0BPrevention and Management of Falls Policy

0BPrevention and Management of Falls Policy Expiry date: 30/09/2024 Version No: 1.0 Page 1 of 13

Prevention and Management of Falls Policy

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P195 Clare Leonard Physical Health Group 3 years

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Contents

Introduction .................................................................................................................................... 3

High Risk Groups ........................................................................................................................... 3

Purpose or aim ............................................................................................................................... 3

Scope .............................................................................................................................................. 3

Definitions ...................................................................................................................................... 4

Policy Description .......................................................................................................................... 4

6.1 Clinical Assessment and Management ................................................................................................... 4

6.2 Identifying people at risk of falling ......................................................................................................... 4

6.3 Multifactorial assessment ...................................................................................................................... 6

6.4 Multi-factorial interventions .................................................................................................................. 6

Roles and responsibilities ............................................................................................................. 8

7.1 Trust board............................................................................................................................................ 8

7.2 Responsibilities of the Chief Executive ................................................................................................... 8

7.3 Responsibilities of the Director of Human Resources.............................................................................. 8

7.4 Responsibilities of All Directors & Clinical Directors ................................................................................ 8

7.5 Clinical responsibilities (inpatient teams only) ........................................................................................ 9

Training......................................................................................................................................... 11

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Audit and Monitoring ................................................................................................................... 11

References ................................................................................................................................... 11

Appendices................................................................................................................................... 12

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Introduction

The prevention and management of patient falls takes a high priority within the organisation. The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and increased morbidity and mortality. Falling also affects the family members and carers of people who fall, and has an impact on quality of life, health and social care costs.

People over the age of 65 are at high risk of falls 30% are more likely to fall at least once a year and increases to 50% over 80.The risk increases for people with cognitive impairment and dementia.

High Risk Groups

• Older people -those suffering from dementia are particularly vulnerable to falls due to cognitive impairment and associated difficulties such as, loss of spatial awareness, reduced insight into risks, side effects of medication or problems with muscle strength, balance and mobility.

• People with cardiac, neurological, musculoskeletal conditions, continence issues and sensory loss and difficulties.

• Learning disabilities-may have a combination of personal sensory and cognitive problems.

Purpose or aim

• To ensure an integrated multi professional approach is taken to prevention and management of falls.

• To set out arrangement to manage falls within the trust settings.

• To raise awareness of risk identification, assessment, management and plans to reduce the falls together with post falls care.

• Raise awareness to clinical staff on those who are particularly at high risk.

• Reduce the risk of falls by carrying out a multifactorial risk assessment, this identifies the factors that may increase risk for falls, then implement appropriate interventions that reduce and mitigate the risk of injury when the likelihood of a fall is identified.

• Raise awareness of bone health and the risk factors of osteoporosis in harmful falls.

• Raise awareness of environmental issues that can lead to patient slip trips and falls.

• To raise awareness of the process following a fall.

Scope

This policy covers all settings and teams within Avon and Wiltshire Mental Health Partnership Trust without exception whether they are clinical settings or not. It is particularly relevant to all staff involved in the assessment, treatment and review of all patients / service users under the care of Avon and Wiltshire Mental Health Partnership NHS Trust. It includes gardens, grounds and paths on Trust property, access and ingress routes and within buildings interiors and access to roof spaces.

Assessment not only includes assessments of patient falls but also assessment of the environmental risks associated with walking surfaces, steps, stairs etc.

The policy takes into consideration national guidance from:

• National Patient Safety Agency

• NICE CG 161

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• RCP Fall safe

Definitions

Slip - to lose ones footing and slide unintentionally for a distance, this can be corrected or can cause a fall

Trip - to stumble often over an obstacle causing individual to lose their balance which can then be corrected or causes a fall

Fall - is an event which causes the person or body part of a person to come to rest inadvertently on the floor or a surface lower than the person whether an injury is sustained or not.

Policy Description

6.1 Clinical Assessment and Management

The three new parts in the Quality Standard for Falls Prevention in Older People relate to clinical matters of identifying people at risk of falling, undertaking multifactorial risk assessment for older people at risk of falling, and the provision of multifactorial interventions.

6.2 Identifying people at risk of falling

A person’s diagnosis or age is not an indicator of risk of falls. Rather, NICE suggests that the following should be considered as indicators of an increased risk.

• Having cognitive impairment

• Having a visual impairment

• Are physically frail or have a condition that affects mobility or balance such as arthritis, diabetes, incontinence, stroke, or Parkinson's disease.

• Are taking multiple drugs, psychoactive drugs (such as benzodiazepines), or drugs that can cause postural hypotension (such as anti-hypertensive drugs).

• Have a fear of falling Practitioners should note that in line with National Guidance the Trust considers Falls Risk Assessments an important part of all Service User Assessments. As part of the Rio Risk Screen, all patients across in-patient and community services must be screened for falls risks with an alert added to their records on Rio as necessary.

If a risk of falls has been identified in the community setting on the Rio Risk Screen, the clinician should make a referral to the relevant physiotherapist or occupational therapist who may guide referral to appropriate generic services to ensure compliance with best practice and good management of falls.

On admission any ward nursing staff should carry out an assessment of risk in line with the guidance given as part of the CPA process, this will be care planned accordingly to manage/control the risks identified and fully documented in the service user’s records. Those service users identified with a diagnosis of dementia or functional illness and a higher number of risk indicators should have a comprehensive multifactorial assessment completed and recorded within risk section of electronic care records Rio. This should inform a plan of care that can best manage any risks whilst maintaining mobility, with an appropriately graded alert added to the records.

The risk assessment should be repeated according to changes in the service user’s condition (including changes in medication), and care planned accordingly, these reviews will be fully documented in the patient records.

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A diagram of the clinical risk management and care pathway is shown below. This summarises the relationships and pathways described in this section.

Clinical Risk Management and Care Pathway

Regular re-assessment and care plan review most notably if patient’s condition changes.

MDT Review if repeated falls ensuring post falls checklist completed on each occasion

Document reassessment date

People with dementia or functional illness and > 4 indicators:

1. Complete multifactorial assessment

2. Carry out Manual Handling and Bedrails assessments if indicated

3. Complete care plan to manage risk of falls and promote mobility

4. Add alert to RIO

5. Refer to Physiotherapist

6. Physiotherapist assessment (updating care plan as required)

People with functional diagnosis and < 4 indicators in community services:

• Record screening outcome in RiO records

• Add alert on RiO as necessary

• Contact Physiotherapist or Occupational Therapist as appropriate

People with functional illness or dementia, and < 4 indicators in inpatient setting:

1. Record screening outcome in RiO

2. Complete care plan to manage risk of falls and promote mobility

3. Add alert to RiO as necessary

Patient screened for risk of falls using risk screen in RIO consider the following questions: • Do they have a

functional or dementia diagnosis?

• Are they aged over 65 or between 50 and 64 with 4 or more of these indicators?

• Have they a history of falls?

• Do they use a walking aid?

• Are they unsteady on their feet?

• Are they taking more than 4 medications?

• Are they not eating or drinking?

Please consider those under 50 may be at risk if meet some of the above risk factors

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6.3 Multifactorial assessment

NICE suggests a multifactorial assessment may include assessment for:

• Chronic conditions that affect mobility or balance (including arthritis, diabetes mellitus, stroke, Parkinson's disease, and dementia).

• Gait, balance, and mobility problems.

• Osteoporosis risk.

• Perceived impaired functional ability and fear relating to falling.

• Visual impairment.

• Cognitive, neurological, and cardiovascular problems.

• Urinary incontinence.

• Home hazards.

• Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants). Appendix 3

• Lying and standing blood pressure, patients are not often aware of being pre-syncopal( feeling as if going to faint) taking a history from witnesses may help in identifying pre-syncope , syncope( fainting) or a seizure

In-patients assessed at risk of falls should have an assessment made of their immediate bed space environment etc. to ensure that appropriate measures are taken to reduce risk, as per Appendix 2 Nursing care plan guidance. This management plan should be reviewed with subsequent ward / clinical area moves if applicable.

6.4 Multi-factorial interventions

NICE advises that multifactorial interventions which may be commonly offered following a multifactorial assessment include:

• Strength and balance training

• Home hazard assessment and intervention

• Vision assessment and referral.

• Medication review — psychotropic drugs are reviewed, with specialist input if appropriate, and discontinued if possible.

Use of Hip Protectors

A hip protector is a specialised form of pants or underwear containing pads (either hard or soft) along the outside of each hip/leg, designed to prevent hip fractures following a fall. Most hip fractures follow an impact due to a lateral fall. The pads are located over the trochanters, the bony extrusions of the hip region. Hip protectors recommended are "energy-absorbing type”. Which is made of a compressible material and diminishes the force of impact.

Hip protectors are mainly used in later life services. A multi-disciplinary assessment should be completed when considering hip protectors with consideration taken around concordance and safety of people who may be at increased risk with their use eg toileting or undressing.

Guidance on their use provided as an appendix 4

Care plans should be modified to ensure that activities undertaken are done as safely as possible in conjunction with the service users’ mobility assessment (see Manual Handling

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Policy) and updated regularly with the date recorded when completed. They should indicate if a service user is a frequent faller.

These additional interventions should be documented in the Care Plan and rationale recorded in the RIO progress notes.

Referral to Occupational Therapy and Physiotherapy should be made for further assessment and intervention

Family and Carers should be made aware of the service users falls risk and advised of any issues that require attention while the patient is an inpatient e.g. provision of suitable footwear, availability of spectacles and they should be given a copy of the Falls leaflet. Time should be given to explain the contents of this leaflet and its implications by a relevant member of the Multidisciplinary Team

Additionally, staff may find this useful Falls: assessment and prevention of falls in older people - CG161 (Appendix 6) whilst this document is designed predominantly for older people it contains useful information for all age groups..

The Discharge Summary sent to the patient’s General Practitioner (GP) on discharge/commencement of leave should clearly identify any risk of falls identified during the hospital stay, including what additional support in the community is required (i.e., referral to the PCT/Commissioning Group Falls Specialists, etc.).

Referrals on to other agencies and Professionals.

If following assessment there are concerns regarding:

Medication Refer for medication review by an AWP responsible prescriber

Postural Hypotension Refer to appropriate medic and / or nursing colleagues.

Vision Recommend eye test or use, the Look Out Bedside vision check for falls prevention Look Out!

Hearing recommend hearing test

Foot Problems Refer to GP to request input from podiatrist.

Specific problems relating to persons environment

Refer to Occupational Therapist.

Nutrition Complete Core Assessment 24hr Physical Monitoring using Nutrition Screening Tool Calculator

MUST Screening Tool only to be used if RiO is unavailable

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Roles and responsibilities

7.1 Trust board

The Board has overall responsibility for the health, safety and welfare of all staff, service users, visitors and others within AWP and to ensure policies are implemented.

All Directors have a corporate responsibility to promote a responsible approach in health and safety in the Trust.

7.2 Responsibilities of the Chief Executive

Executive responsibility is delegated to the Chief Executive for managing health and safety, including compliance with relevant legislation and Trust policies.

7.3 Responsibilities of the Director of Human Resources

The Programme Director for Organisational Development, is the person responsible for training. They take responsibility for ensuring that the Learning & Development Department provides adequate training to ensure this policy is implemented and that the content of the training is regularly reviewed to ensure it continues to provide the necessary skills and knowledge to ensure staff are able to discharge their legal duties and duty of care in accordance with current standards and best practice.

7.4 Responsibilities of All Directors & Clinical Directors

All Directors and Clinical Directors will bring this policy to the attention of all their staff, including new, temporary staff, and management team and ensure that it is observed at all times. Directors and Clinical Directors will also require each team to:

• Ensure the pathway is followed for all in patients. Outcomes should be recorded in electronic care records Rio.

• A care plan is formulated and that adequate actions appropriate to that risk are undertaken. This is recorded in care records Rio.

• Environmental risk assessment findings must be recorded and should be entered on the delivery unit specific risk register. Action should be taken to rectify any significant risks in line with good risk management process. All risk assessments must be reviewed annually or on significant change (i.e. change of use, modification of the building or after a serious adverse incident). The significant findings of risk assessments must be communicated to staff as should the controls and recommendations given as a result of the risk assessment.

• All clinical risk assessments must be reviewed at CPA review or on significant change (i.e. change of presentation, condition or after an adverse incident).

• Ensure control measures and safe systems of work as necessary are developed and implemented. These will include regular inspections to monitor cleanliness, maintenance issues and general wear and tear.

• Ensure that the process is monitored and adequate support is provided for line managers to ensure that their responsibilities are met.

• Ensure arrangements to implement this policy are devised and reviewed.

• Play a key leadership role in developing and sustaining a proactive culture, personal and professional responsibility for health and safety issues.

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7.5 Clinical responsibilities (inpatient teams only)

Ward/team Managers

• Ward/team Managers should ensure that individual patient risk assessments are undertaken on all in-patients as per policy, and all actions as appropriate are taken and documented in the care plan.

• Actions not implemented should be identified to the delivery unit Clinical Risk Lead.

• All in-patient falls should be reported via the Ulysses system. Those patients that fall frequently, and any that sustain an injury, should be investigated following the Policy for the Reporting, Management and Investigation of Adverse Incidents (including Serious Untoward Incidents) (Also known as The Incident Policy). Risk assessments and plans should reviewed in the light of the incident investigation findings. Any event that results in serious harm should be thoroughly reviewed with support from The Patient Safety team so that lessons are learned. A safeguarding referral should be considered if harm has been identified in a vulnerable person. Advice can be sought from the trust safeguarding team.

• Ward/team Managers should ensure that all appropriate referrals are made and that appropriate care providers are advised regarding discharge plans.

• Ward managers and physiotherapists should ensure that there is a regular and multi professional review of all falls on the ward. This is reported via the trust falls group to identifying learning and actions that can be shared.

Prevention of Future/repeated falls

Service users who have fallen will require interventions to reduce their likelihood of further falls. These interventions will be decided upon during the review of the service user’s care post fall, e.g. as part of care planning, Multi-Disciplinary Team (MDT) meetings etc.

Any actions taken and/or referrals made regarding such interventions will be clearly recorded in the service users care plan.

Clinical Staff

• Undertake appropriate falls training dependent of role

• Be aware of service user groups that are at higher risk of falls

• Undertake a falls risk assessment as part of the admission process and create a care plan if risk identified. Nursing care plan guidance

• If risk identified then refer to the appropriate specialist for ongoing support. Trust falls Management Group

Will monitor a strategic approach and action plan for falls prevention and safer mobility relating to patients based on national guidance. It will provide assurance via the Physical Health Management Group.

Trust falls lead

• Update the falls policy and associated practice in line with guidance policy and legislative changes

• Expert member of the trust wide falls group

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Procedure /implementation

Older adult in patients wards

• Each service user will have a risk assessment completed within the risk assessment section of Rio as part of the admission process. It is the responsibility of the admitting nurse to ensure completed within time scales currently within 24 hours of admission.

• The Physiotherapist will also carry out a comprehensive Multi factorial patient assessment; ideally within 72 hours .This will include mobility, strength, balance and falls history.

• If a fall occurs then the post falls guideline (appendix1) should be followed and recorded in Rio care records and reviewed in MDT meeting.

• A medical review should be carried out following a fall within 24 hours unless clinical presentation indicates sooner, and documented in RiO.

• Participate in identification of environmental and clinical risks hazards and report incidents and concerns. Seek advice if required to implement policies and agreed measures to manage risks.

• Report all falls using the Ulysses system.

• Attend training as required in matrix. Adult Mental Health/ forensics

• Each service user admitted to an adult or forensic ward will require a falls risk assessment to be undertaken and if risk identified as identified in the pathway then a care plan completed. Follow post falls guidelines if a fall occurs and ensure a medical review is carried out.

• Participate in identification of environmental and clinical risks hazards and report incidents and concerns. Seek advice if required to implement policies and agreed measures to manage risks

• Report all falls using the Ulysses system refer to above section for further guidance.

• Attend training as required in matrix. Learning Disabilities

• Each service user admitted will have a risk assessment completed if risk identified then care plan completed and necessary referrals made.

• Participate in identification of environmental and clinical risks hazards and report incidents and concerns. Seek advice if required to implement policies and agreed measures to manage risks.

• Report all falls via the trust Ulysses system refer to above section for further guidance.

• Medical review carried out following a fall within 24 hours unless clinical presentation indicates an earlier review, and recorded in clinical patient records.

• Attend training as per matrix Post fall

• Staff to assess following a fall using the post falls checklist, which should be recorded in electronic care records when complete. Appendix 1

• Guidance on managing a suspected head injury can be found in the guidance document (appendix 6)

• Incident reported via Ulysses system

• Fall reviewed using a MDT approach

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• Refer to physiotherapist.

• Request medical review. If a fall has occurred and ambulance has been called please be aware of long lie on floor( can be considered to be more than 30 minutes on the floor) , our client group will be high risk for complications and therefore consider surface, pressure areas and comfort. It is recommended not to move person but may need to consider risk assessing and sliding onto mat or thin mattress while awaiting ambulance.

For guidance on expected waiting times, refer to NHS Ambulance response times

For Further advice, refer too

NICE NG38 Fractures (non-complex) Assessment and Management

NICE NG37 Fractures (complex) Assessment and Management

Community staff

If a risk of falls has been identified in the community setting on the Rio risk screen consider referral to the relevant physiotherapist or occupational therapist; this may be within generic community services, to ensure compliance with best practice and good management of falls.

Training

The Trust's overarching policy for training is the Learning and Development Policy and this should be read in conjunction with this Policy. Falls related L&D will depend on role within AWP.

It will liaise with operational management to ensure that this resource is monitored and that resource reacts according.

The Falls eLearning package is part of the essential training for all clinical staff. The expectation is that all clinical staff complete this training.

Audit and Monitoring

The Trusts falls management group has oversight of falls incidents, trends, falls prevention and best practice. It reports regularly to the Physical Health Management Group.

Annual falls audits are carried out in a number of inpatient wards.

Falls risk assessments required to be completed within 24 hours of admission are reported via the Physical Health Dashboard monthly.

The Learning and Development department will maintain records of falls awareness training and report to the Physical Health Management Group.

References

NICE Guidance CG 161

NICE Guidance NG 37 and 38

NHS Ambulance response times

Royal College of Physicians (currently being updated)

National Patient Safety Association: slips trips and falls in Hospital and mental health units .July 2010

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Using bedrails safely and effectively policy: P068

Engagement and Observation policy: P087

Appendices

Appendix 1 Post falls swim chart

Appendix 2 Nursing falls care plan guidance

Appendix 3 Commonly prescribed drugs that may increase falls risk

Appendix 4 Guidance on use of Hip protectors

Appendix 5 Guidance for Assessing and Monitoring Young People and adults with a suspected HI

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Version History

Version Date Revision description Editor Status

1.0 29/09/2021 New policy CL Approved