5.6 Preventing Falls
Open Resources for Nursing (Open RN)
“Prevent residents from falling” is one of the National Patient Safety Goals for nursing care centers. Client falls, whether in the nursing care center, home, or hospital, are very common and can cause serious injury and death. Older adults have the highest risk of falling. Each year, 3 million older people are treated in emergency departments for fall injuries, and over 800,000 clients a year are hospitalized because of a head injury or hip fracture resulting from a fall. Many older adults who fall, even if they’re not injured, become afraid of falling. This fear may cause them to limit their everyday activities. However, when a person is less active, they become weaker, which further increases their chances of falling.[1]
Many conditions contribute to client falls, including the following:[2]
- Lower body weakness
- Vitamin D deficiency
- Difficulties with walking and balance
- Medications, such as tranquilizers, sedatives, antihypertensives, or antidepressants
- Vision problems
- Foot pain or poor footwear
- Environmental hazards, such as throw rugs or clutter that can cause tripping
Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater their chances of falling. Many risk factors can be changed or modified to help prevent falls.
The Centers for Disease Control has developed a program called “STEADI – Stopping Elderly Accidents, Deaths & Injuries” to help reduce the risk of older adults from falling at home. Three screening questions to determine risk for falls are as follows:
- Do you feel unsteady when standing or walking?
- Do you have worries about falling?
- Have you fallen in the past year? If yes, how many times? Were you injured?
If the individual answers “Yes” to any of these questions, further assessment of risk factors is performed.[3]
Read more information about preventing falls in older adults at CDC’s Older Adult Fall Prevention.
Fall Assessment Tools
By virtue of being ill, all hospitalized clients are at risk for falls, but some clients are at higher risk than others. Assessment is an ongoing process with the goal of identifying a client’s specific risk factors and implementing interventions in their care plan to decrease their risk of falling. Commonly used fall assessment tools used to identify clients at high risk for falls are the Morse Fall Scale, the Hendrich II Fall Risk Model, and the Hester Davis Scale for fall risk assessment. Read more about these fall risk assessment tools using the hyperlinks provided below. Key risk factors for falls in hospitalized clients are as follows:[4]
- History of falls: All clients with a recent history of falls, such as a fall in the past three months, should be considered at higher risk for future falls.
- Mobility problems and use of assistive devices: Clients who have problems with their gait or require an assistive device (such as a cane or a walker) for mobility are more likely to fall.
- Medications: Clients taking several prescription medications or those taking medications that could cause sedation, confusion, impaired balance, or orthostatic blood pressure changes are at higher risk for falls.
- Mental status: Clients with delirium, dementia, or psychosis may be agitated and confused, putting them at risk for falls.
- Continence: Clients who have urinary frequency or who have frequent toileting needs are at higher fall risk.
- Equipment: Clients who are tethered to equipment such as an IV pole or a Foley catheter are at higher risk of tripping.
- Impaired vision: Clients with impaired vision or those who require glasses but who are not wearing them are at a higher fall risk because of their decreased recognition of an environmental hazard.
- Orthostatic hypotension: Clients whose blood pressure drops upon standing often experience light-headedness or dizziness that can cause falls.
View these common fall risk assessment tools:
Interventions to Prevent Falls
Universal fall precautions are established for all clients to reduce their risk for falling. In addition to universal fall precautions, a care plan is created based on the client’s fall risk assessment findings to address their specific risks and needs.
Universal Fall Precautions
Falls are the most commonly reported client safety incidents in the acute care setting. Hospitals pose an inherent fall risk due to the unfamiliarity of the environment and various hazards in the hospital room that pose a risk. During inpatient care, nurses assess their clients’ risk for falling during every shift and implement interventions to reduce the risk of falling. Universal fall precautions have been developed that apply to all clients all the time. Universal fall precautions are called “universal” because they apply to all clients, regardless of fall risk, and revolve around keeping the client’s environment safe and comfortable.[7]
Universal fall precautions include the following[8]:
- Familiarize the client with the environment.
- Have the client demonstrate call light use.
- Maintain the call light within reach. See Figure 5.5[9] for an image of a call light.
- Keep the client’s personal possessions within safe reach.
- Have sturdy handrails in client bathrooms, rooms, and hallways.
- Place the hospital bed in the low position when a client is resting. Raise the bed to a comfortable height when the client is transferring out of bed.
- Keep the hospital bed brakes locked.
- Keep wheelchair wheels in a “locked” position when stationary.
- Keep non-slip, comfortable, and well-fitting footwear on the client.
- Use night lights or supplemental lighting.
- Keep floor surfaces clean and dry. Clean up all spills promptly.
- Keep client care areas uncluttered.
- Follow safe client handling practices.
Interventions Based on Risk Factors
Fall prevention care planning is a process where the client’s risk assessment information is translated into an action plan to specifically address the identified client needs, in addition to universal fall precautions. There are many interventions available to prevent falls and fall-related injuries based on the client’s specific risk factors. See Table 5.6a for interventions categorized by risk factor.
Table 5.6a Interventions Based on Fall Risk Factors[10]
| Risk Factor | Interventions |
|---|---|
| Altered Mental Status | Clients with new altered mental status should be assessed for delirium and treated by a trained nurse or physician. See a tool for assessing delirium below. For cognitively impaired clients who are agitated or trying to wander, more intense supervision (e.g., sitter or checks every 15 minutes) may be needed. Some hospitals implement designated safety zones that include low beds, mats for each side of the bed, nightlight, gait belt, and a “STOP” sign to remind clients not to get up. Clients with altered mental status should also have their medications reviewed, as medications can both contribute to agitation as well as help calm patients whose agitation is a threat to themselves or others or is interfering with the delivery of necessary care. |
| Impaired Gait or Mobility | Clients with impaired gait or mobility will need assistance with mobility during their hospital stay. All clients should have any needed assistive devices, such as canes or walkers, in good repair at the bedside and within safe reach. If clients bring their assistive devices from home, staff should make sure these devices are safe for use in the hospital environment. Even with assistive devices, clients often need staff assistance when transferring out of bed or walking. Use a gait belt when assisting clients to transfer or ambulate per agency policy. |
| Frequent Toileting Needs | Clients with frequent toileting needs should be taken to the toilet on a regular basis via a scheduled rounding protocol. Read more about scheduled rounding in the following subsection. |
| Visual Impairment | Clients with visual impairment should have clean corrective lenses easily within reach and applied when walking. |
| High-Risk Medications (medications that could cause sedation, confusion, impaired balance, orthostatic blood pressure changes, or cause frequent urination) | Clients on high-risk medications should have their medications reviewed by a pharmacist with fall risk in mind and recommendations made to the prescribing provider for discontinuation, substitution, or dose adjustment when possible. If a pharmacist is not immediately available, the prescribing provider should carry out a medication review. See Table 5.6b for a tool to review medications that may increase fall risk. Clients taking medications that can cause orthostatic hypotension should have their orthostatic blood pressure routinely monitored. The client and their caregivers should be educated about fall risk and steps to prevent falls when the client is taking these medications. |
| Frequent Falls | Clients with a history of frequent falls should have their risk for injury assessed, including checking for a history of osteoporosis and use of aspirin and anticoagulants. |
Scheduled Hourly Rounding
Scheduled hourly rounds are scheduled hourly visits to each client’s room to integrate fall prevention activities with client care. Scheduled hourly rounds have been found to greatly decrease the incidence of falls because the client’s needs are proactively met, reducing the motivation for the client to get out of bed unassisted. See the box below for a list of activities to complete during hourly rounds. These activities can be completed by unlicensed assistive personnel, nurses, or nurse managers.[11]
Hourly Rounding Protocol[12]
- Assess client pain levels using a pain-assessment scale. (If staff other than a nurse is doing the rounding and the client is in pain, contact the nurse immediately so the client does not have to use the call light for pain medication.)
- Put pain medication that is ordered “as needed” on an RN’s task list and offer the dose when it is due.
- Offer toileting assistance.
- Ensure the client is using correct footwear (e.g., specific shoes/slippers, no-skid socks).
- Check that the bed is in the locked position.
- Place the hospital bed in a low position when the client is resting; ask if the client needs to be repositioned and is comfortable.
- Make sure the call light/call bell button is within the client’s reach and the client can demonstrate accurate use.
- Put the telephone within the client’s reach.
- Put the TV remote control and bed light switch within the client’s reach.
- Put the bedside table next to the bed or across the bed.
- Put the tissue box and water within the client’s reach.
- Put the garbage can next to the bed.
- Prior to leaving the room, ask, “Is there anything I can do for you before I leave?”
- Tell the client that a member of the nursing staff (use names on whiteboard) will be back in the room in an hour to round again.
Medications Causing Elevated Risk for Falls
Evaluate medication-related fall risk for clients on admission and at regular intervals thereafter. Add up the point value (risk level) in Table 5.6b for every medication the client is taking. If the client is taking more than one medication in a particular risk category, the score should be calculated by (risk level score) x (number of medications in that risk level category). For a client at risk, a pharmacist should review the client’s list of medications and determine if medications may be tapered, discontinued, or changed to a safer alternative.[13]
Table 5.6b Medications Causing High Risk for Falls[14]
| Point Value (Risk Level) | Medication Class | Fall Risks |
|---|---|---|
| 3 (High) | Analgesics, antipsychotics, anticonvulsants, and benzodiazepines | Sedation, dizziness, postural disturbances, altered gait and balance, and impaired cognition |
| 2 (Medium) | Antihypertensives, cardiac drugs, antiarrhythmics, and antidepressants | Induced orthostasis, impaired cerebral perfusion, and poor health status |
| 1 (Low) | Diuretics | Increased ambulation and induced orthostasis |
| Score ≥ 6 | Elevated risk for falls; ask pharmacist or prescribing provider to evaluate medications for possible modification to reduce risk |
View tools used to assess delirium and confusion in the Delirium Evaluation Bundle shared by the Agency for Healthcare Research and Quality.
- Centers for Disease Control and Prevention. (2024). Older adult fall prevention. https://www.cdc.gov/falls/index.html ↵
- Centers for Disease Control and Prevention. (2024). Older adult fall prevention. https://www.cdc.gov/falls/index.html ↵
- Centers for Disease Control and Prevention. (2024). STEADI - Older adult fall prevention. https://www.cdc.gov/steadi/index.html ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
- Agency for Healthcare Research and Quality. (2023). Preventing falls in hospitals: Tool 3H: Morse Fall Scale for identifying fall risk factors. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html ↵
- The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers School of Nursing. (n.d.). Assessment tools for best practices of care for older adults. https://hign.org/consultgeri-resources/try-this-series ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
- “Hill-Rom_hospital_bed_TV_remote_control.JPG” by BrokenSphere is licensed under CC BY-SA 3.0. ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
- Agency for Healthcare Research and Quality. (2024). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html ↵
A set of interventions to reduce the risk of falls for all patients and focus on keeping the environment safe and comfortable.
Scheduled hourly visits to each patient’s room to integrate fall prevention activities with the rest of a patient's care.