After assessment of fall risk by the registered nurse (RN), activities related to reducing a patient's risk for falls may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

• fall risk assessment tool, if available
• PPE, as indicated
• Additional intervention tools, as appropriate (refer to sample intervention equipment in this skill)

At a minimum, fall risk assessment needs to occur on admission to a facility, during an initial home visit, following a change in the patient's condition, after a fall, when the patient is transferred between facilities, and during annual well-visits and health screenings. If it is determined that the patient is at risk for falling, regular assessment must continue. Assess the patient and the health record for factors that increase the patient's risk for falling. An objective, systematic fall risk assessment is made easier by the use of a fall risk assessment tool, combined with additional assessments to evaluate risks not captured by the tool (The Joint Commission, 2015). The Johns Hopkins fall risk assessment Tool (Figure 1) is one example of a fall risk assessment tool. The Hendrich II Fall Risk Model (older adults) and the Humpty Dumpty Falls Scale (pediatric patients) are other tools to evaluate fall risk factors.

Assess for a history of a fall or falls. Once a person falls one time, the chance of falling again increases dramatically regardless of whether the patient is in a hospital, a long-term care facility, or the community (Grossman et al., 2018; Soh et al., 2020). If the patient has experienced a previous fall, assess the circumstances surrounding the fall and any associated symptoms (AGS, n.d.). Review the patient's medication history and medication record for medications that may increase the risk for falls. Assess for the following additional risk factors for falls (AGS, n.d.; Centers for Disease Control and Prevention [CDC], 2019d; CDC, 2017; WHO, 2018):

• Lower extremity muscle weakness
• Gait or balance deficit
• Mobility impairment
• Restraint use
• Use of an assistive device
• Presence of IV therapy
• Impaired activities of daily living (ADLs)
• Age older than 65 years/children
• Altered elimination
• History of falls
• Administration of high-risk drugs, such as narcotic analgesics, antiepileptics, benzodiazepines, and drugs with anticholinergic effects
• Use of four or more medications
• Alcohol or substance abuse
• Postural (orthostatic) hypotension
• Depression
• Visual deficit
• Arthritis
• Fear of falling
• History of cerebrovascular accident
• Cognitive impairment
• Secondary diagnosis/chronic disease
• Home/environmental hazards/dangers

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient. Assess fall risk as outlined above.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors. fall risk assessment aids in providing appropriate interventions for the individual patient.
3. Review the results of the fall risk assessment and fall risk factors with the patient, family, and/or caregivers (Figure 2).	Promotes person-centered, individualized care and engagement, continuity of care and understanding.
4. Explain the rationale for interventions to reduce the patient's risk for fall to the patient, family, and/or caregivers.	Explanation helps reduce anxiety and promotes engagement and understanding.
5. Include the patient, family, and/or caregivers in the plan of care.	Promotes person-centered, individualized care and engagement, continuity of care and understanding (CDC, 2017; CDC, 2019d; Hager et al., 2019; Stoeckle et al., 2019; Tucker et al., 2019; Williams, 2018).
6. Provide time for the patient, family, and/or caregivers to discuss concerns about falling, identify fall risk factors not identified by the risk assessment, confirm their understanding of risk factors and interventions, and to verbalize concerns or questions.	Promotes person-centered, individualized care and engagement, continuity of care and understanding. Active involvement on the part of patients, family, and/or caregivers is an important part of identification of fall risk and associated interventions (CDC, 2017; CDC, 2019d; Stoeckle et al., 2019; Tucker et al., 2019; Williams, 2018).
7. Provide adequate lighting. Use a night light during sleeping hours.	Good lighting reduces accidental tripping over and bumping into objects that may not be seen. Night light provides illumination in an unfamiliar environment.
8. Remove excess equipment, supplies, furniture, and other objects from rooms and walkways. Pay particular attention to high traffic areas and the route to the bathroom.	All are possible hazards.
9. Orient patient and significant others to new surroundings, including use of the telephone, call bell, patient bed, and room illumination. Indicate the location of the patient's bathroom.	Knowledge of proper use of equipment relieves anxiety and promotes engagement.
10. Consider use of a low bed to replace regular hospital bed, as indicated (Figure 3). Low beds should be raised to the appropriate height for each patient to allow safe transition out of bed (Hester, 2015).	The use of low beds is associated with decreased serious fall-related injuries (Hester, 2015).
11. Use floor mats if the patient is at risk for getting out of bed without calling for assistance and is at risk for injury (Quigley, 2015) (see Figure 3). Floor mats should only be on the floor by the bedside on the safest side of the bed for patient exit when the patient is resting in bed (Quigley, 2015).	Floor mats cushion falls and may reduce trauma resulting from falls (Hester, 2015; Quigley 2015). Floor mats should be stored underneath the bed when the patient is not in the bed to reduce the risk of tripping (Quigley, 2015).
12. Provide nonskid footwear and/or walking shoes (Figure 4).	Nonskid footwear prevents slipping and walking shoes improve balance when ambulating or transferring.
13. Institute a toileting regimen and/or continence program, if appropriate.	Toileting on a regular basis decreases risk for falls.
14. Provide a bedside commode and/or urinal/bedpan, if appropriate. Ensure that it is near the bed at all times, if appropriate for individual patient.	This prevents falls related to incontinence or trying to get to the bathroom. It may be necessary to move the bedside commode out of sight to discourage attempts at independent transfer by patients with altered mobility, as appropriate.
15. Ensure that the call bell, bedside table, telephone, and other personal items are within the patient's reach at all times.	This prevents the patient from having to overreach for a device or items, and/or possibly attempt ambulation or transfer unassisted.
16. Confer with the health care team regarding and encourage appropriate exercise and physical therapy (Figure 5).	Exercise programs, such as muscle strengthening, balance training, resistance training, and walking plans, promote improved balance and reduce the risk of falls and fall-related injuries (CDC, 2017; Thomas et al., 2019).
17. Confer with the health care team regarding appropriate mobility aids, such as a cane or walker.	Mobility aids can help improve balance and steady the patient's gait.
18. Confer with the health care team regarding the use of bone-strengthening medications, such as calcium, vitamin D, and drugs to prevent/treat osteoporosis.	Bone strengthening has been suggested to reduce fracture with fall-related injuries (CDC, 2019a).
19. Encourage the patient to rise or change position slowly and sit for several minutes before standing.	Gradual position changes reduce the risk of falls related to orthostatic hypotension.
20. Evaluate the appropriateness of graduated compression stockings for lower extremities.	Graduated compression stockings minimize venous pooling and promote venous return.
21. Confer with the health care team to review medications for potential hazards.	Certain medications and combinations of medications have been associated with increased risk for falls.
22. Keep the bed in the lowest position. If elevated to provide care (to reduce caregiver strain) or when a patient is transferring out of bed, ensure that it is lowered when care is completed.	Keeping bed in lowest position reduces the risk of a fall and fall-related injury (AHRQ, 2013).
23. Make sure locks on the bed or wheelchair are secured at all times (Figure 6).	Locking prevents the bed or wheelchair from moving out from under the patient.
24. Use bed rails according to facility policy, when appropriate, based on individual patient assessment (Figure 7).	Inappropriate bed-rail use has been associated with patient injury and increased fall risk (FDA, 2018b). Side rails that are raised with the intent to prevent the patient from voluntarily attempting or actually getting out of bed are considered a restraint (The Joint Commission, 2017).
25. Anticipate patient needs and provide assistance with activities instead of waiting for the patient to ask.	Patients whose needs are met sustain fewer falls.
26. Consider the use of an electronic personal alarm or pressure sensor alarm for the bed or chair (Figure 8).	The alarm helps alert staff to unassisted changes in position by the patient.
27. Discuss the possibility of appropriate family member(s)/caregiver(s) staying with the patient.	The presence of a family member/caregiver provides familiarity and companionship.
28. Consider the use of a patient attendant or sitter.	An attendant or sitter can provide companionship and supervision; however, the effectiveness of this intervention on patient falls is unclear (Greeley et al., 2020).
29. Increase the frequency of patient observation and surveillance. Utilize 1- or 2-hour patient care rounds/intentional rounding (hourly/nursing rounds), including pain assessment, toileting assistance, patient comfort, making sure personal items are in reach, and meeting patient needs.	Intentional rounding/patient care rounds anticipate and proactively address patient needs (Hicks, 2015; Ryan et al., 2019). Patient care rounds can reduce patient falls (Ryan et al., 2019; Spano-Szekely, 2018).
30. Assess for and make use of safe patient handling equipment (e.g., gait belt, lifts, transfer devices) as appropriate, based on individualized patient assessment and circumstances. Refer to Chapter 9.	Use of safe patient handling equipment facilitates safe patient transfers (lateral and vertical), repositioning, mobility, and transport (VHACEOSH, 2016).
31. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.