A resident fall in a care setting, such as an assisted living community or nursing home, is defined as an unexpected event where a person comes to rest on the ground or a lower level. These incidents are common, with approximately half of nursing home residents experiencing a fall annually. The immediate priority upon discovering a resident on the floor is safety, requiring staff to follow established protocols to protect the resident from further harm and themselves from injury. This structured response ensures the resident receives proper medical attention while initiating administrative steps for compliance and prevention.
Immediate Safety Assessment and Stabilization
The initial step is to pause and ensure the immediate area is safe, removing obvious hazards like spilled liquids or broken equipment that might cause injury to the resident or staff. Staff must call for assistance from colleagues or a nurse before approaching the resident, ensuring the resident is not left alone. The primary focus of this initial assessment is to determine the resident’s responsiveness and check for signs of serious injury, especially to the head, neck, or back.
Never move the resident until a serious injury has been ruled out by a medical professional or senior staff member. Moving a resident with an undiagnosed fracture or spinal injury could cause permanent damage. Staff should communicate clearly with the resident, asking if they are in pain and checking for a clear airway, breathing, and circulation. If the resident is unresponsive or if any sign of a severe injury is detected, emergency medical services (EMS) must be contacted immediately.
While waiting for medical help, staff must stabilize and comfort the resident. This includes covering the resident with a blanket to maintain body temperature, as lying on the floor can lead to hypothermia. Staff should visually inspect the resident for obvious signs of trauma, such as heavy bleeding, swelling, or an abnormal limb position. Ongoing observation for neurological changes is necessary, especially if a head injury is suspected or the fall was unwitnessed, as symptoms may be delayed.
Safely Assisting the Resident
The decision to physically assist the resident is made only after a medical assessment confirms they are uninjured and able to cooperate. If the resident can follow instructions and is safe to move, they may be coached to assist themselves using a chair or stable object, minimizing staff strain. This self-recovery technique, known as “backwards chaining,” is ideal when the resident retains mobility and can safely roll onto their side and kneel.
If the resident cannot stand or staff cannot safely move the person without risk of injury, mechanical aids must be used. There is no safe manual lift from the floor in a healthcare setting. Using a full-body mechanical lift or a specialized floor recovery device is the safest option for both the resident and the caregiver. The equipment should be brought to the resident, and staff must never attempt a lift alone.
Once the resident is safely moved, they should be transferred to a comfortable location, such as a bed or chair. Continuous monitoring is required for a minimum of 72 hours following the incident to detect delayed symptoms or complications. Staff must check vital signs, observe for subtle cognitive changes, and look for any new pain or swelling that may indicate an injury not immediately apparent.
Incident Reporting and Documentation Protocols
The administrative and legal requirements following a fall are important. Comprehensive documentation must be completed immediately, typically involving an official incident report or a structured “Fall Note” within the facility’s electronic charting system. This report must be objective and factual, detailing the exact time, location, and circumstances of the fall, including the activity the resident was performing.
The documentation requires a detailed record of the resident’s condition, including all observed injuries, vital signs, and any statements made by the resident or witnesses. The actions taken by staff, such as calling EMS or notifying a supervisor, and the immediate interventions provided, must also be meticulously recorded. This thorough record supports root cause analysis and meets regulatory requirements for timely reporting of serious injuries.
Following the initial documentation, supervisory staff must be promptly notified to initiate an investigation into the circumstances of the fall. The resident’s primary care provider and family must also be informed of the incident. This communication ensures a medical review can be performed and the care plan can be updated, often within 72 hours, to prevent recurrence.
Comprehensive Fall Prevention Strategies
After the immediate incident is resolved, a strategy for fall prevention must be implemented. This process begins with an interdisciplinary team conducting a root cause analysis to identify the underlying factors that contributed to the fall. This analysis informs a review and revision of the resident’s individualized care plan.
Underlying factors often include:
- Environmental hazards
- Medication side effects
- Mobility issues
- Underlying medical conditions
Environmental modifications are an effective prevention measure, focusing on removing trip hazards and ensuring proper lighting in all areas. This includes securing loose rugs, ensuring clear pathways, and installing grab bars in high-risk areas like bathrooms. Facilities also utilize validated tools, such as the Morse or Hendrich II scales, for routine risk assessments to identify residents requiring enhanced monitoring or specific interventions.
Medication review is another element of prevention, as certain drugs can increase fall risk due to side effects like dizziness or low blood pressure. A pharmacist or physician should regularly review the resident’s medication regimen to minimize the use of high-risk drugs. Promoting physical activity through tailored strength and balance exercises, such as Tai Chi, can improve stability and gait, which lowers the risk of falls.