Falls are a frequent and serious concern in nursing homes, with a significant percentage of residents experiencing an event annually. These incidents carry a substantial risk for severe injuries, such as hip fractures and head trauma, which can lead to long-term disability or health decline. A clearly defined, immediate protocol is necessary to protect the resident and ensure regulatory compliance. Swift, correct action by staff is paramount to stabilizing the individual and preventing the exacerbation of injuries.
Immediate Response and Stabilization of the Resident
The first priority upon discovering a resident fall is to ensure the scene is safe and immediately call for qualified nursing assistance. Staff must avoid moving the resident, especially if they report pain, are unconscious, or sustained a head injury. Moving the individual before a medical assessment can dramatically worsen potential fractures, particularly to the hip or spine.
A rapid visual assessment must be performed while the resident remains in the position in which they fell. Staff should check the resident’s airway, breathing, and circulation (ABC) to rule out life-threatening emergencies requiring an immediate call to EMS. This evaluation includes assessing the level of consciousness, checking for obvious bleeding, and observing for signs of trauma like bruising, swelling, or limb rotation that could indicate a fracture.
Once the initial assessment is complete, the registered nurse or medical staff should check the resident’s vital signs, including temperature, pulse, respiration rate, and blood pressure. Checking for postural hypotension by measuring blood pressure in lying and sitting positions is routinely done to determine if a sudden drop in blood pressure caused the fall. Monitoring must continue until a physician or licensed practitioner completes a full physical examination.
If a resident is fully conscious, denies pain, and insists on getting up, the facility must still proceed with caution. The decision to assist them should only be made after a preliminary assessment by a licensed nurse rules out immediate injury. If the resident is deemed stable, staff should use a mechanical lift device or a two-person assist technique for a safe transition, followed by an immediate head-to-toe medical examination.
Required Documentation and Communication Protocols
Following stabilization and medical assessment, detailed documentation and timely communication are required. Accurate charting must include the exact time, location, and circumstances of the fall, based on witness accounts or the resident’s statement. Documentation must detail the nurse’s initial head-to-toe assessment, all vital signs recorded, and any immediate treatments administered.
An internal incident report (IR) is also completed, serving as a quality improvement tool distinct from the clinical record. This report investigates factors that contributed to the fall, such as environmental hazards or inadequate supervision, to help identify systemic issues. This information is vital for the interdisciplinary team to adjust the resident’s care plan and facility practices.
Timely communication with external parties is a regulatory requirement. The resident’s attending physician must be notified promptly, often within an hour, regarding the fall, the resident’s status, and any injuries sustained. Federal regulations enforced by the Centers for Medicare and Medicaid Services (CMS) require that the legally responsible party, such as the family or Power of Attorney (POA), be notified of any accident or injury within a mandated timeframe, typically 24 hours.
If the fall results in a serious injury or an injury of unknown origin, the facility may be required to report the incident to the appropriate state regulatory agency. Staff must maintain heightened observation for a minimum of 72 hours after the fall, meticulously documenting any changes in the resident’s physical or mental status, as some injuries, like subdural hematomas, may not manifest immediately.
Post-Fall Risk Assessment and Prevention Planning
The final phase involves a comprehensive review designed to prevent subsequent falls, as a resident who has fallen once is at a significantly higher risk of falling again. The interdisciplinary team, including nurses, the physician, and therapists, must conduct a root cause analysis (RCA) to uncover the underlying reasons for the incident. This analysis examines systemic factors beyond the immediate cause, such as medication side effects, poor lighting, or improper use of mobility aids.
Within seven days of the fall, a complete post-fall assessment is necessary, focusing on six core areas. This assessment often includes a detailed functional evaluation of the resident’s gait, balance, and transfer ability, using standardized tests to identify specific deficits. The goal is to match preventative interventions directly to the identified risk factors.
Six Core Assessment Areas
- Fall circumstance
- Associated symptoms
- Functional ability
- Past medical history
- Physical examination
- Necessary diagnostics
Based on the RCA and comprehensive assessment, the resident’s individualized care plan must be revised with specific, targeted interventions. A medication review is a common intervention, where the pharmacist and physician assess medications known to increase fall risk, such as psychotropic drugs or certain blood pressure medicines, for possible dosage reduction or discontinuation. Environmental modifications must also be implemented, such as installing pressure-sensitive alarms, repositioning furniture, or providing specialized assistive devices.
Preventative measures incorporated into the revised care plan may include increasing the frequency of staff checks and assistance, especially during high-risk times. Physical and occupational therapists often prescribe new exercises to improve strength and balance or train the resident on the proper use of mobility aids. The facility is responsible for monitoring the effectiveness of these interventions and adjusting the plan as needed.