| PLAN |
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- Assess patient's fall risk upon admission, change in status, after a change in medications, transfer to another unit and upon discharge.
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- Assess the patient's coordination and balance before assisting with transfer and mobility activities. Transfer patient towards stronger side and use treaded socks.
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- Educate and communicate with team and family members that the patient is a high fall risk and should not be out of bed without assistance.
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- Yellow wristband and yellow intake/output and vital sign documentation sheets at bedside.
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- Move patient closer to nurse's station and/or provide frequent and close observation/supervision.
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- Orient patient to surroundings, explain call system, and assess patient's ability for use. Provide adequate lighting, bed in low, locked position with raised side rails when not present at bedside.
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- Other
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- Place call light, TV controls, bedside table, telephone, and urinal within reach of the patient. Offer frequent toileting.
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| DESIRED OUTCOME |
Morse Fall Scale score of 51 or higher, or score of 25-50 with
antihypertensives, diuretics, psychotropics, sedatives, antianxiety,
pain, antihistamines, or antidiabetic medications started within the
past 30 days
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