• Refer to patient's/residents primary care physician; disease management ( treat conditions associated with fall/injury risk)
  
  
• Based on cause (s) of fall/injury and risk factors for future falls/injury, include specific measures in care plan to prevent falls/injury
  
  
• Consider the use of a fall alarm and/or hip protector, if indicated.
  
  
• Consider the use of arm/leg sleeves to prevent skin trauma.

• Ensure that eyeglasses are clean and that hearing aids are operating properly and worn
  
  
• Encourage patient/resident to wear their eyeglasses/hearing aid
  
  
• Keep areas where patient/ resident walks well-lit
  
  
• Keep floors free from litter and clutter
  
  
• Consider the use of arm/leg sleeves in patients/residents with low vision to prevent skin trauma that may result from bumping into furnishings, etc.

• Anticipate patient's/resident's toileting needs
  
  
• Provide scheduled toileting (cue and/or assist resident to the bathroom every 2 hours, and before and after activities and meals)
  
  
• Utilize bed side commodes (makes toileting easier for patients/residents with urinary frequency; makes sitting and standing safer and easier for patients/ residents with unsteady balance).
  
  
• If associated mobility impairment or risk of injury is present, consider the use of fall alarm and/or hip protector
  
  
• Use gait belt when assisting patient/ resident on or off toilet

• Refer to physical therapy; assess need for cane or walker
  
  
• Provide daily floor ambulation and walking exercises to maintain muscle strength/balance stability
  
  
• Provide safe footwear/non-skid slippers/socks
  
  
• Instruct patients/residents on the proper use of the nurse call bell, including when and how to call for assistance. Consider use of fall alarm for those patients/residents non-compliant with call bell
  
  
• Consider use of hip protector for those patients/residents with balance loss who are at hip fracture risk
  
  
• Use gait belt to assist with ambulation
  
  
• Utilize exercise as a means of improving resident strength, balance, and coordination
  
  
• Continuously assess for environmental hazards interfering with ambulation and eliminate as appropriate

• Observe cognition; pay attention to sudden and/or subtle changes in patient/resident behavior that may increase fall risk
• Utilize volunteers/family members and/or fall alarm to assist with monitoring
• Place patients/residents in rooms near the nurse's station for easier observation.
• If unsafe bed/chair egress and/or injury risk, consider use of fall alarm/hip protector
  

• Anticipatory care (anticipate resident's toileting needs, hunger, thirst, etc. and meet those needs, as appropriate)
  
  
• Supervision/observation (monitor at-risk residents and provide assistance with ambulation/transfers when necessary). Consider use of fall alarm to assist with monitoring.
  
  
• Continuously assess for environmental hazards interfering with safe mobility/eliminate as appropriate
  
  
• Beds (adjust to a height that allows patients/ resident to transfer easily)
  
  
• Chairs (seat height should allow patient/resident to sit and rise easily)
  
  
• Bathrooms (install handrails around the toilet for safe transfers)
  
  
• A gait belt should be used whenever possible, especially when assisting a patient/resident during transfers/ambulation
  
  
• Instruct residents on the proper use of the nurse call bell, including when and how to call for assistance. Consider the use of a fall alarm for those
  patients/resident non-compliant with use of call bell
  
  
• Teach safe transfer techniques from bed, chairs, toilet, and wheelchairs.

• Make sure that canes, walkers, and wheelchairs are in good condition
  
  
• Refer to physical therapy; evaluate canes and walkers to ensure they are the appropriate type, height and weight; teach patient/resident how to use cane or walker correctly
  
  
• Refer to physical therapy; evaluate wheelchair to ensure it is appropriate type, height and weight; teach patient/resident how to use wheelchair correctly
  
  
• Arrange furniture to allow for wide walking/wheeling spaces.

• Attempt to eliminate medications that are associated with falls/fall risk.
  
  
• Observe patients/residents on new medications and observe for side effects that may lead to falls.
  
  
• If medications are associated with orthostatic hypotension, consider use of fall alarm.
  
  
• If medications are associated with balance loss/dizziness, consider the use of hip protector.

Situational

• New admission
• Floor-to-floor transfer
• Post fall
• Change of condition and/or starting new medication (especially one associated with fall risk)
  

• Assess patient/resident for presence of factors that increase fall/injury risk.
  
  
• Based on cause (s) of fall/injury and risk factors for falls/injury, include specific measures in care plan to prevent falls/injury.
  
  
• Observe for changes in patients'/residents' physical, functional and mental status.
  
  
• Consider the use of a fall alarm and/or hip protector to monitor risk/prevent injury.
  
  
• Consider the use of arm/leg sleeves to prevent skin trauma.