Maintain safe unit environment, including:
- Remove excess equipment/supplies/furniture from rooms and hallways.
- Coil and secure excess electrical and telephone wires.
- Clean all spills in patient room or in hallway immediately. Place signage to indicate wet floor danger.
- Restrict window openings.
The following are examples of basic safety interventions:
- Orient patient to surroundings, including bathroom location, use of bed, and location of call bell.
- Keep bed in lowest position during use unless impractical (as in ICU nursing or specialty beds).
- Keep top two side rails up (excludes box beds). In ICU, keep all side rails up.
- Secure locks on beds, stretchers, and wheelchairs.
- Keep floors clutter/obstacle free (with attention to path between bed and bathroom/commode).
- Place call bell and frequently needed objects within patient reach. Answer call bell promptly.
- Encourage patients/families to call for assistance when needed.
- Display special instructions for vision and hearing.
- Ensure adequate lighting, especially at night.
- Use properly fitting nonskid footwear.
| - Institute flagging system: yellow card outside room and yellow sticker on health record. Hill ROM flag (if available), assignment board/electronic board.
In addition to measures listed under low fall risk:
- Monitor and assist patient in following daily schedules.
- Supervise and/or assist bedside sitting, personal hygiene, and toileting, as appropriate.
- Reorient confused patients, as necessary.
- Establish elimination schedule, including use of bedside commode, if appropriate.
- PT (physical therapy) consult if patient has a history of fall and/or mobility impairment.
Evaluate need for:
- OT (occupational therapy) consult
- Slip-resistant chair mat (do not use in shower chair)
- Use of seatbelt, when in wheelchair
| - Institute flagging system: red card outside room and red sticker on health record, assignment board/electronic board: nurse call system flag, if available.
In addition to measures listed under moderate and low fall risk:
- Remain with patient while toileting.
- Observe every 60 minutes unless patient is on activated bed/chair alarm.
- If patient requires an air overlay, remove mattress (unless contraindicated by overlay type) or use side rail protectors.
- When necessary, transport throughout hospital with assistance of staff or trained caregivers. Consider alternatives, for example, bedside procedure. Notify receiving area of high fall risk.
Evaluate need for the following, starting with less restrictive to more restrictive measures in the listed order:
- Moving patient to room with best visual access to nursing station
- Bed/chair alarm
- Specialty fall-prevention bed
- 24-hour supervision/sitter
- Physical restraint/enclosed bed (only if less restrictive alternatives have been considered and found to be ineffective)
|