Date: Care plan no - royalberkshire.nhs.uk

1 RBFT Falls Prevention and post Falls Care Plan May 2016 FALLS PREVENTION AND post FALLS CARE PLAN Name: NHS no. Date: Care plan no: Patient need / problem Patient identified as being at increased risk of falls and /or has fallen, and a Falls Care Bundle has been commenced. Before their illness how did the patient usually manage this? Aim / outcome PREVENTION OF NEEDLESS FALLS / post FALLS MANAGEMENT - maintaining patient safety Date aim / outcome reached Interventions required to meet aim / outcome (Delete and personalise as appropriate) Review interventions each shift and following each fall Review interventions post fall (indicate which interventions implemented) Date of fall Signature Date Nursing Interventions Call Ensure call bell explained and in reach. Consider alternatives for patients unable to recall use of call bell, hand bell, move bed nearer to nurses station. Ensure increased patient contact, minimum 2 hourly. Eyesight & Hearing Ensure glasses are clean, are worn or within reach.

2 Ensure hearing aids are worn. Report any malfunctioning hearing aids to the Audiology Department, replace batteries. Assess, document and address any hearing, visual or other impairments. Bed and Bedrails Assess the need for bedrails (complete form with Care Plan Trigger). If likely to fall from bed, ensure the bed is at the lowest height possible unless this reduces mobility or independence. Consider use of Ultra low bed. Place Select the most observable bedspace on ward to minimise the risk of further falls (potential to fall from height, chair); consider close to nurses station, toilet, quietest area (consider other patients needs as well). Footwear Check footwear for secure fit, non-slip sole, no trailing laces. Encourage relatives to purchase non-slip footwear, if required. Patient label here RBFT Falls Prevention and post Falls Care Plan May 2016 Interventions required to meet aim / outcome (Delete and personalise as appropriate) Review interventions post fall (indicate new interventions implemented) Date Nursing Interventions Review interventions each shift and following each fall Date of fall Signature Toilet If the risk of falls appears to be associated with patient s need to use toilet/safety while using toilet - initiate two hourly offers of toilet/comfort visits and consider supervision whilst using the toilet.

3 Consider use of pressure sensor equipment in toilet environments for patients at high risk of falls or are not capable of using call bells. Assess, document and carry out appropriate continence care/remove unnecessary catheters. Lighting Consider lighting best for patient, bedside light left on overnight (but consider other patients), light in toilet left on overnight. Medication Ensure observations are within therapeutic range prior to administration of medication associated with the treatment of blood pressure, and pulse rate / rhythm. Seek medical advice if the observations are abnormal or vary greatly from the patient s baseline observations. Ensure other medications are given in a timely way in accordance with prescription. Lying and standing blood pressure Ensure lying & standing blood pressures are recorded twice a day for a minimum of 48 hours on admission to hospital and following an In-patient fall . Ideally lying and standing BP should be recorded manually (using a stethoscope and sphygmomanometer).

4 Inform medical team if the observations are abnormal or vary greatly from the patient s baseline observations. Other interventions Implement recommendations/treatment regarding new Delirium/infection prompt administration of antibiotics etc Ensure any diagnostic tests ordered are carried out in a timely way and results are available MSU, CSU, blood cultures etc. Ensure trip and slip hazards are minimised in the ward/patient environment. Ensure individual walking aids are within reach at all times. Identify increased risk of falls by using a red square above bed, a red armband on patient, a red sticker or name band on any walking aids and a red sticker on drug chart to ensure medication review. Ensure appropriate bed and chair heights for patient. If available, consider using a patient movement alarm to prevent unassisted mobilisation. Ensure risk of falls is documented on EPR in problems section. Consider 1:1 observation: document reason if unable/inappropriate to provide.

5 If used, document when 1:1 observation discontinued. RBFT Falls Prevention and post Falls Care Plan May 2016 Interventions required to meet aim / outcome (Delete and personalise as appropriate) Date Nursing Interventions Review interval Sign Following an in-patient fall : Ensure the patient is assessed for serious injury using the Patient fall : Immediate Management Flow Chart . Ensure Medical Team and Outreach are contacted for an urgent review if the patient has neck or back pain, reduced level of consciousness immediately following the fall . Ensure the patient is monitored and frequency of observations performed using the Observation guidelines for adult patients who have fallen protocol. Ensure the Medical Team and Outreach are informed of any deviation in the patient s neurological and physiological observations or if the patient develops worrying symptoms . Ensure larger patients who fall are transferred using the Flow chart for transferring larger patients from the floor who have fallen in hospital.

6 Complete a falls risk assessment and bed rail assessment after each in-patient fall . Ensure a Datix Incident Report is completed in a timely manner following an in-patient fall . Ensure the Datix Incident Report is up-dated if the patient s condition deteriorates or serious injury is identified following the initial fall . Ensure that any patient fall during a shift is highlighted during staff handover. Ensure Falls Prevention and Management Care Plan is reviewed following each fall and indicate any new interventions implemented. Patient /family /carer agrees to manage the following aspects of care: Ensure patient/family/carers are informed of the increased risk of falls or that the patient has fallen in hospital. RBFT Falls Prevention and post Falls Care Plan May 2016