Fall Prevention in Nursing Practice

Falls are the most commonly reported adverse event in hospitals and a major patient safety priority. This note reviews how to identify at-risk patients, implement universal and high-risk fall precautions, manage restraints appropriately, and respond after a fall occurs.

Definition

• A fall is any unplanned descent to the floor, with or without injury.
• Falls can result in fractures, head trauma, and death.
• Fall prevention is a core nursing safety priority.

Risk Factors for Falls

• Patient factors: age >65, history of falls, gait instability
• Medical factors: orthostatic hypotension, confusion, dementia, delirium
• Medications: sedatives, diuretics, antihypertensives, opioids
• Environmental: poor lighting, wet floors, clutter, lack of handrails

Key points:

• History of falls is the strongest predictor of future falls — assess on admission.
• Sedatives, diuretics, and antihypertensives significantly increase risk.
• Orthostatic hypotension causes dizziness on standing; measure orthostatic vitals in at-risk patients.
• Patients with delirium or sundowning are at increased risk for nighttime falls and need extra monitoring.

Fall Risk Assessment

• Common tools: Morse Fall Scale and Hendrich II.
• Assess on admission, daily, and with any change in condition.
• A score above the tool's threshold indicates high fall risk and triggers prevention interventions.

Fall Prevention Interventions

Universal Fall Precautions (All Patients)

• Keep the call light and personal belongings within reach.
• Keep the bed in the lowest position with brakes locked.
• Maintain a clutter-free environment with dry floors and adequate lighting, especially at night.
• Provide non-slip footwear; do not allow walking barefoot or in socks without grips.
• Ensure walkers and canes are within reach and correctly fitted — the top of the cane should reach the patient's wrist crease when standing.

High-Risk Fall Precautions

• Place a yellow fall risk sign on the door and apply a yellow armband (per facility policy).
• Perform hourly rounding to anticipate pain, toileting, and positioning needs.
• Use bed or chair alarms to alert staff when the patient attempts to get up unassisted.
• Use a gait belt during ambulation for weak or unsteady patients.
• Place the patient near the nurses' station and provide scheduled assistance with ambulation and toileting.
• Use low beds or floor mats for patients at very high risk.

Restraint Considerations

• Raising all four side rails may be considered a restraint depending on facility policy and patient condition — a provider order may be required.
• Use restraints only as a last resort and only with a provider order. Restraints do not prevent falls and may increase injury risk.
• Explore less restrictive alternatives first: bed alarms, low beds, and increased supervision.

Post-Fall Management

• Stay with the patient and call for help. Do not move the patient immediately unless there is imminent danger.
• Assess for injury: head trauma, fractures, change in level of consciousness; check vital signs.
• Notify the provider, document thoroughly, and complete an incident report.
• Do not reference the incident report in the patient's medical record.
• Review the fall to identify contributing factors and modify the care plan.

Patient and Family Education

• Teach the patient to call for assistance before getting up and never get up alone if dizzy or weak.
• Teach the patient to rise slowly from lying to sitting to standing to prevent orthostatic hypotension.
• Reinforce correct use of assistive devices (walker, cane) and consistent use of non-slip footwear when out of bed.
• Educate family about nighttime confusion risk and the importance of calling for assistance.

Common Exam Traps

• Do not raise all four side rails without a provider order — this may be a restraint.
• Do not move a patient immediately after a fall; assess for injury first.
• Do not rely solely on alarms; they do not replace direct observation.
• Toileting is the most common activity preceding falls — don't forget it.
• Do not assume a young patient is safe; medications and procedures increase fall risk.
• Reassess fall risk whenever the patient's condition changes.
• Do not ambulate a weak patient without a gait belt.

Key takeaways

• History of falls is the strongest predictor; also assess age >65, orthostatic hypotension, sedating medications, delirium, and environment.
• Universal precautions: low bed, call light in reach, non-slip footwear, dry floors, good lighting, correctly fitted assistive devices.
• High-risk interventions: yellow signage, hourly rounding, bed alarms, gait belt, room near nurses' station, scheduled toileting.
• Raising all four side rails can be a restraint and may require a provider order.
• After a fall: stay with patient, assess for injury, notify provider, document, complete an incident report (do not chart that report exists in the medical record).
• Toileting is the most common activity preceding falls; patients with delirium/sundowning are highest risk at night.