Contents
1 Aim
NICE recommends that all older people (aged 65 or above) who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and, or balance should be offered a multifactorial falls risk assessment (MFRA) as part of their routine healthcare intervention (falls in older people: assessing risk and prevention, CG161 NICE, 2013).
Completion of an MFRA is a key part of the admission process for inpatients with a history of falls or with underlying health conditions which increase their risk of falling.
Likewise, older patients under the care of community or day services who have an identified high falls risk should have a falls risk assessment completed and appropriate care planning put in place to reduce the likelihood of falls or reduce the potential harm from falling.
2 Scope
This is a trust wide procedure which is applicable to all patients under our care. It focuses in particularly on the needs of those patients who are in the higher falls risk groups or who already have a history of falls (over 65’s and patients with pre-existing health conditions which means they are at a higher risk of falling).
3 Link to overarching policy
4 Procedure
4.1 Risk assessment
4.1.1 Older peoples mental health inpatient units, home first inpatient units, neurological rehabilitation inpatient unit, hospice
On admission every patient in the above in-patient settings will have a multifactorial falls risk assessment (MFRA) as part of their admission process. The MFRA must be completed on SystmOne within 12 hours of admission. It will be the responsibility of the admitting nurse or named nurse to ensure that this is completed and any immediate risks addressed.
All in-patient areas will continue to implement the core principles of fall safe which include:
- a history of previous falls taken at the time of admission
- urinalysis completed on admission where applicable, (this isn’t a routine assessment in the above identified ward areas)
- avoidance of unnecessary prescriptions of night sedation
- ensuring that a call bell is within easy reach where appropriate
- ensuring that appropriate footwear is available and in use
- assessment for and provision of walking aids
- clear communication of mobility status
- personal items kept within easy reach
- cognitive assessment
- bedrail assessment
- vision assessment
- lying and standing blood pressure on admission
- medication review
- use of observation or rounding, bed position, and toileting assessment and plan if indicated in some cases a patient’s falls risk may fluctuate shift by shift. Colleagues must exercise vigilance and use clinical reasoning to make decisions about falls intervention and other falls prevention actions in a responsive way for example, at night close intervention may be re-enforced or replaced by use of bed alarms
The clinical team must exercise particular vigilance of patients during ‘higher risk times’ which have been identified as including:
- after admission
- during periods of agitation
- following administration of prn medication
- when commencing night sedation
- on initial use of bed rails
- delirium
- acute illness for example, infection
4.1.2 Adult mental health inpatient units, forensic inpatient units, substance misuse inpatient unit (New Beginnings)
The inpatient multifactorial falls risk assessment (MFRA) will be completed for patients on admission or transfer from another unit who have mobility problems, history of previous falls, medical or physical conditions which may predispose them to falls. It will be the responsibility of the admitting nurse or named nurse to ensure that the assessment is completed on SystmOne within 12 hours of admission and any immediate risks addressed.
4.1.3 Community services
In line with best practice, community services use appropriate tools for assessing falls risks with their patients when required. This may include the MFRA or the FRAT (falls risk assessment tool) or another bespoke risk assessment methods for their patient group.
Community patients who have a history of falls, are over the age of 65, have medical co-morbidities (both physical or mental health) or those with memory and cognitive decline for example, dementia will have a heightened falls risk therefore should receive a falls risk assessment as part of their initial assessment into service.
Community patient who fall under our direct care will be checked for injuries as per the RDaSH post fall clinical decision-making flow chart (appendix C) and managed accordingly. A falls risk assessment will be completed following such incidents and an IR1 report completed.
Onward referrals may be required to other specialist services to help reduce the likelihood of further falls in the future for example, GP for a medicines review, physiotherapy for a balance and mobility assessment, occupational therapy for the provision of safety equipment. This will be decided by the MDT involved in their care or the lead clinician.
4.2 Care planning
Following completion of the MFRA a care plan will be completed. Patients with a certain diagnosis or treatment will be considered as at a higher risk of falls or harm from falls. These include:
- patients with a diagnosis of osteoporosis or osteopenia
- all patients with a recent hip replacement
- patients with cognitive impairment or dementia and delirium
- patients with neurological problems
- patients with significantly impaired mobility
- patients with recent history of recurrent falls
- patients with a history of falls or fear of falling
- patients who are unsafe but who try to walk alone
- patients with a learning disability
- patients with complex physical and mental health needs
- patients who lack capacity with respect to their risk of falling
4.3 Actions to take
- Patient will have individualised multifactorial interventions based upon the issues identified in the MFRA (see section 5 below).
- Where specific risks are identified, the necessary clinical and environmental actions will be taken.
- Actions will be recorded in the most appropriate place for example, on the falls risk assessment document, as part of a separate falls care plan or within the patients overall care plan.
- Hospice: The review process and subsequent actions may differ to other services due to the patient group. The frequency and process of review of risk assessment will be dependent on the needs of the individual patient at that time and their presenting condition.
4.4 Reviewing risk assessments (all areas)
The decision as to how often the MFRA is reviewed should be based on clinical judgment and related to the individual’s specific needs. If unsure, colleagues should discuss further with senior colleagues, other members of the multi-disciplinary team (MDT) or they can contact the trust falls leads for advice. It must be remembered that all identified falls risk factors and care needs must be addressed and reviewed in an ongoing way as part of the continuous care planning process.
Falls assessments must be reviewed:
- if the patient’s condition alters
- there is a change in their medication
- the patient transfers to a different clinical area for example, mental health unit to intermediate care ward
- after a fall or near miss
5 Specific actions as part of an initial assessment
5.1 Identify any information relating to history of falls
This Information is vital to identify patient’s levels of risk.
All patients over the age of 65 and those aged 50 to 64 who are judged by a clinician to be at a higher risk of falling because of an underlying condition should be routinely asked if they have fallen in the past year and asked about the frequency and context and characteristics of the fall(s) (this is applicable to both inpatient and community patients).
Where indicated these patients should be offered a multifactorial assessment and a person-centred care plan developed for any identified risks. This may include referral to other services.
5.2 Identify with patient, carers, family regarding
- Position of bed at patients home, for example, side of bed they normally get out of.
- Any patterns patient may have when getting up at night for example, night-time routine and use of toilet, do they use commode, urine bottle, or which side of the bed would they normally get out of.
- Mobility aids used.
- Preferred night time lighting.
5.3 Avoid commencing sedating PRN medication and night sedation until sleep assessment completed
There is increased risk associated with certain medications and polypharmacy (see medication management and falls procedure).
Studies have found that around two-thirds of hospital patients who fell had received at least one medication that affects the central nervous system in the 24 hours prior to their fall. New medications should not be commenced unless a clear need has been identified through assessment.
5.4 Ensure appropriate footwear (see falls prevention and footwear procedure)
Patients may be admitted without bringing slippers or shoes, or their footwear may not be suitable, safe, or may not fit. Attempts should be made as soon as possible to obtain appropriate footwear for the patient. In emergency slipper socks may be utilised if indicated.
5.5 Ensure call bell within reach
All patients who are able to use the call bell should have it within sight and within reach if appropriate. Every patient must be shown how to use the call bell system. Patients must be reassured and encouraged to use the call bell.
If a patient has cognitive impairment, communication problems, lacks capacity to use a call bell, risk of ligature or where there is no call bell that can be within reach for example, due to bed position and sensors there must be a documented alternative plan to ensure patients individualised needs and requirements are met.
5.6 Urinalysis
Urinalysis is no longer completed routinely as part of admission assessment. Up to half of older adults (over 65 years of age), and most with a urinary catheter, will have bacteria present in the bladder or urine without an infection.
This “asymptomatic bacteriuria” is not harmful and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm. Do not perform routine urine dipsticks for infection in older adults or patients with urinary catheters. Exclude other causes. Send a sample if there are clinical signs of infection.
A physical assessment and bloods will be completed as part of admission assessment Results will be analysed and appropriate treatment commenced if indicated.
5.7 The use of a walking aid
Will be identified on assessment (see walking aid and gait training procedure)
If the patient has brought in their own walking aid this will be clearly labelled and within reach.
If the patient uses a walking aid but has not brought it with them, a walking aid will be provided on admission if nursing or support colleagues and nursing assistants are trained to provide these or as soon as possible by the physiotherapist
If a walking aid is issued by a nursing colleague, this will be reviewed by the physiotherapist as part of their initial assessment.
5.8 A bed rails assessment
Will be considered on admission (see falls intervention procedure) If immediate risks of falls from bed are identified a bed rails assessment will be completed.
This will also be reviewed as further information is obtained for example, how the patient sleeps, any change in clinical presentation such as the patient starts to try and climb out of bed.
5.9 Items within reach
Colleagues will ensure that all patient’s items will be placed within reach particularly if the patient has limited mobility.
5.10 Lying and standing blood pressure
Will be completed as part of the initial assessment. Any postural deficits of 20mg/Hg and, or diastolic 10mm/Hg or more to be discussed with doctor and nurse practitioner.
If it is not possible to obtain a lying standing blood pressure on admission, this must be documented and planned to obtain as soon as possible. If lying standing blood pressure is not possible to obtain there must be an MDT discussion re alternative such as sitting standing blood pressure.
5.11 Within 48 hours (Monday to Friday) of admission, inpatients will be seen for a physiotherapy assessment (except in the hospice where this may not be indicated)
- Establish falls history.
- Review falls assessment and update as required.
- Review and prevision of walking aids.
- Mobility care plan and care goal.
6 Reviewing risk assessments and care plans (all areas)
All identified falls risk factors and care needs must be addressed and reviewed regularly as part of the continuous MDT care planning process.
The decision as to how often multi factorial risk assessments are reviewed should be based on clinical judgement and MDT decision making and related to the individual’s specific needs.
All patients should be medically assessed for risks of falls against their pathology and medications.
If colleagues require advice they should discuss further with senior colleagues, other members of the MDT or they can contact the trust falls leads for advice.
Risk assessment must always be reviewed following a fall or a near miss. Following a fall a full MDT reassessment and review should be undertaken. If the wards use the PIPA model, any falls must be discussed in the purposeful in patient admission (PIPA) meeting the next day.
7 Prevention of future falls
Patients who have fallen will require interventions to reduce their likelihood of further falls. These interventions will be decided upon during the review of the patient’s care post fall, for example, as part of care planning, care programme approach (CPA) review, MDT meetings. Any actions taken and referrals made regarding such interventions will be clearly recorded in the patient’s care plan.
If patients have recurrent falls then the ward manager or modern matron will discuss the case with colleagues and if necessary will themselves lead further review of the falls prevention risk assessments and care planning.
8 Discharge and follow up procedure
- Information regarding falls risks, falls prevention and any care plan and interventions should be included in the patients discharge report or letter.
- For in patients who are being discharged into a care home or similar, information about the patients falls risk and management should be included as part of the discharge procedure.
- Patients who require further intervention to prevent falls should be considered for referral to relevant agencies and have access to interventions in their respective localities.
9 References
Document control
- Version: 1.
- Unique reference number: 1046.
- Date ratified: 1 August 2023.
- Ratified by: Clinical policies review and approval group.
- Name of originator: Clinical team leader.
- Name of responsible individual: Executive director of nursing and allied health professionals.
- Date issued: 11 August 2023.
- Review date: 31 August 2026.
- Target audience: Clinical staff.
- Description of change: Procedure to a manual.
Page last reviewed: April 23, 2024
Next review due: April 23, 2025