Fall Risk Assessment

To be effective, assessment tools need to be sensitive (correctly identify high risk patients/residents) and specific (correctly identify patients/residents not at risk) and, perhaps most importantly, be easy for nurses to use (embedding the fall risk assessment tool into existing nursing assessments helps with “buy-in” and acceptance of the tool/process).

Purpose of Fall Risk Assessments

  • Identify patient/resident problems (rational basis for deciding whether risk exists)
  • Identify those patients/residents most likely to fall
  • Trigger further fall-related assessments (multidisciplinary)
  • Identify interventions (guide patient/resident care planning)
  • Raise staff awareness of fall/injury risk

When to Conduct Fall Risk Assessments

  • Upon admission
  • Post-fall
  • Upon change of health condition (including medication changes)
  • Daily/every shift (confused patients/residents; patients/residents taking sedatives, recent fall, etc.)
  • History of falls
  • Impaired vision/hearing
  • Urinary problems (toileting needs)
  • Muscle weakness
  • Gait/balance impairment
  • Dizziness
  • Orthostatic hypotension
  • Mobility impairment (impaired bed, chair and/or toilet transfers)
  • Uses cane/walker
  • Polypharmacy (>5 medications)
  • Psychotropics
  • Diuretics
  • Antihypertensives
  • Antiseizure
  • Benzodiazepines
  • Hypoglycemics
  • Sedative/hypnotics
Mental Status
  • Dementia
  • Depression
  • Delirium
  • Impaired 'safety' judgment
  • Disruptive behaviors
  • Non-English speaking
  • Exhibits unsafe behavior
  • Lacks understanding of mobility limitations
Situational Conditions
  • New admission
  • Floor-to-floor transfer
  • Post-fall
  • Change of condition and/or starting fall risk medication

Tideiksaar, R. Falls in Older People: Prevention and Management. 4th Edition.
Health Professions Press, Baltimore, MD 2010

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