to evaluate for potential head trauma, such as a subdural hematoma. The Glasgow Coma Scale (GCS) score should be quickly determined and documented to establish a baseline for neurological monitoring. The provider should then look for obvious signs of trauma, including external bleeding, open wounds, deformities, or swelling, paying particular attention to the head, neck, and hips.
Vital Signs and Spinal Precautions
The focused assessment includes obtaining a full set of vital signs: blood pressure, heart rate, respiratory rate, and oxygen saturation. Significant changes in these measurements from the patient’s baseline can indicate internal bleeding, shock, or other serious injury. If the patient reports neck pain, numbness, or tingling, or if a head injury is suspected, the patient must be maintained in cervical spine precautions. This means manually stabilizing the head and neck in the position found until imaging can rule out an unstable spinal injury.
Safe Patient Mobilization and Immediate Care
Moving the patient from the floor should only be attempted after the focused physical assessment has ruled out severe, unstable injuries, particularly a spinal fracture or major limb fracture. If a fracture is suspected, the limb must be immobilized, and the patient must be kept comfortable on the floor until the medical team can assess and stabilize the injury. If no severe injuries are found, the patient can be moved using safe patient handling techniques.
The transfer requires adequate staff and often specialized equipment, such as a mechanical lift, inflatable mat, or a three-person team lift, to protect both the patient and the staff from injury. Once the patient is safely transferred back to the bed or a chair, immediate post-fall care protocols begin, which includes an increased frequency of monitoring.
Post-Fall Monitoring and Documentation
Neurological checks and vital signs are typically performed every 15 minutes for the first hour, then hourly for a few hours, and then every four hours for 24 hours, depending on the facility protocol. This period of increased monitoring is designed to catch delayed symptoms, such as those that may occur with a slow-onset intracranial bleed. Immediate care also includes a thorough skin assessment for any bruising, abrasions, or skin tears, pain management, and the initiation of the administrative documentation process. The fall must be immediately documented in the medical record, and an incident report must be initiated to investigate the cause of the fall and implement preventative measures.