While preventing falls before they happen is the best line of defence for managing falls, this is not always possible, and clients in your care will inevitably fall from time to time.
Falls are common in older adults in particular and are a major cause of injury. Even minor falls have the potential to cause serious injury or even death in vulnerable clients (Healthdirect 2020; DoH 2018).
Knowing how to best respond and provide immediate assistance to a person who has fallen is crucial in preventing further harm and distress to your clients in cases when the fall can not be prevented.
Immediately After a Fall
Note: Never try to catch the person if you witness a fall in progress, as this can result in injury to yourself. It is not possible to ‘control’ a fall by intervening (ACC 2017).
Reassure and comfort the person.
Perform a DRSABCD assessment (Danger, Response, Send for help, Airway, Breathing, CPR, Defibrillator).
Call for help.
Do not attempt to move the person until you have performed a head-to-toe assessment and assessed safety.
If the person has a physical injury, they must not be moved.
If the person is unconscious, perform basic life support and call for emergency services.
If the person is experiencing head or neck pain, do not move them until a medical practitioner arrives (only if it is safe to do so).
Move the person if deemed appropriate upon clinical assessment. This should be performed by an experienced nursing or medical practitioner (always follow your organisation’s policies and procedures).
Increase the frequency of observations including neurological assessment and baseline physical observations such as pulse, blood pressure, oxygen saturation, respiratory rate, conscious state and conduct a pain assessment.
If necessary, consider administering pain relief if you are authorised to do so, to ensure the person is made comfortable before moving them safely.
Call for manual handling equipment such as lifting machines, inflatable mats etc. if applicable and appropriate for the person and the environment.
Undertake the following investigations if required:
Blood glucose level (consider this test if the person is known to have diabetes or there is an altered state of consciousness)
Electrocardiogram (ECG) (if the environment is safe to do so, free from water and hazards etc.)
Cognitive impairment screening (refer to your organisation’s policies and procedures)
If the person has sustained significant physical injuries, escalate patient care to assigned medical services to ensure timely care is received within 30 minutes (always follow your organisation’s policies and procedures).
Investigate any pre-fall symptoms such as dizziness or unsteadiness or any other factors that may have contributed to the fall and the patient’s condition.
Notify registered nurse or facility manager and escalate care accordingly. In an emergency, call 000 directly if required.
(WA DoH 2018; QLD DoH 2018)
Do not attempt to move the person until you have performed a head-to-toe assessment and assessed safety.
Assessing Signs of Fall Injuries
Signs that the person may have sustained a serious injury from the fall include:
Airway or breathing difficulties
Loss of consciousness or unresponsiveness
Confusion
Limb or chest pain
Bleeding or extensive bruising (Note: People who have a coagulopathy disorder (blood clotting disorder) or are taking anticoagulants or antiplatelet therapy are at increased risk of intracranial, intrathoracic or intra-abdominal haemorrhage (WA DoH 2018).)
Difficulty moving limbs on command.
(WA DoH 2018)
Within the First Four Hours After a Fall:
Increase frequency of patient observations
Notify the person’s Next of Kin
Provide physical, behavioural, and cognitive injury care where required
Identify and report any signs of deterioration
Escalate care to medical personnel
Re-screen the person using a falls risk assessment tool (refer to your organisation’s policies and procedures)
Perform a medical and medication review
Document and report the fall
Make any notifications as required by local policies and procedures.
(WA DoH 2018)
Within the First Six Hours After a Fall:
Provide the client’s family or carer with information and education. Develop ongoing falls management care together with the client and their family or carers
Review and action the results of any tests that were performed
Discuss the incident with the client’s interprofessional team in order to identify any further risks or required interventions
Consider a structured post-fall safety discussion with the interprofessional team.
(WA DoH 2018)
Within the First 24 Hours After a Fall:
Continue to monitor for any signs of physical, behavioural or cognitive deterioration and escalate care as required
Notify the client’s occupational therapist or physiotherapist and anyone who is part of the care team
Notify the client’s pharmacist
Refer the client to other healthcare professionals if required.
(WA DoH 2018)
Post-Fall Interventions
you may need to provide increased staff assistance and supervision after a fall.
About 30 to 40% of people who have experienced a fall will fall again. For this reason, after a fall has occurred, it is essential that interventions are immediately put into place in order to reduce the risk of another fall. These interventions should be performed within 24 hours (AHRQ 2017).
Depending on the context of the fall, immediate interventions may include:
Increased toileting with more assistance from staff
More staff assistance and supervision for high-risk situations
More monitoring of the client
Pain management
Protective clothing such as wrist guards or hip protectors
Safer footwear
A low bed or mat
Behaviour management strategies.
(AHRQ 2017)
Within the First 48 Hours After a Fall:
Review the client’s observations. If there is no sign of clinical deterioration, return to appropriate observations
Complete all actions that are outlined in your organisation’s post-fall policies and procedures
Undertake a comprehensive review of the client’s care plan.
(WA DoH 2018)
Look out for the following symptoms, which may require an escalation of care:
Headache that is getting worse and/or not responding to basic analgesic medicines
Blurred vision, double vision or difficulty focusing vision
Dizziness, difficulty walking steadily, loss of balance or limb weakness
Confusion, difficulty speaking or listening, difficulty recognising people or places, or other atypical behaviour
Seizures or blackouts
Persistent clear fluid or bleeding from the ear or nose.
(WA DoH 2015)
Communication
After a fall, ensure that:
All required documentation has been completed by the primary carer, nurse or health worker in the client’s records, as well as in the local reporting database
Ensure the client and their family understand the event and the ongoing care that is being provided
Communication approaches are appropriately tailored to the person’s disability and/or culture (e.g. the use of interpreters)
The fall has been discussed in handovers between clinical care staff members
A debrief session occurs after the fall with all of the staff who were involved
Visual signs indicating the client’s falls risk are displayed in their room (adhere to your organisation’s policies and procedures).
(WA DoH 2018)
Within the First Week After a Fall:
In the first few days following the fall, the person may experience mild symptoms such as:
Minor headaches
Irritability, anxiety or tearfulness
Concentration or memory difficulties
Nausea
Dizziness
Reduced appetite
Sleeping difficulties
Fatigue.
(WA DoH 2015)
Escalate care if these symptoms worsen or persist for over one week (WA DoH 2015).
Documenting the Fall
All falls must be documented and reported (VIC DoH 2018).
The following details must be documented in the client’s medical record:
The client’s observations, appearance or response to the fall
Evidence of any injuries
Location of the fall
Notification of medical provider
Actions that were taken in response to the fall.
(ACSQHC 2009)
A falls reporting form must also be completed for all falls, regardless of where the fall occurred and whether the client was injured (refer to your local policies and procedures) (ACSQHC 2009).
The report should, at a minimum, include the following details:
The client’s description of the fall (if possible)
The location and time of the fall
What the client was doing immediately before falling
Mechanism of the fall (e.g. slip, trip, overbalance, dizziness)
Whether the client lost consciousness.
(ACSQHC 2009)
Falls and Major Injury Under the National Aged Care Mandatory Quality Indicator Program
As part of an update to the National Aged Care Mandatory Quality Indicator Program, which came into effect on 1 July 2021, all government-subsidised residential aged care providers must collect and report data on falls that occurred within their organisation every quarter (DoH 2021a).
This process should involve reviewing the care records of all care recipients for the quarter and reporting the required data, which is:
The number of care recipients whose records were assessed for falls and major injury
The number of care recipients excluded because they were absent from the service for the entire quarter
The number of care recipients who experienced a fall (one or more) at the service during the quarter
The number of care recipients who experienced a fall at the service, resulting in major injury (one or more), during the quarter.
(DoH 2021b)
Note: A fall resulting in major injury is defined by the QI Program manual as a fall that resulted in a bone fracture, joint dislocation, closed head injury with altered consciousness and/or subdural haematoma.
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