Fall

Also Consider:  Abrasion, Bruise, Fainting, Fractures/Dislocations, Dizziness, Head Injury, Laceration, Sprain/Strain, Unsteadiness, Weakness (general), Wound (surgical/traumatic) 

1. Take Vital Signs

• Temperature:

• Blood Pressure lying:

• Blood Pressure standing:

• Heart Rate lying:

• Heart Rate standing: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Do Not remove from the floor until assessed for injury

• Injuries (bruising, laceration, fractures), head trauma

• Assess all joints for change in normal range of motion, weight bearing, etc

• Acute mental status change

• Not eating or drinking as much as usual

• Pain assessment:  exact locations, persistent or intermittent, exacerbating factors

• Fainting, dizziness or lightheadedness when standing up

• Signs of dehydration

• Diaphoresis: Cold, clammy, pale skin

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress

• Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema

• GI: Nausea, vomiting, diarrhea, constipation, heartburn, abdominal distention or tenderness, rebound tenderness, bowel sounds

• GU: New or worsened incontinence, pain with urination, blood in urine, urinary retention / bladder scan

• Neurologic  changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)

• Alcohol intoxication or drug use

• Fingerstick glucose (patients with diabetes)

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • With any suspected serious injury (e.g., fracture, laceration requiring sutures, head injury)

• Notify medical staff & resident representative within the next 16 hours. 

  • Persistent pain after fall without suspicion of serious injury, or minor injury potentially requiring medical intervention

• Notify medical staff on the next business day 

  • Fall with only insignificant injury

• Notify medical staff at the next regular rounds 

  • Repeated falls since last medical visit

4. Implement Management Plan

• Complete fall assessment per facility policy/procedure

• Neuro checks per facility policy/procedure

• Monitor vital signs every 4-8 hrs for 2-3 days

• Offer fluids frequently

• Oral, IV, or subcutaneous fluids if needed for hydration

• Place on Intake & Output monitoring

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of:

• Significantly abnormal values in lab tests (refer to appropriate Situation)

• WBC > 12,000 or neutrophils > 90%

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative

• Update advance directives if appropriate

2025-04-27