Falls: Policy and Procedure for the Prevention and ...

1 Date of Next Review: 13 Sep 2019. Reference Number: Previous Trust/LHB Reference Number: Version Number: 3 T 395. Falls: Policy and Procedure for the Prevention and Management of Adult In-patient Falls Policy Statement To ensure the Health Board delivers its aims, objectives, responsibilities and legal requirements transparently and consistently, we will, by the issue of this Policy and Procedure , work to ensure that the risk of harm to adult patients caused by falls is minimised. Policy Commitment We are committed to ensuring that this Policy and Procedure regarding the Prevention and management of falls is followed by our staff when they are caring for adult patients who may be at risk of falls. Supporting procedures and Written Control Documents The supporting Procedure describes the following with regard to falls Prevention and management - The identification of those adult patients who may be at risk of falls Actions to be taken to prevent falls where possible Actions to be taken if a patient falls Other supporting documents are: Mental Capacity Act 2005 Code of Practice Assessing and Prescribing Levels of Special Nursing Observations Restraint in the Care Management of Adults with Impaired Mental Capacity Policy Bedrails Procedure Incident, Hazard and Near Miss Reporting Policy NICE CG 161.

2 Welsh Health Circular (2016) 002. Scope This Procedure applies to all healthcare professionals employed by the UHB, including those on honorary contracts, who are involved in the care of in-patients. It also applies to academics, healthcare support workers, students and locums. Distribution Document Title: Policy and Procedure for the 2 of 29 Approval Date: 13 Sep 2016. Prevention of Adult inpatient Falls Reference Number: UHB 045 Next Review Date: 13 Sep 2019. Version Number: 3 Date of Publication: 26 Oct 2016. Approved By: Quality, Safety and Experience Committee This Policy and Procedure will be made available on the UHB intranet, clinical portal and internet sites. Review This Policy and Procedure will be reviewed by the falls steering group every three years or sooner if appropriate.

3 Equality Impact An Equality Impact Assessment (EqIA) has been completed Assessment and this found there to be no impact. Note: if an EqIA has not been completed indicate why Health Impact This was not considered necessary at the time of writing, but Assessment will be completed when the Policy is reviewed as part of the new UHB process that combines the Equality and Health Impact Assessments Policy Approved by Quality Safety and Experience Committee Group with authority to Falls steering group approve procedures written to explain how this Policy will be implemented Accountable Executive Executive Director for Therapies and Health Science or Clinical Board Director Disclaimer If the review date of this document has passed please ensure that the version you are using is the most up to date either by contacting the document author or the Governance Directorate.

4 Document Title: Policy and Procedure for the 3 of 29 Approval Date: 13 Sep 2016. Prevention of Adult inpatient Falls Reference Number: UHB 045 Next Review Date: 13 Sep 2019. Version Number: 3 Date of Publication: 26 Oct 2016. Approved By: Quality, Safety and Experience Committee Summary of reviews/amendments Version Date Review Date Summary of Amendments Number Approved Published 1 10/05/2011 13/06/2011 New Document UHB 2 Jan 2012 09/03/2012 Updated Appendices 15/08/2012 Appendix 23 added 15/08/12. 26/09/2012 Appendix 11 updated to UHB Policy 30/11/2012 Appendix 9 updated to v UHB Aug 2014 19/08/2014 Updated Appendices: Appendices 1,2, 3, 4, 7, 8, 15a, 15b, 21, 22, & 23. New Appendices: Appendix 24 - Familiarisation with flat-lifting and use of Hoverjack UHB Jan 2015 23/01/2015 Update Appendix 5.

5 UHB 3 13/09/2016 26/10/2016 New Policy and Procedure - This is a New Policy which has been added to the existing Procedure using the same UHB Number New appendices Appendix 16. Amended Frop-Com Form Appendix 17. L&S BP Procedure Poster Document Title: Policy and Procedure for the 4 of 29 Approval Date: 13 Sep 2016. Prevention of Adult inpatient Falls Reference Number: UHB 045 Next Review Date: 13 Sep 2019. Version Number: 3 Date of Publication: 26 Oct 2016. Approved By: Quality, Safety and Experience Committee Appendix 18. L&S Procedure Reference Cards Appendix 19. Basic Bedside Vision Assessment Appendix 20. Delirium Screen the 4A's Document Title: Policy and Procedure for the 5 of 29 Approval Date: 13 Sep 2016. Prevention of Adult inpatient Falls Reference Number: UHB 045 Next Review Date: 13 Sep 2019.

6 Version Number: 3 Date of Publication: 26 Oct 2016. Approved By: Quality, Safety and Experience Committee Adult In-patient Falls Procedure Contents Reference Number: TBA unless document for review .. 1. 1 Introduction .. 6. 2 Responsibilities .. 6. 3 Abbreviations .. 9. 4 Underpinning key principles .. 9. 5 Framework for assessment .. 10. 6 Standard Guidance for falls Prevention actions and Interventions for all adult In-patients .. 11. 7 Multi-Factorial Assessment and Multi-Factorial actions and Intervention .. 14. 8 Additional targeted interventions .. 15. 9 Ongoing Multi-Factorial Assessment, actions and Interventions .. 18. 10 Consider Unintended Consequences .. 19. 11 Assessment and Immediate actions following an adult in-patient fall 19.

7 Potential head injury .. 22. Escalation 23. 12 Triple immobilisation .. 23. 13 Urgent Escalation to Doctor .. 24. 14 Screen for a possible or actual fracture .. 25. 15 Reporting and record 26. 16 26. 17 Training .. 27. 18 Implementation .. 27. 19 Equality .. 27. 20 28. 21 Distribution .. 28. Document Title: Policy and Procedure for the 6 of 29 Approval Date: 13 Sep 2016. Prevention of Adult inpatient Falls Reference Number: UHB 045 Next Review Date: 13 Sep 2019. Version Number: 3 Date of Publication: 26 Oct 2016. Approved By: Quality, Safety and Experience Committee 22 Review .. 28. 23 Appendices .. 28. 1 Introduction Health care professionals have a duty of care to minimise risks to their patients. Cardiff and Vale University Health Board (UHB) aims to take all reasonable steps to ensure the safety and independence of its patients, and respects the rights of patients to make their own decisions about their care.

8 In-patient falls are the most frequently reported incident for the UHB (and this is true throughout the UK). Falls can be both a cause and a consequence of delayed transfer of care. With the UHB's patient population increasing in age and complex multi-morbidity, the challenge to reduce the number of falls and injuries from falls is significant. A previous or recent fall is an indicator of the risk of a future fall . Adult patients in hospital may be at risk of falling for many reasons including a history of falls, medically unwell, dementia or delirium, the effects of their treatment or medication, poor mobility, visual and other sensory impairments along with their general wellbeing. Although most falls result in no physical harm or minor physical injuries like scrapes and bruises, falls do sometimes result in catastrophic injury, including death.

9 Fear of falling is a common presentation but is outside of the scope of these procedures . 2 Responsibilities All healthcare staff who are involved with the care of in-patients have a responsibility to familiarise themselves with and follow the content of this Policy and Procedure . Where staff are unsure about the reduction of risk strategies, they must seek advice from a senior colleague. Clinical Board Quality and Safety Leads are responsible for ensuring: Document Title: Policy and Procedure for the 7 of 29 Approval Date: 13 Sep 2016. Prevention of Adult inpatient Falls Reference Number: UHB 045 Next Review Date: 13 Sep 2019. Version Number: 3 Date of Publication: 26 Oct 2016. Approved By: Quality, Safety and Experience Committee that staff are aware of this Policy and Procedure , how to access it and what to do if they have related queries about it falls incidents are reviewed on a regular basis at quality and safety meetings the development and completion of annual departmental in- patient falls improvement plans as part of the Heath and Care Standards the incident reporting Policy is adhered to Directorate/Locality Management Teams are responsible for.

10 Ensuring that an assessment of staff training needs in relation to this Policy and Procedure is carried out and, where appropriate, staff are required to undertake relevant training, including refresher training monitoring implementation of this Policy Procedure and present and act on their findings Lead Nurses / Senior Nurses are responsible for: ensuring that the Policy and Procedure is monitored and that any associated governance issues are highlighted through an appropriate route and corrective actions taken ensuring falls compliance tools audit is completed on a regular basis determined by to Clinical Board Quality Safety and experience meetings and reported to the adult In-patient Falls Steering Group Consultants /Ward Sisters/Charge Nurses/Allied Health Professional Team Managers are responsible for ensuring that.