Deviation in the Standard of Nursing Care When Conducting a Falls Risk Assessment Resulting in Injury

Evaluate breaches in the standard of care when determining if there has been a Deviation in the Standard of Nursing Care When Conducting a Falls Risk Assessment Resulting in Injury

Answer the following questions to find out if the standard of care was followed for your case.

  • Did the patient present with a history of previous falls?
    Yes
    No
    Answer unknown
    Why is this important?
    A fall is “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level”.
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  • Which of the following intrinsic risk factors were not elicited from the patient? (Choose all that apply) Why is this important?
    Answer this question
    Fall risk factors are generally considered to fall into one of two categories. Intrinsic risk factors are those pertaining to the physical and cognitive status of the individual.
    (2012) 23 EPMRCA 2 305-314

  • Which of the following extrinsic risk factors were not elicited? (Choose all that apply) Why is this important?
    Answer this question
    Fall risk factors are generally considered to be either intrinsic (i.e. those pertaining to the physical and cognitive status of the individual) or extrinsic (i.e. environmental hazards or factors affecting the interface between the individual and the environment, such as footwear, assistive devices or spectacles). The common denominators that contribute to falls in the Inpatient Rehabilitation Facility (IRF) setting must be understood to identify patients at high risk and target interventions that can be useful in reducing their risk for falling.
    (2012) 23 EPMRCA 2 305-314

  • Which the following risk factors were not considered for the prevention of falls? (Choose all that apply) Why is this important?
    Answer this question
    A risk factor is a variable that has a causal association with a disease or disease process; the presence of the variable in an individual or a population is associated with an increased risk of the presence or future development of the disease. Thus, risk factors may be useful for identifying subjects at increased risk for a disease or for a particular outcome that results from a disease process.
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  • Were situational risk factors addressed? Why is this important?
    Answer this question
    Situations risk factors for falls include tripping over obstacles, carrying heavy items, descending/ascending stairs, rapid turning, reaching overhead, climbing ladders etc.
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  • Was a medical history obtained? Why is this important?
    Answer this question
    A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's examination, enables the clinician to make educated evaluations, and be better equipped to advise the patient.
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  • Was a falls risk assessment scoring performed during admission? Why is this important?
    Answer this question
    Falls risk assessment should be performed during admission to identify and evaluate the fall risk factors and predicting falls. It is important to differentiate between measures used to simply identify people at increased risk of falling and tools used to identify risk factors amenable to intervention to provide a basis for tailoring a falls prevention strategy.
    (2005) 19 EBPRCR 6 913-935

  • Was the Timed-Up-and-Go Test (TUGT) performed to assess postural stability? Why is this important?
    Answer this question
    Guidelines recommend the timed-up-and-go test (TUGT) as a simple screening tool to identify people warranting more detailed assessment of gait and balance. It involves measuring the time taken for a patient to rise from a chair, walk a specified distance at a normal pace and with usual assistive devices, turn, return to the chair and sit back down.
    (2005) 19 EBPRCR 6 913-935

  • Was the patient’s risk status communicated to the patient, family and healthcare team? Why is this important?
    Answer this question
    Communication of risk factors to the patient, family, and all members of the health care team is essential.
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  • Which of the following evaluation were not performed during the physical examination? (Choose all that apply) Why is this important?
    Answer this question
    The physical examination of all patients admitted to a healthcare facility should include elements that evaluate the potential for falls.
    (2012) 23 EPMRCA 2 305-314

  • Were diagnostic investigations performed? Why is this important?
    Answer this question
    Routine laboratory studies can provide important clues to diagnosis.
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  • Was the patient referred to a specialist? Why is this important?
    Answer this question
    Once a diagnosis has been made, and in many cases if a diagnosis is unclear, referral to the appropriate specialists needs to be made in a timely manner. To deliver care requires a coordinated approach that allows sharing of skills and expertise. The skills of members from all professional disciplines should be utilized.
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  • Were the plans for preventing and managing falls developed and adhered to? Why is this important?
    Answer this question
    Care goals should include prevention of falls when possible, a decrease in the number of falls, and a decrease in the risk and severity of injury.
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  • Which of the following universal precautions for preventing falls were not adhered to? (Choose all that apply) Why is this important?
    Answer this question
    Basic universal fall prevention interventions should be used for all patients, regardless of risk categorization. These interventions include strategies such as keeping beds in a low-locked position, provision of well-fitting, nonslip footwear, and familiarizing patients with their new environment.
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  • Was an appropriate bowel and bladder control program initiated? Why is this important?
    Answer this question
    The presence of incontinence further increases the risk of fall in older adults. If incontinence is identified, bowel and bladder control measures should be initiated by the clinician to assist in fall prevention.
    (2012) 23 EPMRCA 2 305-314

  • Was the patient screened for osteoporosis? Why is this important?
    Answer this question
    Screening and treating for osteoporosis is essential as low bone density increases the risk of hip or other fractures.
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  • Which of the following causes of fall were identified and treated? (Choose all that apply) Why is this important?
    Answer this question
    Medical treatment needs to be initiated for reversible or potentially reversible medical conditions such as nutritional deficiencies, diabetes mellitus, visual impairments, and underlying cardiac diseases.
    (2005) 16 EPMRCA 1 109-128

  • Was the patient’s pain managed? Why is this important?
    Answer this question
    Presence of pain increases the risk of fall.
    (2012) 23 EPMRCA 2 305-314

  • Was Vitamin D supplementation provided for malnourished adults? Why is this important?
    Answer this question
    Vitamin D supplementation of at least 800 IU per day is needed to keep bones strong and thus is helpful for preventing falls.
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