Page 27 - FALL GUIDELINES MOH 2019

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INTERVENTION
INTERVENTION
INTERVENTION

INTERVENTION

Standard Falls Risk Interventions (for all patients)
Standard Falls Risk Interventions (for all patients)
INTERVENTION
Standard Falls Risk Interventions (for all patients)

INTERVENTION
Standard Falls Risk Interventions (for all patients)

1. Orientate the person to the surrounding environment daily (or more often if the person
1. Orientate the person to the surrounding environment daily (or more often if the person
Standard Falls Risk Interventions (for all patients)
1. Orientate the person to the surrounding environment daily (or more often if the person
is confused or disorientated)
Standard Falls Risk Interventions (for all patients)
1. Orientate the person to the surrounding environment daily (or more often if the person
is confused or disorientated)

is confused or disorientated)
2. Ensure the person uses their glasses and/or hearing aids and walking aids (if required)
is confused or disorientated)
2. Ensure the person uses their glasses and/or hearing aids and walking aids (if required)
1. Orientate the person to the surrounding environment daily (or more often if the person
2. Ensure the person uses their glasses and/or hearing aids and walking aids (if required)
3. Advice the use of covered shoes or nonslip footwear to prevent slipping
1. Orientate the person to the surrounding environment daily (or more often if the person
2. Ensure the person uses their glasses and/or hearing aids and walking aids (if required)
3. Advice the use of covered shoes or nonslip footwear to prevent slipping
is confused or disorientated)
3. Advice the use of covered shoes or nonslip footwear to prevent slipping
4. Ensure that clothing is not interfering with the person’s mobility
is confused or disorientated)
3. Advice the use of covered shoes or nonslip footwear to prevent slipping
4. Ensure that clothing is not interfering with the person’s mobility
2. Ensure the person uses their glasses and/or hearing aids and walking aids (if required)
4. Ensure that clothing is not interfering with the person’s mobility
5. Instruct the patient to call for assistance
2. Ensure the person uses their glasses and/or hearing aids and walking aids (if required)
4. Ensure that clothing is not interfering with the person’s mobility
5. Instruct the patient to call for assistance
3. Advice the use of covered shoes or nonslip footwear to prevent slipping
5. Instruct the patient to call for assistance
6. Secure a call bell at the bed table or bedhead
3. Advice the use of covered shoes or nonslip footwear to prevent slipping
5. Instruct the patient to call for assistance
6. Secure a call bell at the bed table or bedhead
4. Ensure that clothing is not interfering with the person’s mobility
6. Secure a call bell at the bed table or bedhead
7. Ensure the bed or wheelchair is locked, and bed rails are up (where appropriate)
4. Ensure that clothing is not interfering with the person’s mobility
6. Secure a call bell at the bed table or bedhead
7. Ensure the bed or wheelchair is locked, and bed rails are up (where appropriate)
5. Instruct the patient to call for assistance
7. Ensure the bed or wheelchair is locked, and bed rails are up (where appropriate)
8. Conduct regular enviromental rounds to look out for falls hazards (ie.ensure bathroom
5. Instruct the patient to call for assistance
7. Ensure the bed or wheelchair is locked, and bed rails are up (where appropriate)
8. Conduct regular enviromental rounds to look out for falls hazards (ie.ensure bathroom
6. Secure a call bell at the bed table or bedhead
8. Conduct regular enviromental rounds to look out for falls hazards (ie.ensure bathroom
lights are on and the floor is dry)
6. Secure a call bell at the bed table or bedhead
8. Conduct regular enviromental rounds to look out for falls hazards (ie.ensure bathroom
lights are on and the floor is dry)
7. Ensure the bed or wheelchair is locked, and bed rails are up (where appropriate)
lights are on and the floor is dry)
9. Provide education to the patient and caregiver
7. Ensure the bed or wheelchair is locked, and bed rails are up (where appropriate)
lights are on and the floor is dry)
9. Provide education to the patient and caregiver
8. Conduct regular enviromental rounds to look out for falls hazards (ie.ensure bathroom
9. Provide education to the patient and caregiver

8. Conduct regular enviromental rounds to look out for falls hazards (ie.ensure bathroom

9. Provide education to the patient and caregiver
lights are on and the floor is dry)

lights are on and the floor is dry)

9. Provide education to the patient and caregiver

Moderate Falls Risk Interventions
9. Provide education to the patient and caregiver
Moderate Falls Risk Interventions

Moderate Falls Risk Interventions

1. Identify delirium and observe closely
1. Identify delirium and observe closely
Moderate Falls Risk Interventions
1. Identify delirium and observe closely
2. Check for postural hypotension and manage appropriately
Moderate Falls Risk Interventions
2. Check for postural hypotension and manage appropriately
1. Identify delirium and observe closely
2. Check for postural hypotension and manage appropriately
3. Reinforce instructions to call for assistance
2. Check for postural hypotension and manage appropriately
3. Reinforce instructions to call for assistance
1. Identify delirium and observe closely
3. Reinforce instructions to call for assistance
4. Supervise and assist ambulation and activities of daily living when necessary
1. Identify delirium and observe closely
4. Supervise and assist ambulation and activities of daily living when necessary
3. Reinforce instructions to call for assistance
2. Check for postural hypotension and manage appropriately
4. Supervise and assist ambulation and activities of daily living when necessary
5. Conduct 4-hourly safety checks
2. Check for postural hypotension and manage appropriately
5. Conduct 4-hourly safety checks
4. Supervise and assist ambulation and activities of daily living when necessary
3. Reinforce instructions to call for assistance
5. Conduct 4-hourly safety checks
6. Check the person when visitors leave
3. Reinforce instructions to call for assistance
5. Conduct 4-hourly safety checks leave
6. Check the person when visitors
4. Supervise and assist ambulation and activities of daily living when necessary
6. Check the person when visitors leave
7. Apply a Falls “MODERATE Risk” tag at the person’s bed and in the medical notes
4. Supervise and assist ambulation and activities of daily living when necessary
6. Check the person when visitors leave
7. Apply a Falls “MODERATE Risk” tag at the person’s bed and in the medical notes
5. Conduct 4-hourly safety checks
7. Apply a Falls “MODERATE Risk” tag at the person’s bed and in the medical notes

5. Conduct 4-hourly safety checks

7. Apply a Falls “MODERATE Risk” tag at the person’s bed and in the medical notes
6. Check the person when visitors leave

6. Check the person when visitors leave

7. Apply a Falls “MODERATE Risk” tag at the person’s bed and in the medical notes

High Falls Risk Interventions
7. Apply a Falls “MODERATE Risk” tag at the person’s bed and in the medical notes
High Falls Risk Interventions

High Falls Risk Interventions

1. Place near nurses’ station (if possible)
1. Place near nurses’ station (if possible)

High Falls Risk Interventions
1. Place near nurses’ station (if possible)
2. Lower the bed to the lowest position
1. Place near nurses’ station
High Falls Risk Interventions (if possible)
2. Lower the bed to the lowest position

2. Lower the bed to the lowest position
3. Place a padded area (ie. Airex mattress) on the floor bedside if the patient is confused

2. Lower the bed to the lowest position
3. Place a padded area (ie. Airex mattress) on the floor bedside if the patient is confused
1. Place near nurses’ station (if possible)
3. Place a padded area (ie. Airex mattress) on the floor bedside if the patient is confused
but mobile
1. Place near nurses’ station (if possible)
3. Place a padded area (ie. Airex mattress) on the floor bedside if the patient is confused
but mobile
2. Lower the bed to the lowest position
but mobile
4. Reinforce education to the patient and caregiver
2. Lower the bed to the lowest position
but mobile
4. Reinforce education to the patient and caregiver
3. Place a padded area (ie. Airex mattress) on the floor bedside if the patient is confused
4. Reinforce education to the patient and caregiver
5. Apply a Falls “HIGH Risk” tag at the person’s bed and in the medical notes
3. Place a padded area (ie. Airex mattress) on the floor bedside if the patient is confused
4. Reinforce education to the patient and caregiver
5. Apply a Falls “HIGH Risk” tag at the person’s bed and in the medical notes
but mobile
5. Apply a Falls “HIGH Risk” tag at the person’s bed and in the medical notes

5. Apply a Fall
but mobile s “HIGH Risk” tag at the person’s bed and in the medical notes

4. Reinforce education to the patient and caregiver

5. Apply a Falls “HIGH Risk” tag at the person’s bed and in the medical notes

FALLS RISK
INTERVENTIONS
5. Apply a Falls “HIGH Risk” tag at the person’s bed and in the medical notes

INTERVENTIONS
FALLS RISK

INTERVENTIONS
FALLS RISK Standardized falls risk interventions
INTERVENTIONS
FALLS RISK
All patients
Standardized falls risk interventions
All patients
All patients Standardized falls risk interventions
INTERVENTIONS
FALLS RISK
Standardized falls risk interventions
All patients
Moderate risk Standardized + moderate falls risk interventions
FALLS RISK
INTERVENTIONS
Standardized + moderate falls risk interventions
Moderate risk
Standardized + moderate falls risk interventions
Moderate risk
Standardized falls risk interventions
All patients
Moderate risk Standardized + moderate + high falls risk interventions
Standardized + moderate falls risk interventions
High risk
Standardized falls risk interventions
All patients
High risk
Standardized + moderate + high falls risk interventions
High risk
Standardized + moderate falls risk interventions
Standardized + moderate + high falls risk interventions
High risk
Moderate risk Standardized + moderate + high falls risk interventions
Moderate risk Standardized + moderate falls risk interventions
High risk
Standardized + moderate + high falls risk interventions
Bed rails may be used as a safety barrier or as a support for transfer. They should be
High risk
Standardized + moderate + high falls risk interventions
Bed rails may be used as a safety barrier or as a support for transfer. They should be

Bed rails may be used as a safety barrier or as a support for transfer. They should be
lowered by default and only be raised at the discretion of the staff. Bed rails are
Bed rails may be used as a safety barrier or as a support for transfer. They should be
lowered by default and only be raised at the discretion of the staff. Bed rails are
lowered by default and only be raised at the discretion of the staff. Bed rails are
inappropriate for patients who are confused and mobile enough to climb over them.
inappropriate for patients who are confused and mobile enough to climb over them.
lowered by default and only be raised at the discretion of the staff. Bed rails are
Bed rails may be used as a safety barrier or as a support for transfer. They should be
inappropriate for patients who are confused and mobile enough to climb over them.
Bed rails may be used as a safety barrier or as a support for transfer. They should be
inappropriate for patients who are confused and mobile enough to climb over them.
lowered by default and only be raised at the discretion of the staff. Bed rails are
lowered by default and only be raised at the discretion of the staff. Bed rails are
inappropriate for patients who are confused and mobile enough to climb over them.
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inappropriate for patients who are confused and mobile enough to climb over them.
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