Patient Fall Prevention SOP Template

1.Purpose

To identify patients at risk of falling early, apply consistent interventions, and reduce the number and severity of falls on the unit.

2.Scope

Applies to fall risk assessment and prevention for adult inpatients. Pediatric fall prevention and response to a fall that has already occurred are covered by separate SOPs.

Definitions

Fall risk assessment

A standardized tool used to score a patient's likelihood of falling based on factors such as mobility, medications and mental status.

Hourly rounding

A scheduled check-in with the patient roughly every hour to address needs such as pain, positioning, toileting and personal items within reach.

Bed alarm

A device that alerts staff when a patient attempts to get out of bed unassisted.

3.Responsibilities

Registered Nurse (RN)

Completes the fall risk assessment, sets up interventions and reassesses risk after any status change.

Nursing Assistant (CNA)

Performs hourly rounding, assists with mobility and toileting, and reports changes in patient condition.

Charge Nurse

Confirms high-risk patients have interventions in place and reviews fall incidents on the unit.

Physical Therapist

Assesses mobility for high-risk patients and recommends assistive devices or activity levels.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →Fall risk assessment tool in the EHR
• →Bed and chair alarms
• →Yellow fall-risk wristbands and door or bed signage
• →Non-slip socks or footwear
• →Hourly rounding log or checklist
• →Assistive mobility devices (gait belt, walker, cane)

5.Procedure

1. 5.1

   Complete the fall risk assessment on admission

   Registered Nurse (RN)

   Complete the standardized fall risk assessment tool in the EHR within the required timeframe of admission, scoring mobility, medications, mental status and fall history.

2. 5.2

   Reassess after any status change

   Registered Nurse (RN)

   Repeat the fall risk assessment after a change in condition, a new sedating medication, a procedure, or a transfer, in addition to the routine reassessment schedule.

   Checkpoint: Fall risk is reassessed after any significant change in condition, not only on the routine schedule.

3. 5.3

   Apply the fall-risk identifier

   Registered Nurse (RN)

   For patients scoring as high risk, apply the yellow wristband and post door or bed signage so all staff recognize the risk at a glance.

4. 5.4

   Set up the patient environment

   Nursing Assistant (CNA)

   Keep the bed in the lowest position with brakes locked, the call light and personal items within reach, and the path to the bathroom clear of clutter and cords.

5. 5.5

   Activate bed or chair alarms for high-risk patients

   Registered Nurse (RN)

   Turn on and test the bed or chair alarm for patients identified as high risk, and confirm it is functioning before leaving the room.

   Checkpoint: Bed and chair alarms for high-risk patients are tested and confirmed active at the start of each shift.

6. 5.6

   Provide non-slip footwear

   Nursing Assistant (CNA)

   Provide non-slip socks or the patient's own non-slip footwear before any out-of-bed activity.

7. 5.7

   Request a mobility assessment for high-risk patients

   Registered Nurse (RN)

   Refer high-risk or newly deconditioned patients to physical therapy for a mobility assessment and recommended assistive device or activity level.

8. 5.8

   Assist with transfers and ambulation

   Nursing Assistant (CNA)

   Use a gait belt and the recommended number of staff for transfers and ambulation according to the mobility assessment, never leaving a high-risk patient unattended during a transfer.

   Warning: Never leave a high-risk patient unattended while out of bed or mid-transfer.

9. 5.9

   Perform hourly rounding

   Nursing Assistant (CNA)

   Round on every patient approximately every hour, addressing pain, positioning, toileting needs and placement of personal items within reach.

10. 5.10

    Respond promptly to call lights and alarms

    Nursing Assistant (CNA)

    Answer call lights and bed or chair alarms as quickly as possible, especially for patients flagged as high fall risk.

11. 5.11

    Communicate fall risk at handover

    Registered Nurse (RN)

    Include fall risk status, active interventions and any recent near-misses in the shift handover report for every patient.

12. 5.12

    Review fall trends with the unit

    Charge Nurse

    Review fall and near-miss data at unit meetings, identify recurring contributing factors, and adjust interventions or staffing where needed.

6.Quality checks

• →100 percent of admissions have a fall risk assessment completed within the required timeframe.
• →All identified high-risk patients have an active bed or chair alarm and visible signage.
• →Hourly rounding is documented for every patient every shift.
• →Fall risk status is included in every shift handover report.

7.Records

• →Fall risk assessment scores in the EHR
• →Hourly rounding log
• →Fall and near-miss incident reports
• →Physical therapy mobility assessment notes

8.KPIs

• →Falls per patient days
• →Percentage of high-risk patients with active interventions in place
• →Hourly rounding compliance rate
• →Falls with injury as a share of total falls

9.Common mistakes

• →Leaving a bed alarm turned off after repositioning the patient.
• →Skipping fall risk reassessment after a new sedating medication is given.
• →Leaving a high-risk patient unattended on the toilet or during a transfer.
• →Not mentioning fall risk status during shift handover.

10.Revision history