Patient falls often lead to serious injuries such as fractures or head trauma. Immediate actions determine the patient’s well-being and the success of subsequent treatment. A structured protocol is necessary to minimize harm and ensure a comprehensive response. Following a clear, step-by-step procedure is paramount for staff to manage the situation effectively.
Immediate Response and Stabilization
The immediate response focuses on securing the scene and stabilizing the patient before moving them. Do not move the patient unless they are in immediate danger, such as from a fire or flood. Moving a patient with an unknown injury risks spinal cord damage or converting a simple fracture into a complex one. Suspected spinal or hip injuries require the patient to be kept flat on the floor until trained personnel can conduct an assessment and use specialized lifting equipment.
Call for help immediately using the facility’s established protocol. While waiting for responders, perform a rapid initial assessment of the patient’s Airway, Breathing, and Circulation (ABC). Check for consciousness, observe the breathing pattern, and look for massive external bleeding that requires immediate pressure.
Reassure the patient and keep them comfortable in their current position. Providing a blanket or covering can help maintain body temperature and offer a sense of security. The person who discovered the fall should quickly check the environment for hazards, such as spilled liquids or displaced equipment. This stabilization ensures potential internal injuries are not exacerbated by premature movement.
Post-Fall Patient Assessment
Trained personnel initiate a clinical assessment once the patient is stabilized and immediate life threats are ruled out. This assessment begins with a detailed head-to-toe check for visible injuries, including lacerations, bruising, deformity, or swelling. Specific attention is paid to the lower extremities; for example, a shortened leg or external rotation of the foot indicates a hip fracture.
A neurological status check is conducted using the Glasgow Coma Scale (GCS) to determine the level of consciousness. The assessment includes checking for new complaints of headache, dizziness, or visual changes, and observing for unequal pupil reaction or vomiting. These observations are important to identify a potential head injury, which may have delayed symptoms.
Baseline vital signs (blood pressure, heart rate, oxygen saturation, and respiratory rate) are measured and recorded. Orthostatic blood pressure measurements may be taken to determine if a sudden drop in blood pressure contributed to the fall. A comprehensive pain assessment is performed to locate and quantify the severity of any pain. Only after the clinical assessment confirms the patient’s safety and stability can a decision be made regarding the safest method for moving the patient.
Documentation and Communication Requirements
After the physical assessment, documentation and communication requirements must be met to ensure accountability and continuity of care. A formal Incident Report (IR) must be completed promptly, even if the patient appears uninjured. The report must contain specific data points, including the exact time and location of the fall, the patient’s activity beforehand, and a detailed description of the observed injuries and the staff’s response.
Mandatory communication begins with immediately notifying the primary physician or healthcare provider. The provider must be informed of the circumstances of the fall and the results of the post-fall assessment, including any new symptoms or changes in vital signs. This immediate notification allows the provider to order necessary diagnostic tests, such as X-rays or CT scans, in a timely manner.
Communication also extends to the patient’s family or next of kin, who must be informed about the incident in a transparent manner. Notification should occur as soon as the patient is stable and the clinical team has a clear picture of the situation. Accurate documentation of all communication, including the time and content of discussions with the provider and family, is logged in the patient’s health record.
Updating the Fall Prevention Strategy
The final phase involves reviewing the event to prevent future occurrences. A post-fall review meeting, or “huddle,” is conducted shortly after the incident to determine the immediate and underlying causes. This functions as a rapid root cause analysis, examining factors like environmental hazards, medication side effects, or changes in clinical status.
Immediate interventions are implemented within the first 24 hours to mitigate identified risk factors. For instance, if the fall was due to urgency, interventions might include increasing staff assistance for toileting or providing a bedside commode. If medication side effects are suspected, the regimen may be reviewed for drugs that cause dizziness or hypotension.
The patient’s individualized Fall Risk Assessment and overall care plan must be formally updated, as the fall indicates a change in their risk profile. This update incorporates new interventions, such as the use of a low bed, hip protectors, or increased monitoring. The care team collaborates to ensure the revised plan is comprehensive and consistently reinforced.