Preventing Falls and Injuries in Long-Term Care (LTC) : Bridges To Care Resource Manual

Bridges to Care Resource Manual
Preventing Falls and

Injuries in
Long-Term Care
(LTC)
Preventing Falls and Injuries
in Long-Term Care
Section Table of Contents Pg
Acknowledgements 1
1.0 Introduction: Falls and Injuries in Long Term Care 3

2.0 Risk Factors: Falls, Osteoporosis and Fractures 14
3.0 Overview of Falls and Injury Prevention in LTC 23
4.0 Assessment of Fall Risk 24
5.0 Post-Fall Management 32
6.0 Interventions to Reduce the Risk of Falls and/or Fractures 34
7.0 Education 47
8.0 Quality Improvement 52
9.0 References 61
10.0 Resources 65
Section 11.0 Appendices 67

Fall Prevention
11.1 2002 Beers Criteria for Potentially Inappropriate Medication Use in Older 71
Adults: Independent of Diagnosis or Conditions
11.2 Risk factors for falls and fall-related injuries 75
11.3 Universal Fall Precautions: SAFE and Three Questions Before Exiting a 77
Resident’s Room
11.4 Common Medications and Substances Associated with Increased Falls in the 79
Elderly
11.5 RNAO Summary of Recommendations: Prevention of Falls and Fall Injuries in 81
the Older Adult
Fall Risk Assessment Tools & Hazard Checklists
11.6 Morse Fall Scale and Checklist for Residents Assessed Based on Level of Risk 89
11.7 Identification of Falls Risks and Intervention for Falls and Injury Reduction Tool 93
11.8 NPS Medication Review Form 97
11.9 General environmental checklist 99
11.10 Environmental Hazards Checklist 101
in Long-Term Care
11.11 Equipment safety checklist 103
Post-Fall Resources
11.12 Fraser Health Post Fall Flowchart 107

11.13 Fall Report 109
11.14 Post Fall Investigation 111
11.15 Post-Fall Assessment Tool 115
11.16 Notifying the Family That a Fall has Occurred 117
Resident and Family Education
11.17 A Guide for Preventing Falls and Related Injuries 121

11.18 Footwear Guidelines 123
11.19 Safe shoe checklist 125
11.20 Hip Protectors; Always on your Side Info Sheet 127
Quality Improvement
11.21 Check sheet: Activities at Time of Fall 131

11.22 Check sheet: Factors Contributing to Falls 133
11.23 Check sheet: Location of Fall 135
11.24 Check sheet: Fall Injuries 137
11.25 Safer Healthcare Now National Falls Collaborative Indicators 139
11.26 Ontario Health Quality Council – LTC Quality Indicators for Public Reporting: 141
Falls
11.27 Monitoring Indicators NWLHIN Falls Prevention Project 143
11.28 Injury Severity Rating Scale 147
Medical Directives
11.29 Medical Directive: Bone Mineral Density 151

11.30 Medical Directive Template: Bisphosphonates 153
Acknowledgements:
This toolkit was compiled for the Bridges to Care Project (Healthforce Ontario 2009-
10) by the Centre for Studies in Aging & Health (CSAH) at Providence Care,
Kingston, Ontario.
Deanna Abbott-McNeil Dr. John Puxty

Dr. David Barber Bettina Stanulis
Phileen Dickinson Gordon Wood
Susanne Murphy
Special thanks to the following individuals for their contributions to this toolkit:
BC Injury Research and Prevention Unit - Dr. Vicky Scott

BC Injury Research and Prevention Unit (Contractor) - Anne Higginson
BC Injury Research and Prevention Unit - Sarah Elliott
Center for Education and Research in Aging & Health – Darlene Harrison
Deborah Ripley – London, UK
Fairmount Home - Stacey Karp
Fairmount Home (Shoppers Drug Mart) - Leigh-Ann Mullen
Fairmount Home (Shopper’s Drug Mart) - Scott Ford
Fairmount Home - Dawn Ware
Jenny Ripley – Sussex, UK
Kingston Frontenac Lennox Addington Public Health Unit – Rhonda Lovell
Ontario Health Quality Council – Dr. Ben Chan
Ontario Health Quality Council – Cathie Easton
Ontario Health Quality Council – Natalie Ceccato
Osteoporosis Canada – Sharon Lewis
Providence Care – Shari Brown
Providence Manor – Shelagh Nowlan
Providence Manor – Lianne Wennick
Providence Manor – Marian Mulvihill
Providence Manor – Connie Cordeiro
Registered Nurses Association of Ontario – Janet Evans
Registered Nurses Association of Ontario – Heather Woodbeck
Rideaucrest Home – Dawn Thomas
Rideaucrest Home – Krystal Mack
Vancouver Coastal Health Authority – Anne Earthy
Bridges to Care Resource Manual: Preventing Falls and Injuries in Long-Term Care
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This project and resource is a collaborative effort between the following partners:
Statistics Canada information is used with the permission of Statistics Canada. Users are forbidden to copy the
data and disseminate them, in an original or modified form, for commercial purposes, without permission
from Statistics Canada. Information on the availability of the wide range of data from Statistics Canada can be
obtained from Statistics Canada's Regional Offices, its World Wide Web site at www.statcan.gc.ca, and its toll-
free access number 1-800-263-1136.
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1.0 Introduction: Falls and Injuries in Long-Term Care
Key Concepts:
Half of all residents in long-term care fall at least once per year.
Residents who fall are very susceptible to injury and hospitalization.
Osteoporosis and falls can lead to hip fractures, which has devastating
consequences in terms of shorter life expectancy and residual disability.
Many falls can be prevented through assessment of risk and
implementing standard and individualized interventions.
Falls are common in the senior population and the rate increases with age. Thirty-
five percent of seniors age 65 and above and 40% of seniors age 80 and above who
live in the community fall at least once per year. (Public Health Agency of Canada,
2005)
The falls rate in long-term care is three times higher than for seniors living in the
community. Approximately 50% of all long-term care residents fall each year and of
those who fall, 40 % fall two or more times. (PHAC, 2005)
Residents in long-term care are already at a higher risk for falls and injuries. Forty
percent of all admissions to Canadian long-term care homes are due to falls; this
number includes the 24% of fracture survivors from the community that are admitted
to long-term care. (PHAC, 2005a) It is important to note that a prior history of falling
and fracturing is one of the strongest predictors of future falls and fractures.
(Agostini, Baker & Bogardus, 2009)
In addition, residents in long-term care tend to be older, frailer, have more chronic
conditions, problems with thinking or memory, difficulty with walking and balance,
and are more likely to be on several medications than their community counterparts.
These are all factors that are linked to falling (Centers for Disease Control and
Prevention, 2009). In fact, a fall is very often a symptom of some underlying
condition that effects how the resident safely interacts with the environment. (Earthy,
2009a)
Exposure to environmental hazards account for approximately 27% of all falls in

long-term care (Registered Nurses Association Ontario, 2005) The most common
fall hazards in LTC homes are: beds that are too high, poor lighting, slippery floors,
lack of rest areas, and a lack of kick space under the bed, which is important for
maintaining balance when rising to standing from a sitting position. It is logical to
conclude that this may be a factor explaining why so many institutional falls occur in
and around the bed. (PHAC, 2005)
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Characteristics of Falls in Long-Term Care
The bedside is the most common location for falls, followed by the bathroom. Many
falls are associated with transfers around the bed, and with toileting. The majority of
falls happen during the day, mostly during times when care providers are less
available, either due to peak care demands, or processes such as shift change. A
high percentage of falls are un-witnessed. Men tend to fall more in long-term care,
but women have higher rates of fracture associated with falls. (Tideiksaar, 2009)
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Falls in Long-term Care: High Rates of Injury and Hospitalization
Falls in institutions contribute a far larger proportion of hospital admissions
compared to other settings. (PHAC, 2005) For every 100 residents in Ontario LTC
homes, there are about 9 falls that are serious enough that the resident needs to be
sent by ambulance to the emergency department. (Ontario Health Quality Council,
2009) Falls among residents in residential institutions account for 21% of fall-related
hospitalizations and 20% of fall-related deaths among those aged 65 and over – a
disproportionate amount, considering that only 7% of the Canadian adult senior
population lives in long-term care homes. (PHAC, 2005)
Fall-related hospital admissions, by place of occurrence of fall, age 65+, 1998-2003
(Adapted from PHAC, 2005)

Adapted from PHAC 2005 © Copyright CSAH 2009
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Osteoporosis, Falls and Injuries
Residents in long-term care are not only more susceptible to falling but also more
susceptible to injury when they fall. (Scott, Pearce & Pengelly, 2005) Up to 35% of
falls in residential institutions result in serious injury and up to 8% in fractures (Social
Care Institute for Excellence, 2005), primarily due to the bone fragility found in
osteoporosis.
It is important that osteoporosis, fracture prevention, and falls are recognized as a

trio of interrelated health issues in long-term care and that any intervention targeting
one of these three health issues should acknowledge the other two. (Ontario
Osteoporosis Strategy for Long-Term Care, 2009)
Osteoporosis, falls, and fracture prevention must be addressed together.
Adapted from Seniors Health Research Transfer Network (2008)
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Hip Fractures in LTC: Devastating Consequences
Falls in long-term care can cause a variety of physical injuries including hip
fractures, head injuries, and death. Fracture due to falls is the third most common
reason for transfer from LTC to acute care, after respiratory and circulatory
conditions. (Canadian Institute for Health Information, 2007)
Almost all fractures in LTC residents (at least 95%) are due to falls and
osteoporosis. (OOSLTC, 2009) In fact, one-third of all hip fractures in Canada
occur in LTC. (Osteoporosis Canada, 2009) In LTC, 1% of falls result in hip
fractures, which is a hip fracture rate that is four times that of community-dwelling
seniors (Scott et al., 2005). For women, the risk is especially high. Female
residents in LTC have a risk of sustaining a hip fracture that is 10.5 times that of
women living in the community. (OOSLTC, 2009)
Hip fractures are referred to as “the most devastating osteoporotic fracture” because
of the resultant reduced quality of life, reduced life expectancy, and persistent pain
and disability. (OOSLTC, 2009)
Persistent disability:
• Less than 15% of LTC residents who sustain a hip fracture ever regain pre-injury
ambulation status. (PHAC, 2005)
• Approximately half are never functional walkers again. (Todd & Skelton, 2004)
Decreased life expectancy:

• The death rate for those living in LTC at the time of fracture
• at 6 months: 31%
• at 12 months: 39%
• The death rate in the first year after fracture is higher for men:
• Men: 34%
• Women: 25%
Adapted from OOSLTC 2009 © Copyright CSAH 2009
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Osteoporosis in LTC: Under-diagnosed and Under-treated
Despite the high prevalence of osteoporosis in long-term care settings, osteoporosis
remains seriously under diagnosed and under treated. A survey of Canadian LTC
physicians reported that half do not routinely assess for osteoporosis and one-
quarter do not usually treat it. (OC, 2009) In a recent Canadian chart review, only
14% of newly admitted residents could be identified as osteoporotic and only 39% of
them were on any osteoporosis therapy. (OC, 2009) Less than 12% of Canadian
LTC residents are receiving osteoporosis treatments, primarily calcium or vitamin
supplements. (OC, 2009)
Deterrents to Assessment and Treatment of Osteoporosis in LTC

There are many reasons that lead to the under-diagnosis and under-treatment of
osteoporosis in long-term care. However, most of these barriers are unfounded and
in general, the benefits of treatment outweigh the risks and barriers.
© Copyright CSAH 2009

(Adapted from OC, 2009)
Efficacy of Calcium, Vitamin D, and Bisphosphonates in LTC:

In the long-term care setting, Vitamin D supplementation has been proven to
decrease the risk of fractures by 26% and also the risk of falls by 22%.
Bisphosphonates (the primary bone-enhancing drugs for treating osteoporosis) are
effective for increasing bone density and decreasing the risk of fracture. (OC, 2009)
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Side Effects and Polypharmacy:
Although poorly absorbed and associated with GI problems, bisphosphonates are
generally well tolerated. Once-daily formulations are being replaced by weekly or
monthly oral preparations, and in some cases, yearly injections, to improve
compliance, ease of administration, and minimization of side effects. Polypharmacy
should not be a deterrent to treatment of osteoporosis if all medications are reviewed
for their appropriateness. (OC, 2009)
Life expectancy: To Treat or Not to Treat
The average life expectancy for a Canadian resident in long-term care is 2.5 years;
research demonstrates that bisphosphonates may lead to bone mineral density and
fracture benefits in as little as six months. (OC, 2009)
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Psychological Consequences of Falling
Not only do falls in LTC result in high rate of physical injury, but they have negative
psychological consequences for residents as well. Even without injury, a fall can
lead to a loss in confidence and curtailment of activities that lead to risk of further
falls, loss of strength and mobility, social withdrawal and reduced quality of life.
(PHAC, 2005)
Fear of falling is a well-documented risk factor for further falls. (PHAC, 2005) After a
fall, residents themselves, family members, and care providers often attempt to
restrict mobility to prevent further falls. However, reducing mobility and limiting
activity has the opposite effect as it leads to deterioration in physical condition, which
increases the risk of a fall. (Burland, 2008)
Fear of falling is common in new admissions to long-term care. Research suggests

that the incidence of falls in residential care facilities can double after older people
are relocated to a new environment and then return to baseline after the first three
months. (Gillespie & Friedman, 2007)
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Fall Management versus Fall Prevention
“…fall management is an important part of a larger effort to move toward a more
social model of care (i.e., person centered care) that acknowledges that quality of
life is as important as (if not more important than) simply extending life. “ (Burland,
2008, p.138)
The traditional approach to falls in LTC has focused on prevention. However, many
patient safety advocates suggest that a focus on fall management as opposed to fall
prevention may be appropriate as it might balance the fine line between encouraging
ongoing mobility and functionality through exercise and mitigating some of the risk
factors for falls. (CIHI, 2009)
With fall management, rather than trying to prevent falls, the goal is to prevent or at
least minimize injuries while simultaneously encouraging mobility and functionality.
(Burland, 2008)
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Many Falls in LTC Are Preventable
Although many falls in LTC homes are inevitable, many can be prevented.
Preventable falls in nursing homes often fall into one of the following categories:
1) physical obstacles
2) inadequate assessment for fall risk
3) improper maintenance of a resident’s safety equipment
4) poor internal design
5) inadequate supervision
(Todd and Skelton, 2004 from Wagner, 2007)
Comprehensive Assessments
Whether a LTC home adopts a fall prevention or fall management approach, the
overall strategy needs to take into account that falls are typically caused by a
number of factors that require many different interventions. Residents at risk for falls
need a comprehensive falls assessment in order to identify contributory risk factors
so that a tailored and individualized care plan can be created.
Individualized, Multifactorial Care Plans

There are effective interventions to prevent falls including exercise, discontinuing
unsafe medications such as benzodiazepines or others found on the Beers List,
treating residents with osteoporosis with calcium, Vitamin D, and bisphosphonates,
reducing hazards in the LTC home such as poor lighting and clutter, and using hip
protectors. (OHQC, 2009)
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Definitions Used in Fall Prevention
Fall:
Unintentionally coming to rest on the ground, floor or other lower level whether or not
the faller is injured. (Scott et al, 2007, p 25)
Severe injury (from a fall):

One that requires medical attention, including a visit to a physician, emergency
department visit, admission to hospital or an immediate fall-related death (Scott et al,
2007, p22)
Near fall:
A sudden loss of balance that does not result in a fall or other injury that can include
a person who slips, stumbles or trips without a fall or other injury, or a person who
slips, stumbles or trips but is able to regain control prior to falling. (Toronto Falls Best
Practice Long Term Care Working Group, 2006)
Unwitnessed fall:
Occurs when a resident is found on the floor and neither the resident nor anyone
else knows how he or she got there. (Toronto Falls Best Practice LTC Working
Group, 2006)
Single intervention:
A fall or fracture prevention intervention that has proven to be effective on its own,
without the need to be paired with other interventions. Examples of single (or stand
alone) interventions include discontinuation of benzodiazepines and Tai Chi.
Multifactorial Intervention:
A fall or fracture prevention intervention that is not effective when used on its own,
but has demonstrated effectiveness when used as a component of a comprehensive
fall or fracture risk prevention strategy. Examples of multifactorial interventions
include resident education and environmental hazard review and modification.
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2.0 Risk Factors: Falls, Osteoporosis and Fractures
“Falling itself is not a diagnosis but rather may be a symptom of multiple underlying
disease, and/or environmental hazards or obstacles that interfere with safe mobility.”
(Krueger, Brazil & Lohfeld, 2001, p 117)
Key Concepts:
Every resident in long-term care is at risk for falls.
A person’s risk of falling is particularly high in the week after moving to a
long-term care home.
Falls result from the interaction of age-related changes, underlying
conditions, and environmental hazards.
The risk of falling increases exponentially as the number of risk factors
increases.
The strongest predictor of falling is history of previous falls.
The strongest predictors of fracture are transfer independence, age, and
prior fracture.
Falls result from a complex interaction of risk factors. As the number of risk factors
increases, there is a dramatic increase in the risk of falling and injury. (Scott et al,
2007) The chart below depicts the compounding nature of risk factors.
(Adapted from Earthy, 2009a)

Adapted from Statistics Canada © Copyright CSAH 2009
In about one-third of falls, a single potential cause can be identified; in two-thirds,

more than one risk factor will be involved. (CIHI, 2005)
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Categorizing Fall Risk Factors
A common way of categorizing fall risk factors and their interrelationships is to
classify them in the following four categories:
1. biological / medical factors
2. behavioural factors
3. environmental factors
4. socio-economic factors
1. Biological / Medical Risk Factors

Risk factors in this category comprise a continuum from effects of healthy aging to
pathological conditions, illnesses, and diseases, all of which cause physical,
cognitive, and emotional changes associated with falls.
Female gender:
Women fall more often than men and tend to sustain more serious injuries, primarily
due to osteoporosis. (Scott et al, 2007)
Advanced age:
With increasing age there is a greater likelihood of having multiple health conditions
and risk factors. (Scott et al, 2007)
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Chronic illness/disabilities:
• Stroke: individuals tend to fall on their weaker side and are four times more
likely to fracture their hip due to a fall (Scott et al, 2007)
• Parkinson’s disease: characterized by rigidity, postural instability, and fear

of falling, and have a two-fold risk of fracturing due to a fall
• Arthritis: predisposes the adult to falls and injuries due to decreased knee
extensor (quadriceps) strength, decreased lower extremity proprioception,
and increased postural sway.
• Cardiovascular diseases: conditions such as orthostatic hypotension,

carotid sinus syndrome, vasovagal syndrome, syncope, cardiac arrhythmias,
and transient ischemic attacks (TIAs) can cause falls. People that fall due to
cardiovascular causes have a greater mortality than those who fall from other
causes. (Scott et al, 2007)
• Bowel and bladder problems: associated with incontinence, urgency,

frequency, infections, dehydration and imbalanced electrolytes and can result
in falls due to weakness, impaired decision-making, “rushing” to the
bathroom, making several trips (especially during the night), and slipping on
urine.
• Foot disorders: deformities, corns, bunions, and hammertoes can lead to

pain, impaired gait and balance.
Acute illness:
Symptoms such as weakness, dizziness and fatigue can lead to falls in acute illness
(e.g. infection). In addition, periods of immobility can lead to decreased muscle
mass and bone density.
Cognitive impairment:
A resident with acute or prolonged cognitive changes (delirium or dementia) is
unable to anticipate obstacles or situations in the environment, or make rapid
postural changes to recover balance. In addition, many medications used to treat
cognitive and behavioural symptoms are associated with falls. Also, wandering is
associated with an increased fall risk. (CIHI, 2007)
Gait disorders and poor balance:

Age-related changes in the neural, sensory, and musculoskeletal systems can
hinder the resident’s ability to maintain or recover balance. These balancing
reactions can be impaired even in relatively healthy and mobility seniors. In
addition, neurological disorders such as stroke and Parkinson’s disease can cause
even more significant impairments.
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Muscle weakness:
Weakness, especially of the lower body, can lead to an inability to maintain or
recover balance.
Poor vision:
Age-related changes such as a reduction in visual acuity, depth perception, contrast
sensitivity, and visual fields, and ocular impairments such as cataracts, macular
degeneration, and glaucoma can prevent the individual from noticing objects in the
environment. In addition, residents who are adjusting to new glasses, or have
impaired depth perception due to bifocals, are at increased risk of falls.
Impaired touch:
A reduction in the ability to sense contact with surfaces beneath the feet is a normal
age-associated change.
Impaired proprioception:
Incorrect or delayed feedback from the sensory system that provides an awareness
of limb and body position can impair the balance maintenance or recovery systems.
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Behavioural Risk Factors
Multiple medications:
An individual with polypharmacy (five or more medications) is considered to be “high
risk” for falls due to an increased chance of an adverse drug reaction. (RNAO, 2005)
Aging results in altered mechanisms for digesting and metabolizing drugs that
causes an increase of the active levels of the drug and makes cumulative effects of
medications unpredictable. (Scott et al, 2007)
Certain medications:
Benzodiazepines, psychotropics, and antihypertensives have side effects, such
as sedation, drowsiness, dizziness, postural hypotension, stiffness, and weakness
that increase the risk of falling. (Scott et al, 2007) The risk with benzodiazepines
appears to be increased in the first two weeks after starting therapy, and with higher
doses (i.e. > 8mg Diazepam or equivalent per day). (Ruddock, 2004) One of every
25 residents of long-term care homes in Ontario takes a medication that is on the
“Beers List”, a list of medications considered unsafe for the elderly. (OHQC, 2009)
Risk-taking behaviours:
Elderly individuals who do not recognize their changing physical abilities can engage
in activities that are risky, such as not using a walking aid or grab bar when one is
needed. Falls due to risk-taking behaviours are particularly prevalent among men.
(Scott et al, 2007)
Lack of exercise:
Atrophy of the musculoskeletal system causes negative changes in the balance
maintenance and recovery systems.
Previous fall or recurrent falls:

A history of falls is the best predictor of future falls for residents in long-term care
and often leads to physical injury, a fear of falling, and/or subsequent activity
restriction which causes deconditioning and a loss of strength, balance, and
confidence.
Fear of falling:
Fear of falling is common in the elderly and is a strong predictor of future falls.
(PHAC, 2005) Fears can include fear of being hurt or hospitalized, not being able to
get up, social embarrassment, or losing independence. (Scott et al, 2007) Fear of
falling can either motivate some seniors to adopt risk reduction strategies or lead to
restriction in mobility and socialization, physical deterioration and a reduced quality
of life. (Australian Council for Safety and Quality in Health Care, 2005) It is
estimated that 50% of newly admitted residents in long-term care have a fear of
falling. (Gillespie & Friedman, 2007)
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Inappropriate footwear:
Poorly fitting or inappropriate footwear can cause alterations in an individual’s base
of support, proprioception and/or ability to sense the floor surface. People who have
fallen are four times more likely to have been wearing socks or slippers without a
proper sole. (Scott et al, 2007) Going barefoot or wearing stockings are associated
with a ten-fold increase risk of falling, with athletic shoes being associated with the
lowest risk (ACSQHC, 2005). Inappropriate footwear is implicated in about 20% of
falls in long-term care. (Hignett & Masud, 2006)
Lack of mobility aids, or improper use:

Many residents benefit from the stability provided from a walking aid such as a cane
or walker. However, incorrect use, such as failing to apply brakes, or using
equipment in ill repair or at incorrect heights (e.g. worn cane tips or brake pads) can
lead to falls. An occupational therapist or physiotherapist should assess the
resident’s mobility, select the appropriate type of aid, adjust the height, and provide
education for proper use.
Poor nutrition or hydration:

Generalized weakness, fatigue, and electrolyte imbalances can increase the risk of
falling, and even trigger a delirium. (Scott et al, 2007)
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Environmental Risk Factors
Poor building design and/or maintenance:
A lack of rest areas in hallways, insufficient handrails and grab bars, obstacles and
clutter can cause tripping hazards. Poor lighting and high contrast, or
insufficiently contrasting colours can pose problems for those with visual
impairments.
Fall hazards specific to long-term care homes include:

• chair and beds that are too high
• slippery floors
• poor lighting
• glare from surfaces
• lack of rest areas
• bed rails that do not allow for a ‘kick space’ beneath the bed, which is needed
for proper balance when rising from bed
(Scott et al, 2007)
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Social / Economic Factors
The social determinants of health, such as level of income, housing, education, and
social connectedness affect fall and fracture risk indirectly and cumulatively over an
individual’s lifetime due to their relationship with health, level of disability and
longevity. (PHAC, 2005)
Risk of Falls in Long-Term Care

Of the multitude of risk factors for falls, the ones most highly correlated with long-
term care include:
• impaired cognition
• wandering or impulsive behaviours
• use of psychotropic medications
• use of multiple medications
• being female
• incontinence and urgency
• lack of exercise
• mobility problems
• exposure to institutional hazards
• low staffing levels
(Wagner, 2007)
Risk of Injury from a Fall in Long-Term Care

Ten to 25 percent of falls in long-term care result in serious injuries, such as
fractures, lacerations or hospitalization. (Hignett & Masud, 2006 from Wagner, 2007)
The risk factors most highly associated with injury are:

• Osteoporosis
• Poor quadriceps strength and postural sway (common in arthritis)
• Chronic conditions
o Anemia, rheumatic disorders, stroke, cognitive impairment, muscle
weakness, balance and gait impairment, and low body mass. (Scott et
al, 2007)
• Gender: Female
• Medications: Benzodiazepines
• Flooring: Vinyl (compared to carpeting)
(Wagner, 2007)
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Risk Factors for Hip Fractures
Transfer independence is the strongest risk factor for fracture; other significant risk
factors are age (> 85) and previous fracture. (OOSLTC, 2009)
Other risk factors for hip fractures:

• independent transfers
• age > 80
• caucasian
• prior fracture
• cognitive impairment
• anxiolytic use
• history of falls
• BMD values below median
• poor balance
• multiple medications
• low weight
• longer leg length
• long-term (more than three continuous months) use of glucocorticoid therapy
such as prednisone
• family history of osteoporotic fracture
(OOSLTC, 2009)
• depression
• SSRI use
• inability to rise from a chair without using one’s arms
(OC, 2009)
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3.0 Overview of Falls and Injury Prevention in LTC
“Best practice in fall and injury prevention includes implementation of standard strategies,
identification of fall risk, and implementation of targeted individualized strategies that are
adequately resourced, regularly reviewed and monitored. The most effective approach to
fall prevention is likely to be one that includes all staff in health care facilities engaged in a
multifactorial fall-prevention program.” (ACSQHC, 2005)
The following overview summarizes the key strategies, components and processes of a fall
and injury prevention program in long-term care and the corresponding toolkit section.
Strategy Components Processes Section
Assessment of Risk Assessment Tool (RAI or other) Assessment

Assessment Risk Medication Review
of Fall Risk Risk Status Wristbands, icons, chart stickers, etc Assessment
Identification
Communication Between care providers, resident, family Education
Document risk level
Comprehensive Comprehensive multidisciplinary risk assessment for Assessment
Assessment high risk residents
Medical Optimize health status and remediable conditions Interventions

Preventing Treatment
Falls Rehabilitation Tailored exercise program Interventions
Assistive devices and equipment
Environmental Measures to make environment safe Interventions
Modification
Education Resident and family education Education
Staff / care provider education
Organizational Least Restraint Interventions
Policies Side Rails
Environmental monitoring and modification
Immediate Assisting to floor Post-fall

When a Fall Response Complete assessment & treatment management
Occurs Monitoring
Comprehensive Comprehensive multidisciplinary fall risk assessment Assessment
Reassessment Communication of Risk Status
Revision of Care Review and revise care plan Interventions
Plan Documentation
Disclosure to Communicate specifics of fall; intervention and Education
Resident/Family monitoring plan
Facility Tracking Track fall occurrences Quality
Process for investigating falls Improvement
(Adapted from RNAO, 2005)
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4.0 Assessment of Fall Risk
Identifying risk and risk factors is very important to efficient targeting of falls
prevention interventions. Application of a comprehensive falls risk assessment can
be the basis for effective falls prevention for individuals, particularly those at
increased risk.
(Hill, 2009, p.2)
Key Concepts:
Ascertain a person’s fall history on the day of admission to long-term care.
Every resident in long-term care is at risk for falls.
Each resident should have a comprehensive fall / fracture risk assessment on
admission, after a fall, and after a change in status.
The main purpose of a fall/fracture risk assessment is to identify specific risk
factors that can then be addressed through an individualized intervention plan.
Assessment tools that include suggested interventions with risk factors are
recommended.
The following evidence-based recommendations and clinical practice guidelines regarding

assessment of fall risk in older persons have been made by the RNAO (2005), the
American Geriatrics Society (2001), the Canadian Task Force on Preventive Health Care
(2005), and Osteoporosis Canada / Ontario Osteoporosis Strategy (2009).
Assessment Recommendations:
1. Prevention of Falls and Fall Injuries in the Older Adult

1. Assess fall risk on admission.
2. Risk factors to assess include:
• history of previous fall
• age
• gender
• medical conditions
• cognitive impairment
• balance
• gait
• ambulatory aids
• environmental hazards
• vision
• systolic hypotension, and
• total number of risk factors
3. Assess fall risk after a fall.
4. Conduct periodic medication reviews: residents taking psychotropic drugs or
more than five medications should be identified as high risk. (RNAO, 2005)
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2. Guidelines for the Prevention of Falls in Older Persons
1. Those who report a fall or recurrent falls, or demonstrate abnormalities of gait

and/or balance should have a fall evaluation performed.
2. The fall evaluation should assess the following:
• history of fall circumstances
• identification of acute or chronic medical conditions
• medication review
• sensory evaluation (vision, neurological, lower limb sensation)
• environmental assessment and modification
• assistive device / walking aid review
• continence management
• gait, balance, mobility, and lower extremity muscle strength
• cardiovascular status: heart rate and rhythm, postural pulse and
pressure
(AGS, 2001)
3. Prevention of Falls in Long-Term Care Facilities
1. Residents should be assessed on admission and re-assessed after a fall.

2. All persons admitted to LTC should undergo a comprehensive and
individualized risk assessment of the broad range of intrinsic and extrinsic risk
factors.
3. Assessment of medication history, cognition, strength, and balance, nutrition,
meds and environmental hazards requires a multidisciplinary approach
4. Quick screening procedures or risk scales are not sufficient for LTC settings
(Norris, Walton, Patterson, Feightner & CTFPHE, 2005)
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4. Osteoporosis Canada and the Ontario Osteoporosis Strategy for
Long-Term Care
1. Admission: an interprofessional team should assess for osteoporosis, falls,
and fracture risk.
2. Ideally, all LTC residents would undergo BMD testing as recommended by
the 2002 Osteoporosis Canada Guidelines.
3. Central (hip and spine) dual-energy x-ray absorptiometry (DXA) is the gold
standard for BMD assessment.
4. Reassessments must be done any time a new fracture is suspected, most
often involving the hip, rib, or spine.
5. Osteoporosis screening and intervention should focus on the healthiest, more
mobile, most functionally independent subset of residents who have more
opportunities for unprotected falls and are at the greatest risk for fracture.
(OC, 2009; OOSLTC, 2009)
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Falls Risk Assessment:
There are two main goals for conducting a fall risk assessment:
1. To tailor interventions to individual risk profiles
2. To maximize resources by targeting interventions to those at greatest risk
(Scott et al, 2007)
Three Basic Categories of Fall Risk Assessment Tools

1. Multifactorial tools: series of questions that cover a wide range of risk factors
2. Functional mobility tools: assessment of gait, strength and/or balance
3. Environmental hazard checklists: potential hazards in a resident’s room or in
the facility that are associated with slips, trips, and falls
(Scott et al, 2007)
Assessment tools are classified as either quick screening tools or in-depth

assessments.
Quick screening tools are typically used to sort people into high and low risk groups
(risk stratification). Examples of quick screening tools are the RAI-MDS (7 items)
and the Morse Fall Scale. Sorting residents into “high risk” or “low risk” categories
can be misleading as every resident is at risk for falls in long-term care. The most
important part of a fall risk assessment is to identify a person’s individual risk profile
and tailor interventions to those risk factors.
In-depth assessments are designed to uncover specific risk profiles of residents with
a view to tailoring prevention strategies at the identified risks. Examples of in-depth
assessments are the RAI-MDS Falls RAP and the Identification of Falls Risks and
Intervention for Falls and Injury Reduction Tool.
Recommended Fall Risk Assessment Tools:

1. Mobility Fall Chart*
2. Area Ellipse of Postural Sway*
3. Tinetti Balance Subscale*
(* Recommended for use in residential care settings)
(Scott et al, 2007)
4. Morse Fall Scale**

5. STRATIFY Risk Assessment Tool**
6. Hendrich II Fall Risk Model**
(RNAO, 2005)
(** Validity and reliability demonstrated in the acute care setting but not the residential care setting)
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Falls risk assessment can only reduce fall risk when risk factors are addressed
through individualized intervention plans. For this reason, it is recommended that
LTC homes use a risk assessment tool that is paired with suggested interventions.
(Scott et al, 2007)
Fall Risk Assessment with RAI-MDS:
Many of the assessment items in the RAI-MDS 2.0 have been widely reported as
risk factors for falls, such as history of falling, cognitive impairment, use of
psychotropic medications and use of physical restraints (CIHI, 2007). The following
items can be thought of as a “quick screen” or “risk stratification”. The presence of
any of the indicators below denotes “high risk” for additional, or initial, falls, and
triggers a Falls RAP (“in-depth assessment”).
RAI item Description Rationale as risk factor
J4a Fell in the past 30 The number one predictor of falls risk is a previous
days fall.
J4b Fell in the past 31-
180 days
E4aA=1,2,3 Wandering (risk) Problems with cognition and behaviour are often
associated with falls in the literature. In a recent
Canadian study, residents who wandered were
found to be more likely to fall; 19% of residents who
wandered had a fall documented, compared with
only 7% of those who did not wander (CIHI, 2007)
J1f Dizziness / vertigo Conditions such as postural hypotension, or
impairments in the vestibular system can cause
balance problems.
P4c=1,2 Use of trunk restraint Research supports the fact that restraints do not
prevent falls. Conversely, the use of restraints may
lead to mobility limitations, muscle weakness and
deconditioning which will increase the risk of falling
(Burland, 2008)
O4b=1-7 Use of antianxiety Can cause agitation, dizziness, orthostatic
drugs (risk) hypotension, gait abnormalities, extrapyramidal
reactions, sedation, drowsiness, and visual
O4c=1-7 Use of disturbances; there is also an increased risk of falls
antidepressant drugs due to depression independent of medication effect
(Scott et al, 2007)
(Adapted from CIHI, 2005)
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Falls Risk Assessment: Falls RAP (RAI-MDS)
The Falls RAP key contains guidelines for a more detailed assessment of
contributory risk factors that may be addressed. The assessment domains include:
• Recurrent falls
• Internal factors:
o Cardiovascular
o Neuromuscular/functional
o Orthopedic
o Perceptual
o Psychiatric or cognitive
• External factors:
o Medications
o Appliances/devices
o Environmental/situational hazards
o Circumstances of recent falls
(CIHI, 2005)
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Screening for Osteoporosis and Fracture Risk with the RAI-MDS
Relevant risk factors for osteoporosis and fracture risk in addition to those for falls
include:
RAI item Description Rationale as risk factor
G1Ab Transfer status Transfer independence is the strongest risk

factor for fracture (OOSLTC, 2009)
I1m Hip fracture Prior fracture is highly correlated to
increased risk of hip fractures (OOSLTC,
J4c Hip fracture in last 180 days 2009)
J4d Other fracture in last 180 days
I1o Osteoporosis Osteoporosis increases the risk of fracture
(OC, 2009)
(Adapted from CIHI, 2005)
Chart Review
In addition to information gained in the MDS-RAI assessment, it is also important to
gain the following information from the resident’s health record:
• Bone Mineral Density test results
• Family fracture history
• Height loss of more than 6 cm
(OC, 2009)
Physical Examination – Signs of a Vertebral Fracture

• Curved back/kyphosis
• Protuberant abdomen
• Loss of 6 cm or more of adult height
• Less than 3 cm space between bottom or rib and top of hip
• Standing against the wall, the back of the head is more than 6 cm from the
wall
(OOSLTC, 2009)
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Environmental Hazards Checklists
These checklists consist of a list of potential hazards within the resident’s room or
within the facility. There are no validated environmental hazard checklists for
predicting fall risk; however, the utility of using such tools to individualize preventive
strategies is supported in the literature. (Scott et al, 2007)
It is recommended that the checklist contain recommended interventions. Without

follow-up and support, the likelihood of change happening is significantly reduced.
(Scott et al, 2007)
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5.0 Post-Fall Management
“Fall Recovery goes beyond healing the physical injury: fall outcomes are not limited to
physical trauma but include social withdrawal, psychological trauma and increased
dependence.” (PHAC, 2005, p47)
Key Concepts:
Immediate post-fall management involves providing comfort and
reassurance, ruling out severe injury (e.g. hip fracture or head trauma),
transferring with a mechanical lift, monitoring, communication and
documentation.
A comprehensive post-fall assessment should be completed to identify
contributing factors and review of the resident’s fall / fracture risk factors.
Post-fall reports should be reviewed for trends and quality improvement
ideas.
Post-fall Assessment Recommendations:

Post-fall assessment, as a component of a comprehensive program, may detect previously
unrecognized health concerns. (Norris et al, 2005)
Purpose of Post-fall Assessment:

1. Determine the presence and severity of injury, and required treatments or external
assessments/investigations
2. To identify the reason for the fall and circumstances surrounding the fall, if possible,
and review and revise the care plan:
o reassessment using the Fall risk assessment tool
o complete a post-fall report
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Care of Resident After a Fall
Injury Not Serious
• Leave resident on the floor until nurse has completed an assessment and appropriate
transfer determined
• Comfort measures and reassurance; 1:1 staffing
• Pillow under head only if no suspected head/neck injury
• Obtain a mechanical lift, and two staff members to safely raise the resident from the
floor
• Inform the physician or nurse practitioner and family members during waking hours,
unless otherwise indicated, if hospitalization is not required
• Initiate or review:
o Fall Risk Assessment Tool (RAI or other)
o Post-fall Report
o Review and revise care plan
o Communicate with staff members: occurrence, post-fall interventions & follow-up
o Document in health record
Injury is Serious
• Call physician or nurse practitioner to discuss condition
• Comfort measures and reassurance; 1:1 staffing
• No pillow under head if neck/head injury suspected; immobilized neck/head
• If a fracture is suspected, leave resident on floor until paramedics arrive to transfer
to emergency, or until appropriate transfer determined
• Arrange transport to emergency if necessary
• Inform family member as soon as possible and/or before transfer to emergency
• If resident is not transferred to emergency, initiate or review, if applicable:
o RAI – MDS Change of Condition
o Fall Risk Assessment tool (if not using RAI)
o Post-fall report
o Review and revise care plan
o Communicate with staff members: occurrence, post-fall interventions & follow-up
o Document in health record
Unwitnessed Fall
• neuro checks immediately and for next 48 hours
(Adapted from Fraser Health Authority, 2007)
Signs of a Hip Fracture:

• suddenly can’t walk or weight bear
• leg is unusually rotated
• new or sudden hip pain
(OOSLTC, 2009)
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6.0 Interventions to Reduce the Risk of Falls and/or Fractures
A potential factor limiting effectiveness of falls prevention activities is low levels of uptake
and sustained engagement in recommended falls prevention activities by the older
individual. Improving knowledge among older people, health professionals and carers and
other staff involved with older people – that evidence based interventions can reduce falls
– is likely to improve engagement with recommendations (Hill, 2009, p. 2)
Key Concepts:
A number of interventions are effective at preventing falls and fractures.
Interventions should be matched to the resident’s risk factors and
preferences.
It is essential to involve the resident and family in the decision-making
process regarding fall and fracture prevention interventions.
Introduction
For many health care providers and residents, falls are seen as an inevitable part of
aging. However, there are several interventions and strategies – often simple and
easy to achieve – that can prevent falls or reduce the risk of falling and subsequent
injury. Fall and fracture risk prevention strategies need to be customized to the
resident’s specific risk factors and preferences.
Discussions about falls and fracture prevention require the active involvement of the
resident and family in making decisions based on their wishes and values. The
philosophy widely accepted when discussing falls prevention is “maximizing
freedoms and minimizing risk of injury.” (Earthy, 2009a) There are often tradeoffs of
fall management solutions with respect to the resident’s quality of life, safety,
autonomy, privacy, dignity, and independence.
In addition, care providers should be aware that there is a tendency for elderly
individuals to dissociate themselves from the likelihood of falling. (PHAC, 2005) The
fall prevention message should be presented within the context of maintaining
independence. (ACSQHC, 2005)
Recommendations for Implementing Falls Interventions in LTC

A multi-factorial intervention program should be tailored for each resident to
optimally reduce extrinsic and intrinsic risk factors. (Norris et al, 2005)
Conditions for successful implementation of best practice guidelines require:
• Clearly defined responsibilities of all staff
• Clear falls management policies and procedures for all members of the
interdisciplinary team
(Todd & Skelton, 2004)
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Interventions That Decrease the Risk of Ralls and/or Fractures
Environmental modification
Older persons at increased risk of falls should have an environmental assessment of
their room. (Wagner, 2007)
Periodic Medication Review and Withdrawal of Psychotropics

Residents who have fallen or are at risk for falling should have their medications
reviewed. Those taking four or more medications, or taking psychotropic
medications, should be classified as “high risk for falls”. (RNAO, 2005) Reduction of
medications is an effective and prominent component of fall reducing interventions in
long-term care and community-based studies. (Wagner, 2007) Benzodiazepines
should be tapered and discontinued and doses of antipsychotics should be reduced
if possible. (Scott et al, 2007)
Assistive Devices
Assistive devices such as canes, walkers, safety poles or bathroom grab bars have
demonstrated benefit when used as a component of multifactorial interventions.
(Wagner, 2007) It is important that the resident is assessed for the proper type of
devices, and receives training in correct use.
Vision care
Residents should have their vision formally assessed if they report any visual
problems. Wearing corrective eyewear and treating remediable visual abnormalities
can decrease the fall and fracture risk. (Wagner, 2007) In addition, environmental
changes can be implemented which can compensate for vision problems; for
example: a nightlight, motion light, bathroom light, or outlining the path to the
bathroom with fluorescent tape.
Footwear
Improper footwear is responsible for about 20% of falls in long-term care. (Hignett &
Masud, 2006) Slippers, high-heeled or narrow-soled shoes, bare feet, nylons, or
sock feet can increase the risk of falls. (ACSQHC, 2005) There are certain footwear
features that can decrease the risk of falls including, low-heel, hard-sole, lightweight
walking or athletic shoes. In addition, non-slip socks are available for wearing to bed
to decrease the risk of slipping for residents who get up through the night.
Residents should also be screened for foot pain and other foot problems, receive
education and info about foot care and be referred to a podiatrist where indicated.
(ACSQHC, 2005)
A common misperception for safe footwear for an older adult is one with a thick sole.
In reality, a thinner sole with a good tread is preferable as the ability to sense the
walking surface with the foot is reduced as a consequence of aging. (Scott et al,
2007)
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Education has not demonstrated effectiveness as a single intervention to reduce
falls and fractures in long-term care, but it is an essential component in an overall
strategy. (Wagner, 2007) Residents and families should receive education on their
level of fall risk, and interventions that can reduce their risk of falls and fractures,
such as hip protectors, calcium, Vitamin D, bisphosphonates, proper footwear, and
exercise. (ACSQHC, 2005)
Exercise
Individualized exercise programs, as a component of a multifactorial risk reduction
strategy, can improve balance, strength, and bone density which leads to a
decreased risk of falls and fractures. Lower limb strengthening combined with
balance exercises has demonstrated the most effectiveness. Tai Chi is the only
single exercise intervention effective for improving balance and decreasing falls.
(Wagner, 2007)
Treatment of Postural Hypotension and Cardiovascular Disorders

Residents with dizziness should be assessed and treated for orthostatic hypotension
and taught to rise slowly from bed to prevent fainting. (SCOTT ET AL, 2007)
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Hip protectors
Hip protectors are effective in reducing the risk of hip fractures in older individuals
but they do not decrease the risk of falling (Wagner, 2007). It is recommended that
those at risk for falls and fractures, and those with a fear of falling wear hip
protectors. (OOSLTC, 2009) However, there are many barriers to using hip
protectors, causing a low adherence rate. Many individuals report discomfort, In
addition, there is a potential for skin irritation and breakdown. (Wagner, 2007) The
user may not clearly understand the linkage between falls and hip protectors as a
form of prevention, which may explain the high dropout rate (SCIE, 2005). Expert
knowledge supports the position that wearing hip protectors can lead to
incontinence. The adherence rate is improved by staff education. (Todd & Skelton,
2004)
Who should wear a hip protector?
• Osteoporosis and / or arthritis in the hip
• Fallen or at high risk for falls
• Previous hip fracture
• Unsteady walking; independent transfer
• And/or dementia
(OOSLTC, 2009)
Bowel and Bladder Management Program

It is recommended that residents have an individualized toileting program to reduce
the occurrence of unassisted transfers, the risks of infections or skin breakdown, and
to prevent slipping in urine. (Wagner, 2007).
Staff Education
Contrary to findings in community-based falls prevention programs, staff education
programs for falls prevention in long-term care are a beneficial component of a
global falls prevention strategy. (Wagner, 2007)
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Other interventions that may be of benefit in fall and fracture
prevention
ID Bracelets, Signs or Tags for High-Risk Residents
There is currently insufficient information to conclude whether ID bracelets as a
single intervention are effective in decreasing falls risk. However, no potential harm
for its use has been identified and the costs for implementation are minimal. The use
of ID bracelets and/or falls icons is an accepted practice in identifying high-risk
residents as part of a multi-factorial risk reduction strategy. (Wagner, 2007)
Bed alarms
There is currently insufficient evidence regarding the effectiveness of bed alarms;
however, there is no potential harm associated with their use. Bed and chair alarms
are often recommended for use with cognitively impaired individuals and/or those
who wander and/or those who cannot call for assistance with transfers or
ambulation. (Wagner, 2007)
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Treatment of Osteoporosis
Osteoporosis remains seriously under diagnosed and undertreated in LTC. However,

there are a number of safe and effective non-pharmacologic and pharmacologic
interventions. Residents with fractures or multiple risk factors may be treated even
without BMD information. (OC, 2009)
Non-Pharmacologic Treatment Recommendations for Long-Term Care:

• Individualized exercise: weight-bearing, strengthening, balance, and postural
• Hip protectors
Pharmacological Treatment Recommendations for Long-Term Care:

• Calcium 1500 mg/day from all sources (diet and supplements)
• Vitamin D at least 800 IU/day from all sources (diet, supplements, sun)
• First-line antiresorptives: bisphosphonates
• Second-line antiresorptives:
o Women: selective estrogen receptor modulators
o Calcitonin
• For pain due to acute vertebral fractures: calcitonin
• (note anabolic agents e.g. teriparatide not yet recommended in LTC)
(OC, 2009)
Calcium Supplementation
Residents in long-term care should receive 1500 mg/day of calcium from all sources
(diet and supplements). If supplementation is required, start at 500 mg daily and
gradually increase to avoid constipation. (OOSLTC, 2009) Many residents have
difficulty swallowing the large pills, however, and the liquid form of calcium is not
currently covered by OHIP. (Mullen, 2009)
Vitamin D Supplementation
Residents in long-term care should receive a minimum of 800 IU daily of Vitamin D
(preferably 1000 IU) from all sources. Vitamin D significantly reduces the risk of hip
fractures (by 26%) and falls (by 22%), due to improved muscle growth and function and
is a tremendously cost-effective intervention. (OC, 2009) The estimated cost to provide
1000 IU of Vitamin D to 140 residents for one year is $300. (Lewis, 2009)
Supplements are likely essential as the majority of residents in Canadian LTC facilities
have insufficient dietary levels of Vitamin D. (OC, 2009) Exposure to sunlight is also
insufficient for generating optimum levels as aging skin in sunlight does not effectively
synthesize Vit D. (OOSLTC, 2009)
A recent Canadian study found that 9% of LTC residents were severely Vitamin D-
deficient in autumn, 18% in spring, and 38-60% in winter. (OC, 2009) Exposure to 15
minutes of noon sun every day for an entire week would only generate 400 IU of
Vitamin D. (Lewis, 2009)
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Bisphosphonates
After ensuring adequate intake of calcium and vitamin D, bisphosphonates should
be considered. When taken with vitamin D and calcium, bisphosphonates reduce
the risk of all fractures by 40-80% (OC, 2009). A recent Canadian study showed
that many long-term care physicians do not routinely assess for osteoporosis or
initiate bisphosphonates, as they believe that the benefits are not proven in this
population or that the life expectancy prevents realization of benefits. However, the
average life expectancy of a resident in Canadian long-term care home is 2.5 years
and the BMD and fracture-reducing benefits of bisphosphonates may emerge in as
little as six months. (OC, 2009)
A trial of alendronate in institutionalized women shows that it significantly increases

hip and spine BMD, with a trend to fewer fractures and a side-effect profile similar to
placebo. (OC, 2009)
Bisphosphonates are generally well tolerated; however, since they are poorly
absorbed, they are frequently associated with GI problems and require strict dosing
requirements:
• give first thing in the morning at least ½ hour before breakfast
• remain sitting upright for at least 1 hour
• take only with tap water
• take alone, with no other medications
• never crush bisphosphonates tablets
• give only to residents who can swallow effectively
• never suck on bisphosphonates tablets
• vitamin D and calcium supplements should be given later, with lunch and
supper
(OOSLTC, 2009)
To increase adherence and minimize side effects, there are alternatives to once-
daily bisphosphonates; however, many of these forms are very costly and not
covered by OHIP. Examples are:
• Residronate once weekly
• Residronate monthly (covered by OHIP since June 2009)
• Zoledronic acid injections yearly (very expensive; not covered by OHIP)
(Mullen, 2009)
Recent research on yearly injections of zoledronic acid demonstrates that it reduces

vertebral, hip and newer fractures; and in those with a hip fracture, prevents new
clinical fractures and lowers all-cause mortality an effect not seen with other
bisphosphonates to date. (OC, 2009)
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Osteoporosis Treatment Decision-Making in LTC
Indications for treatment:
• Osteoporosis risk factors without BMD data
• BMD-diagnosed osteoporosis
• Previous or new fragility fractures
Resident considerations:
• Cognitive and nutritional status
• Fall and fracture risks: implement fall prevention measures as needed
• Mobility: do not treat if bedridden (unless risk of falling from bed)
• Co-morbidities
• Medications: polypharmacy (use of > 4 drugs) does not rule out osteoporosis
treatment if all medications are appropriately prescribed
• Preferences of resident or proxy-decision maker
(Adapted from OC, 2009)
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Recommended Interventions for Residents With Special Needs
Cognitive/memory problems:
• Bed and chair alarms
• Placing bed along wall to allow exit on stronger side
• Hip protectors
• Frequent checks
Impaired mobility:
• Occupational Therapy assessment
• Trapeze, transfer enabler, ½ or ¼ side rails, or transfer pole
• Proper footwear; non-skid socks in bed
Fear of falling:
• Balance and strength exercises
• Hip protectors
• Bed in very low position
(Wagner, 2007)
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Interventions That Are Not Recommended or Potentially Harmful
Restraints
Physical restraints have not been found to reduce falls or injuries and may result in
other problems that increase fall risk such as pressure sores, incontinence, muscle
wasting and worsening mental health. (SCIE, 2005) Conversely, it appears that
reducing their use may actually decrease the risk of falling. The RNAO recommends
that long-term care homes establish a corporate policy for least restraint that
includes components of physical and chemical restraints. (RNAO, 2005)
Side rails
The use of bedrails should never be automatically considered. (RNAO, 2005) Full
side rails should not be used for fall prevention, because they are ineffective at
preventing falls, can increase the likelihood of death due to bed entrapment, can
increase the severity of injury if an individual falls when climbing over the side rails,
and can increase the likelihood of falls through a loss of muscle mass and balance
due to immobility (National Center for Patient Safety, 2004). Long-term care staff
should not use side rails as an intervention for fall prevention; however resident
factors may influence this decision. (RNAO, 2005) For example, rails may promote
independence with bed mobility and transfers. When discontinued, side rails should
be decreased in a gradual and systematic manner. (Wagner, 2007)
Care providers are encouraged to consider alternatives to side rail use, such as:
• Placing the bed against a wall
• Using bed monitors
• Lowering the bed
• Using floor pads or cushioning around the bed
• Having a commode at the bedside
(Wagner, 2007)
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Individual Roles in Preventing Falls and Fractures in Long-Term
Care
The successful implementation and sustainability of fall prevention programs
depends on having:
• Clearly defined responsibilities, and
• Clear falls management policies and procedures for all members of the
interdisciplinary team
(Todd & Skelton, 2004)
Physicians or Nurse Practitioners:

• Identify and treat reversible cardiovascular, neurological, genitourinary, and
other contributory factors
• Screen and treat for vision and hearing problems
• Review medications; minimize number and eliminate those known to cause
falls in older individuals
• Consider treatments for osteoporosis, including Calcium and vitamin D
supplementation, and bisphosphonates
• Educate residents about hip protectors and encourage their use
• Educate residents and families about proper footwear
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Managers and Administrators:
• Ensure individual and group exercise sessions or physical activity options are
available for residents
• Review home environment for safety
Personal Support Workers / Health Care Aids:

• Maintain adequate fluid intake to avoid dehydration and confusion
• Assist resident to bathroom frequently in the case of a urinary tract infection
• Encourage the safe use of assistive devices
• Encourage slow changes in position – sitting to standing or lying to sitting
• Ensure brakes on bed or chair are locked when changing positions
• Encourage proper footwear – non-skid, good fit
• Encourage wearing of recommended eye glasses and hearing aids
• Reinforce use of call bell and ensure call bell is within reach
• Ensure proper lighting – use of a nightlight or leave bathroom light on
(Central East Best Practice Guideline Initiative, 2007)
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Allied Health Professionals (Occupational Therapy, Physiotherapy):
• Identify balance, mobility and strength problems, then tailor an individual
exercise or activity program
• Supervise and assist people with delirium and dementia to ensure safe
transfers and ambulation
• Give education and information about footwear features that may reduce fall
risk
• Modify the resident’s room to ensure safe mobility
• Provide assistive devices and equipment and training in their safe use
• Encourage the use of hip protectors in residents at high risk of falls and
fractures
Dietitian:
• Assess fluid and nutrient intake and provide dietary and supplement
recommendations for increasing calcium, Vitamin D intake, and fluids if
required
(Earthy, 2009a)
Nurses (RNs & RPNs):

• Supervise and assist people with delirium and dementia to ensure safe
transfers and ambulation
• Introduce an individualized toileting program
• Give education and information about footwear features that may reduce fall
risk
• Encourage the use of hip protectors in residents at high risk of falls and
fractures
• Encourage the safe use of assistive devices
• Encourage slow changes in position – sitting to standing or lying to sitting
• Ensure brakes on bed or chair are locked when changing positions
Support Staff (Cleaners, Dietary, and Transport Staff):

• Reduce clutter at the bedside
• Ensure a resident’s walking aid is within reach
• Ensure food and water are within reach
• Ensure the call bell is within reach
• Provide casual observation and report falls or near misses
Podiatrist:
• Assess feet for pain, deformity, poor sensation
• Provide orthotics, recommendations for appropriate footwear
(ACSQHC, 2005)
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7.0 Education

“Communications need to take into account the tendencies of people to dissociate from
the likelihood of a future fall, displace blame for falls, and maintain a sense of personal
control and independence. Also, understanding the complexity of fear of falling is
important for effective communication. Communications should emphasize ‘healthy
fear’ that results in risk reduction rather than ‘unhealthy fear’ that may lead to increased
risk of falls.”
(PHAC, 2005)
Key Concepts:
Involve residents and families in discussions about fall/fracture prevention.
Older individuals tend to underestimate their risk of falling and injury.
Fall prevention messages should be delivered in the context of “maintaining
independence”.
Staff education is a key factor in the success of fall prevention initiatives.
Education and Behaviour Change in Falls and Fracture Prevention

Comprehensive fall / fracture prevention strategies in long-term care should consist of
behaviour changes, activities, and processes at four levels:
intrapersonal (the resident), interpersonal (family and staff), institutional (policies,
procedures, and “philosophies”) and public policy at the local, provincial, and federal
levels. (Magaziner, Miller & Resnick, 2007) This toolkit focuses on behaviour change
at the first three levels.
1. Intrapersonal (the resident)

In care planning for fall and injury prevention strategies with the resident and family, it is
important to find out what changes a resident is wiling to make. There are often
tradeoffs of fall management solutions with respect to the resident’s quality of life,
safety, autonomy, privacy, dignity, and independence. Care providers need to be aware
that:
• Many residents may view falling as an inevitable consequence of aging
(PHAC, 2005)
• The terms “fall prevention” or ”fracture prevention” may be unfamiliar
concepts to residents (ACSQHC, 2005)
• The fall/fracture prevention message needs to be presented within the context
of staying independent for longer (ACSQHC, 2005)
• There is a tendency for elderly individuals to dissociate themselves from the
likelihood of falling (PHAC, 2005)
• Approximately half of all newly admitted residents have a fear of falling that
limits their abilities (Gillespie & Friedman, 2007)
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• Residents and families should receive education on their risk of falling as it
reduces fear of falling and improves self-efficacy (RNAO, 2005)
• Conversations about fall and fracture risk can cause healthy fear which
motivates positive change, or unhealthy fear, leading to further limitations in
mobility
2(a) Interpersonal: family

Fall and fracture prevention requires the active involvement of the family in planning and
implementation. (ACSQHC, 2005) In the presence of falls or fall risk, families often
request measures such as restraints or side rails which are ineffective at preventing
falls, and in fact can increase the risk of falls and injuries (Wagner, 2007). Families
need to be informed about the detrimental effects of restrictive measures and about the
individual resident’s risk factors. Ways in which families can be involved in fall and
fracture prevention strategies are presented below.
2(b) Interpersonal: staff

Health care providers may view falling as an inevitable part of aging. They may not be
aware that several interventions and strategies exist that can prevent or reduce the risk
of falls and injury. Care providers should plan interventions with consideration of the
resident’s desire for autonomy and functional independence and with awareness that
the resident has the right to live in dignity and at risk. (ACSQHC, 2005)
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3. Institutional/organizational:
Organizational policies and procedures in fall and fracture prevention strategies
should reflect an overall philosophy of “maximizing freedoms while minimizing the
risk of injury”. (Earthy, 2009a) It is recommended that long-term care homes
embrace a “least restraint” philosophy and have policies that reflect this. (RNAO,
2005) Policies and procedures can be instated or revised that reflect reduction of
environmental hazards for residents and staff. An underpinning guiding principle is
that “everyone is at risk for falls, and everyone has a role in preventing falls.” (FHA,
2007)
Four levels of
behaviour change
required for
effective falls and
fracture prevention
strategies in long-
term care.
(Adapted from
Magaziner et al, 2007)
Adapted from Magaziner et al, 2007 © Copyright CSAH 2009
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Specific Education Recommendations for Residents and Families:
Provide education to the resident and family on admission and after a fall regarding:
• universal precautions
• hip protectors
• least restraint policy
• facility philosophy regarding use of side rails and least restraint
• alternatives to restraint
• their individual measures that can decrease chance of falls and injuries
• dietary, lifestyle and treatment options for prevention of osteoporosis (calcium
and Vitamin D supplementation, bisphosphonates, exercise)
• importance of exercise and services available – PT, OT, exercise classes
(FHA, 2007)
• how family members can help with falls prevention (Toronto Best Practice in
LTC Working Group, 2006)
Care givers should provide relevant and appropriate written or other forms of
education to complement the care planning discussions, and to document the
resident and family response to education. (FHA, 2007)
The resident and family should receive instruction regarding:

• proper ambulation and use of assistive devices
• using handrails in hallways, bathrooms and tub rooms
• wheelchair safety (brakes, pedals)
• avoiding pulling down on walkers when rising to a standing position
• sitting on the edge of the bed for several minutes before rising
• other techniques for orthostatic hypotension such as elastic stockings, ankle
pumping in the sitting position
• appropriate footwear characteristics
• not relying on furniture to support when walking
• use of treaded socks
• using call bell/requesting assistance with ambulation (repeat instructions to
call for help on each shift)
(Toronto Best Practice in LTC Working Group, 2006)
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Involving Families
Open and honest communication between staff and family members is a key
factor in improving resident safety. (Wagner & Mafrici, 2007) Encourage families
to:
• alert staff to history of falls
• alert staff to hazards
• inform staff when they are leaving so they can resume monitoring
• limit amount of clutter in the resident’s room and don’t bring in throw
rugs
• check with staff before giving resident new shoes
• let staff know if they wish to be called in middle of night if a loved one
falls and no injury is present, or if the notification can wait until morning
• join a falls quality improvement team
(Wagner & Mafrici, 2007)
Specific Recommendations for Staff:

Staff should receive on-going education with specific attention to:
• promoting safe mobility
• risk assessment
• multidisciplinary strategies
• risk management including post-fall follow-up
• alternatives to restraints and/or other restricted devices
(RNAO, 2005)
• training on conducting individualized assessments of fall risks (SCIE,
2005)
• the role of hip protectors, as it increases their compliance rate
(Wagner, 2007)
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8.0 Quality Improvement
Key Concepts:
There are several indicators used to track falls and injuries in long-term
care.
There are a variety of sources of change ideas (literature, other LTC
homes).
Successful change ideas from other sources typically require
modifications for successful implementation in other LTC homes: this is
best-done by testing change ideas using Plan-Do-Study-Act cycles.
Common Measures in Falls Quality Improvement Initiatives
Safer Healthcare Now – National Falls Collaborative
Outcome Measures:
1. Falls per 1000 resident days.
Target: reduce by 40%
2. Percentage of harmful falls.

Target: reduce by 40%
Process Measures:
3. Percentage of Residents with Completed Fall Risk Assessment on
Admission
Target: 100%
4. Percentage of Risk Assessments Following Status Change

Target: 100%
5. Percentage of “at risk” residents with intervention plans

Target: 100%
Balancing Measures:
6. Restraint use
Target: 0%
The Safer Healthcare Now website also includes excel-based measurement

sheets and run charts. A link is provided in the resources section.
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Check sheets
Check sheets are useful tools for analyzing fall or incident reports to determine the
characteristics associated with falls, location and time of day, associated symptoms, and
injury severity.
The Appendix contains tools for use in falls Quality Improvement projects.
Change Ideas: Successful Falls Intervention Strategies from the Literature
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Change Ideas: Successful Falls Intervention Strategies from the
Literature (cont’d)
In 2004, a nursing home in the USA implemented the “Falls and Fall Risk Clinical Practice
Guidelines” of the American Medical Directors Association:
Step 1: Education and Encouragement:

• Educate staff about impact of falls on older adults and implementation process
• Skills to carry out falls risk assessment
• Skills to carry out comprehensive post-falls evaluation
• Instill confidence that program can reduce falls and improve quality of life of
residents
• Walk around rounds by NP to ensure skills uptake
Step 2: Recognition and Problem Identification

• Falls risk assessment for all residents
• Then use this to develop an interdisciplinary care plan for each resident
depending on level of fall risk
Step 3: Assessment of the Fall and Evaluation of Cause

• If a resident falls, staff completed the resident post-fall evaluation forms
Step 4: Reaping the benefits and seeing and setting examples

• Informing staff of clinical outcomes of the implementation particularly the number
of falls
• Families and administrative staff were also informed of the outcomes
Results:
• Number of falls decreased
• Decreased percentage of residents who needed help with ADL’s
• Infection rates down
• Pain rates down
• Restraint use down
• Percent with pressure sores down
• Most falls in rooms and bathrooms – highlighted need to make frequent checks
Why they were so successful:

• Forms checked for completeness
• DOC followed up with staff who did not complete forms
• Facility provided non-skid socks for all residents (Wagner, 2007)
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Another study evaluated an intervention program to prevent falls and fall-related injuries in
a group of high-risk residents. Interventions were based in four domains:
Environmental and personal safety
• Install wheel locks for beds
• Change lighting
• Change flooring
• Reposition or repair call lights
• Raise toilets
• Label wheelchairs, other equipment, furniture & belongings with resident’s names
• Repair or replace furniture
• Use proper fitting shoes
• Remove clutter and maintain clear area
Wheelchair use
• Correct wheelchair problems immediately
• Adjust or repair brakes
• Clean/lube moving parts
• Install anti-tip rods
• Add brake extensions
• Implement a wheelchair maintenance program (lots of web sites)
Psychotropic drug use

• Identify treatments that pose less fall risk
• Suggest psychosocial interventions
• Taper and discontinue benzodiazepines
• Reduce antipsychotics
• Implement behaviour management plan
Transferring and ambulation

• Increase observation of resident
• Toilet / nourish q2h minimum
• Repair / modify cane
• Always assist resident during transfer
• Remind resident of safe transferring techniques
Results
• The falls prevention program was most effective for frequent fallers
• 19% fewer recurrent falls compared with control facilities
• 31% reduction in rate of injurious falls
(Ray, Taylor, Meador, Thapa, Brown, Kajihara, Davis, Gideon, & Griffin, 1997)
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A recent 12-month trial involving 518 psychogeriatric nursing home residents in the
Netherlands assessed the effect of a multidisciplinary/multifactorial fall prevention
intervention on the number of falls.
Intervention:
• a general medical assessment
• an additional specific fall risk evaluation tool, applied by a multidisciplinary fall
prevention team assessing:
o fall history
o medication intake
o mobility
o use of assistive and protective aids
• general and individual fall prevention activities resulting from the multidisciplinary
evaluation:
o critical review of medication and adjustment / modification
o individually designed exercise programmes
o need assessment for assistive/ protective aids and education for proper use
• screen of main areas of each ward using a environmental hazard checklist
• general fall prevention activities, such as staff training and education
Multidisciplinary fall prevention team members:

• physician
• two nurses
• physiotherapist
• occupational therapist
Team procedure:
• q2week fall prevention conferences
• discussed each patient:
o at admission
o after a fall
o at request of professionals on the ward
o minimum twice a year, even if there had been no fall incident or request
Results:
• intervention group had a significantly lower mean fall incidence rate than the control
group
• fall risk declined further as patients participated longer in the intervention program
(Neyens, Dijcks, Twisk, Schols, van Haastregt, van den Heuvel & de Witte, 2009)
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Multifactorial Interventions in Ontario Long-Term Care Homes
Environmental Initiatives
• Adjust bed height
• Assess / rearrange furniture to reduce clutter, remove scatter mats
• Use non-glare floor wax
• Colour band across doors to reduce wandering (dementia residents)
• Install secure doors to all exits
• Conduct environmental scan of building and safety scan of resident rooms
• Multifactorial changes:
o Adhesive strips in front of sinks
o Brakes on wheels of kitchen carts
o Secure TV’s to stands
o Raise height of lounge chairs
o Direction signs for elevators
Assistive Device Initiatives

• Check of ambulatory aids: routine and after a fall
• Use of helmets (frequent fallers on dementia unit)
• Hip protectors (frequent fallers)
• Anti-slippery socks (frequent fallers / all mobile residents)
• Inservice education: use of lifts
Restraint Reduction and Monitoring

• Call-bells put in bathrooms with yellow cords
• Personal alarm attached to clothes (frequent fallers)
• Tabs alarm on bed / chair (frequent fallers)
• Motion detector (frequent faller)
• Encourage frequent family visits (frequent fallers)
• Mechanical lifts (non-ambulatory)
• Assess safety of beds
Assessment and Individualized Care Planning Initiatives

• Fall risk education and supervision (frequent fallers)
• Bathroom scheduling (frequent fallers)
• Fall risk assessment on admission, condition change, or after a fall, and
• Orange dots to identify high fall risk residents
• Post-fall assessment to determine role that fatigue played: followed by family
education
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Policy/Procedure and Organizational Initiatives
• Fall surveillance report completed after every fall
• Restraint / transfer pictogram (transfer status)
• Establishment of fall working group
• Policy to remove scatter mats from resident’s rooms
• Policy to have all furniture assessed by PT and OT
• Hip protector policy
Exercise / Activities
• Routine exercise program (3 x per week – all residents)
• Walking group (all ambulatory residents)
• Combined walking, strength, and balance group
Medication / Nutrition Initiatives

• Individualized assessment and prescription of Calcium, Vitamin D, dietary
supplements
• Individualized assessment and prescription of bone enhancing medication
(Didrocal, Fosamax, etc.)
• Water tank at every unit; encourage 3-4 glasses / day
• Medication review after a fall
• Ongoing use of Falls Surveillance Tool
• Fortification of one item / day with powdered milk to increase calcium
and Vitamin D
(Gallagher, Scott, Kozak, Johnson & Brussoni, 2005)
Safer Healthcare Now – National Falls Collaborative: Areas of Focus

Assessment, identification and communication of risk for falls:
• evidence-based, including RNAO Best Practice Guidelines
• routinely assessing residents for fall risk
• clear identification of those at risk for falls
• communicating results of assessment and follow-up interventions
• all have a significant impact on falls and fall injuries
Prevention of falls:
• evidence-based education programs, policies, and environmental strategies
to reduce incidence of falls
(CPSI, 2009)
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Other Multifactorial Falls Initiatives
1. Fraser Health Authority
• Created Clinical Practice Guideline for Falls Prevention in LTC
• Learning collaboratives - “clinical commitments” from falls teams across the
health authority (27 practice councils)
• Developed a falls strategy for the entire sector from community to ER to LTC
• Main intervention: management of incontinence as a contributing factor to
falls
• Used quality improvement science/PDSA cycles
• Education – highlight key messages
• Chart audits
• Benchmarking for several indicators: # toilets, equipment, PT/OT involvement
• Dignified bowel and bladder care – toilet in private area, sitting upright with
postural support if required
• Previous falls interventions: hip protectors, low beds, drop mats, bed alarms
(Earthy, 2009b)
2. Providence Manor
• Vitamin D and Calcium for all residents Dementia Unit (next initiative)
• Post-fall assessment tool (PFAT)
• Observation q ½ hr for high risk fallers on Dementia Unit
• Play music from 2:45 to 3:30 (change of shift) on dementia unit – distraction
and group supervision
• Tracking: # falls/1000 bed unit; # transfers due to falls to ER
(Mulvihill, 2009)
3. Rideaucrest Home
a. Falls Best Practice Champion (BPC) - dedicated time: 1 day/month and 4-5
“intense focus” days every few months (rotate between 4 projects)
b. Open house for residents and families
c. Chart review to obtain BMD results and/or meds for osteoporosis. If not, get
consent and NP orders BMD or starts Calcium or Vit D
d. Email reminders from BPC – bed in lowest position
e. HgbA1C monitoring for diabetic residents on oral meds, insulin – in order to
avoid hypoglycemic reactions causing falls
f. Falling leaf icon – magnetic – door frame – to identify high risk fallers
g. Fall Risk Assessment Tool – everyone who is admitted
h. Looking at Least Restraint Policy from RNAO for organization
i. Looking into Tai Chi group classes for residents
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j. Medication review
k. Hip protectors
l. Bed alarms
m. Chair alarms
n. Exercise – restorative care program: physiotherapy 3 x/week for all residents
o. Tracking: print-out of falls statistics from nursing clerk
p. Incident report sent to Falls BPC – reassessment done by Falls BPC and
Physiotherapist
(Thomas, 2009)
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9.0 References
Agostini, J.V., Baker, D.I., Bogardus, S.T. Chapter 26: Prevention of falls in hospitalized
and institutionalized older people. In: Shojania, K.G., Duncan, B.W., McDonald,
K.M., editors. Making health care safer: A critical analysis of patient safety practices.
Evidence report/technology assessment No. 43. Rockville, MD: Agency for
Healthcare Research and Quality; 2001. p. 281-99. Available at:
http://www.ahrq.gov/clinic/ptsafety/chap26a.htm
American Geriatrics Society, British Geriatrics Society, and American Academy of

Orthopaedic Surgeons Panel on Falls Prevention (2001). Guideline for the
Prevention of Falls in Older Persons. Journal of the American Geriatrics Society, 49,
5, p. 664-672.
Australian Council for Safety and Quality in Health Care (2005). Preventing falls and harm
from falls in older people; best practice guidelines for Australian hospitals and
residential aged care facilities. ACSQHC, 2005. Available at:
http://www.health.gov.au/internet/safety/publishing.nsf/content/1D340710CCBB1C4
0CA25744F001DE63E/$File/FP-Guide.PDF
Burland, M.J. (2008). An evaluation of a fall management program in a personal care home
population. Healthcare Quarterly, 11 (Sp), pp137-140.
Canadian Institute for Health Information (2009). Patient pathways; transfers from
continuing care to acute care. (Ottawa, Ont.: CIHI, 2009).
Canadian Institute for Health Information (2007). Resident safety: characteristics

associated with falling in Ontario complex continuing care. (CIHI Analysis in Brief,
February 2007). Available at:
http://ecomm.cihi.ca/ec/product.asp?dept_id=24&sku=RSCAWFIOENPDF
Canadian Institute for Health Information (2005). Resident assessment instrument (RAI)
MDS 2.0 and RAPs Canadian version; Users manual. 2nd Ed. CIHI, March, 2005.
Canadian Patient Safety Institute (2009). Safer health care now; National collaborative on
falls in long-term care falls resources. Available at:
http://www.saferhealthcarenow.ca/EN/Interventions/Falls/Pages/default.aspx
Centers for Disease Control and Prevention: Department of Health and Human Services.
(2008) Falls in nursing homes. Available at:
http://www.cdc.gov/ncipc/factsheets/nursing.htm
Central East Best Practice Guideline Initiative (2007). BPGs to the bedside; Actions for
personal support workers. Central East BPG, November 2007. Available at:
http://ltctoolkit.rnao.ca/sites/ltc/files/resources/falls/EducationResources/FactSheets
PamphletsPocketCardsLogos/Falls6_29.BPGsBedside.pdf
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Earthy, A. (2009). Journey of falls reduction and maximizing freedoms. Fraser Health;
Vancouver Coastal Health. Powerpoint presentation.
Earthy, A (2009). Personal communication with Anne Earthy, CNS Gerontology,

Vancouver Island Health Authority. July 30, 2009.
Fraser Health Authority (2007). Identification of fall risks and interventions for falls and
injury reduction – Clinical practice guideline (CPG); Residential complex care. FHA,
October 15, 2007.
Gallagher, E.M., Scott, V.J., Kozak, J.F., Johnson, S., & Brussoni, M. (2005) Stepping in:
Long-term care collaborative falls prevention project. Public Health Agency of
Canada, Final Report, Canada Health Agency, Population Health Fund, April 30,
2005.
Gillespie, S.M. & Friedman, S.M. (2007). Fear of falling in new long-term care enrollees. J
Am Med Dir Assoc. 8, 5, p307-313.
Hignett, S., & Masud, T. (2006). A review of environmental hazards associated with in-
patient falls. Ergonomics. 49, 5-6, p. 605-616.
Hill, K. (2009). Don’t lose sight of the importance of the individual in effective falls
prevention interventions. BMC Geriatrics, 9, 13. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675527/pdf/1471-2318-9-13.pdf
Krueger, P.D., Brazil, K., & Lohfeld, L.H. (2001). Risk factors for falls and injuries in a long-
term care facility in Ontario. Canadian Journal of Public Health, 92, 2, p117-120.
Lewis, S. (2009) Personal communication with Sharon Lewis, Osteoporosis Canada Area
Manager / Ontario Osteoporosis Strategy. July 16, 2009.
Magaziner, J., Miller, R., & Resnick, B. (2007) Intervening to prevent falls and fractures in
nursing homes: are we putting the cart before the horse? Journal of the American
Geriatrics Society, 55, 3, p. 464-466.
Mullen, L.A. (2009). Personal communication with Leigh-Ann Mullen, Pharmacist. October
19, 2009.
Mulvihill, M. (2009). Personal communication with Marian Mulvihill, RN Manager,

September 14, 2009.
National Center for Patient Safety (2004). NCPS 2004 falls toolkit. United States
Department of Veteran’s Affairs. Available at:
http://www4.va.gov/ncps/SafetyTopics/fallstoolkit/index.html
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Neyens, J.C.L, Dijcks, B.P.J., Twish, J. Schols, J.M.G.A., van Haastreght, J.C.M, van den
Heuvel, W.J.A, & de Witte, L.P. (2009). A multifactorial intervention for the
prevention of falls in psychogeriatric nursing home patients, a randomised controlled
trial (RCT). Age and Ageing, 38, 2, p.194-199. Available at:
http://ageing.oxfordjournals.org/cgi/content/full/38/2/194#R16
Norris, M.A., Walton, R.E., Patterson, C.J.S., Feightner, J.W. and the Canadian Task Force
on Preventive Health Care (2003). Prevention of falls in long-term care facilities:
Systematic review and recommendations. CTFPHC Technical Report June, 2003.
London, ON: Canadian Task Force. Available at:
http://www.ctfphc.org/Full_Text/CTF_FallsPrevn_TR_Jun03.pdf.
Ontario Health Quality Council (2009). Long-term care in Ontario; A report on quality.
Ontario Health Quality Council, May 2009. Available at: www.ohqc.ca
Ontario Osteoporosis Strategy for Long Term Care (2009). Osteoporosis falls and fracture
prevention for long-term care. PowerPoint presentation. Available at:
http://www.osteostrategy.on.ca/index.php/ci_id/6333/la_id/1.htm
Osteoporosis Canada (2009). Osteoporosis update; a practical guide for Canadian

physicians. Osteoporosis Canada, Winter 2009; vol. 13 no 1. Available at:
http://www.osteoporosis.ca/multimedia/local/files/health_professionals/pdfs/OU_wint
er09_EN.pdf
Public Health Agency of Canada: Division of Aging and Seniors. (2005). Report on Seniors
Falls in Canada. Ottawa: Minister of Public Works and Government Services
Canada. Available at: http://www.phac-aspc.gc.ca/seniors-aines/alt-
formats/pdf/publications/pro/injury-blessure/seniors_falls/seniors-falls_e.pdf
Ray, W., Taylor, J., Meador, K., Thapa, P., Brown, A., Kajihara, H., Davis, C., Gideon, P., &
Griffin, M. (1997). A randomized trial of a consultation service to reduce falls in
nursing homes. JAMA, 278, 7, p.557-562.
Registered Nurses Association of Ontario (2005). Prevention of Falls and Fall Injuries in the
Older Adult. Available at: http://www.rnao.org/Storage/12/617_BPG_Falls_rev05.pdf
Ruddock, B. (2004) Medications and falls in the elderly. Canadian Pharmaceutical Journal,
137, 6, p. 17-18.
Scott, V., Lockhart, S., Gallagher, E., Smith, D., Asselin, G., Belton, K. & Duncan, B.
(2007). Canadian Falls Prevention Curriculum (CFPC) Resource Manual. BC Injury
Research and Prevention Unit, Vancouver, BC.
Scott, V., Pearce, M., & Pengelly, C. (2005) Technical report: Hospitalizations due to falls
among Canadians age 65 and over living in residential care facilities. Public Health
Agency of Canada. Available at: http://www.phac-aspc.gc.ca/seniors-
aines/publications/pro/injury-blessure/falls-chutes/tech/residential-eng.php
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Seniors Health Research Transfer Network (2008). The SHRTN exchange. Seniors Health
Research Transfer Network, Issue 7, December 2008. Available at:
Social Care Institute for Excellence (2005). Preventing falls in care homes. Social Care
Institute for Excellence. Available at:
http://www.scie.org.uk/publications/briefings/briefing01/index.asp
Thomas, D. (2009). Personal communication with Dawn Thomas, Best Practice Champion,
Falls. September, 16 2009.
Tideiksaar, R. (2009) Fall prevention in institutions; extent of falling. Available at:

http://www.seekwellness.com/fallprevention/
Todd, C., Skelton, D. (2004). What are the main risk factors for falls among older people
and what are the most effective interventions to prevent these falls? World Health
Organization, Europe (Health Evidence Network Report). Available at:
http://www.euro.who.int/document/E82552.pdf
Toronto Falls Best Practice in Long-Term Care Initiative (2006). Policy and procedure; Falls
prevention and management. Available at:
http://rgp.toronto.on.ca/torontobestpractice/Policyprocedurefallspreventionmanagem
ent.pdf
Wagner, L. (2007). Falls in long-term care. Website. http://www.fallsinltc.ca
Wagner, L., & Mafrici, N. (2007). Resident falls; how staff and families can improve
communications. The Long-Term Care Magazine. Ontario Long-Term Care
Association, June/July, 2007.
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10.0 Resources
Alberta Centre for Active Living (2009): Preventing Falls Through Physical Activity; A
Guide for People Working with Older Adults:
http://www.centre4activeliving.ca/older-adults/rural/guides/guide-falls.html
Australian Council for Safety and Quality in Health Care (2009): Preventing falls and
harm from falls in older people; best practice guidelines for Australian hospitals and
residential aged care facilities:
http://www.health.gov.au/internet/safety/publishing.nsf/content/FallsGuidelines
Canadian Falls Prevention Curriculum (BC Injury and Research Prevention Unit):
http://www.injuryresearch.bc.ca/categorypages.aspx?catid=1&subcatid=7
Canadian Falls Prevention Curriculum E-learning course registration (University of

Victoria): http://www.continuingstudies.uvic.ca (click on "Health, Wellness and Safety")
College of Nurses of Ontario Practice Standard (2009): Restraints:

http://www.cno.org/docs/prac/41043_Restraints.pdf
Current perspectives in the Literature on Falls in Long-Term Care: J.W. Crane

Memorial Library: http://myuminfo.umanitoba.ca/Documents/694/falls.pdf
Falls in long-term care:

http://www.fallsinltc.ca
KFL&A Falls Prevention Coalition:

http://www.stepsafe.com/
National Center for Patient Safety Falls Toolkit 2004:

http://www4.va.gov/ncps/SafetyTopics/fallstoolkit/index.html
Northwest LHIN-wide Falls Prevention Coalition:

www.fallsprevention.ca
Ontario Health Quality Council:

www.ohqc.ca
Ontario Osteoporosis Strategy in Long-Term Care:

Osteoporosis Canada:
www.osteoporosis.ca
Public Health Agency of Canada: Division of Aging and Seniors:

http://www.phac-aspc.gc.ca/seniors-aines/index-eng.php
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Registered Nurses Association of Ontario: Best Practices in LTC Toolkit: Falls:
http://ltctoolkit.rnao.ca/resources/falls
Safer Healthcare Now! National Collaborative on Falls in Long-Term Care:

http://www.saferhealthcarenow.ca
Toronto Falls Best Practice in Long-Term Care Initiative (2006). Policy and procedure;
Falls prevention and management:
http://rgp.toronto.on.ca/torontobestpractice/Policyprocedurefallspreventionmanagement.pdf
Seniors Health Research Transfer Network:

www.shrtn.on.ca
Technology for Long-term Care:

www.techforltc.org
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in Long-Term Care
Section 11.0 Appendices 67

Fall Prevention
11.1 2002 Beers Criteria for Potentially Inappropriate Medication Use in Older 71
Adults: Independent of Diagnosis or Conditions
11.2 Risk factors for falls and fall-related injuries 75
11.3 Universal Fall Precautions: SAFE and Three Questions Before Exiting a 77
Resident’s Room
11.4 Common Medications and Substances Associated with Increased Falls in the 79
Elderly
11.5 RNAO Summary of Recommendations: Prevention of Falls and Fall Injuries in 81
the Older Adult
Fall Risk Assessment Tools & Hazard Checklists
11.6 Morse Fall Scale and Checklist for Residents Assessed Based on Level of Risk 89
11.7 Identification of Falls Risks and Intervention for Falls and Injury Reduction Tool 93
11.8 NPS Medication Review Form 97
11.9 General environmental checklist 99
11.10 Environmental Hazards Checklist 101
11.11 Equipment safety checklist 103
Post Fall Resources
11.12 Fraser Health Post Fall Flowchart 107

11.13 Fall Report 109
11.14 Post Fall Investigation 111
11.15 Post-Fall Assessment Tool 115
11.16 Notifying the Family That a Fall has Occurred 117
11.17 A Guide for Preventing Falls and Related Injuries 121

11.18 Footwear Guidelines 123
11.19 Safe shoe checklist 125
11.20 Hip Protectors; Always on your Side Info Sheet 127
Quality Improvement
11.21 Check sheet: Activities at Time of Fall 131
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in Long-Term Care
11.22 Check sheet: Factors Contributing to Falls 133
11.23 Check sheet: Location of Fall 135
11.24 Check sheet: Fall Injuries 137
11.25 Safer Healthcare Now National Falls Collaborative Indicators 139
11.26 Ontario Health Quality Council – LTC Quality Indicators for Public Reporting: 141
Falls
11.27 Monitoring Indicators NWLHIN Falls Prevention Project 143
11.28 Injury Severity Rating Scale 147
Medical Directives
11.29 Medical Directive: Bone Mineral Density 151

11.30 Medical Directive Template: Bisphosphonates 153
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Preventing Falls and Injuries in

Long-Term Care (LTC)
11.0 Appendices
11.1 – 11.5
Fall Prevention
11.1 2002 Beers Criteria for Potentially Inappropriate Medication Use
in Older Adults: Independent of Diagnosis or Conditions
11.2 Risk factors for falls and fall-related injuries
11.3 Universal Fall Precautions: SAFE and Three Questions Before
Exiting a Resident's Room
11.4 Common Medications and Substances Associated with Increased
Falls in the Elderly
11.5 RNAO Summary of Recommendations: Prevention of Falls and
Fall Injuries in the Older Adult
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2002 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults:
Independent of Diagnosis or Conditions
Drug Concern Severity
Rating
(High or
Low)
Propoxyphene (Darvon) and combination Offers few analgesic advantages over acetaminophen, yet has the adverse Low
products (Darvon with ASA, Darvon-N, and effects of other narcotic drugs.
Darvocet-N)
Indomethacin (Indocin and Indocin SR) Of all available nonsteroidal anti-inflammatory drugs, this drug produces High
the most CNS adverse effects.
Pentazocine (Talwin) Narcotic analgesic that causes more CNS adverse effects, including confusion High
and hallucinations, more commonly than other narcotic drugs. Additionally, it is a
mixed agonist and antagonist.
Trimethobenzamide (Tigan) One of the least effective antiemetic drugs, yet it can cause extrapyramidal High
adverse effects.
Muscle relaxants and antispasmodics: Most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly High
methocarbamol (Robaxin), carisoprodol patients, since these cause anticholinergic adverse effects, sedation, and
(Soma), chlorzoxazone (Paraflex), weakness. Additionally, their effectiveness at doses tolerated by elderly patients
metaxalone (Skelaxin), cyclobenzaprine is questionable.
(Flexeril), and oxybutynin (Ditropan). Do not
consider the extended-release Ditropan XL.
Flurazepam (Dalmane) This benzodiazepine hypnotic has an extremely long half-life in elderly High
patients (often days), producing prolonged sedation and increasing the
incidence of falls and fracture. Medium- or short-acting
benzodiazepines are preferable.
Amitriptyline (Elavil), chlordiazepoxide- Because of its strong anticholinergic and sedation properties, amitriptyline High
amitriptyline (Limbitrol), and perphenazine- is rarely the antidepressant of choice for elderly patients.
amitriptyline (Triavil)
Doxepin (Sinequan) Because of its strong anticholinergic and sedating properties, doxepin is rarely High
the antidepressant of choice for elderly patients.
Fick, D.M., Cooper, J.W., Wade, W.E., Waller, J.L., MacLean, R. and Beers, M.H. (2003). Updating the Beers criteria for potentially inappropriate
medication use in older adults. Archives of Internal Medicine, 163(8/22), 2716-2724.
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Meprobamate (Miltown and Equanil) This is a highly addictive and sedating anxiolytic. Those using meprobamate for High
prolonged periods may become addicted and may need to be withdrawn slowly.
Doses of short-acting benzodiazepines: doses Because of increased sensitivity to benzoadiazepines in elderly patients, smaller High
greater than lorazepam (Ativan), 3 mg; doses may be effective as well as safer. Total daily doses should rarely exceed
oxazepam (Serax), 60 mg; alprazolam (Xanax), the suggested maximums.
2 mg; temazepam (Restoril), 15 mg; and
triazolam (Halcion), 0.25 mg
Long-acting benzodiazepines: These drugs have a long half-life in elderly patients (often several days), High
chlordiazepoxide (Librium), producing prolonged sedation and increasing the risk of falls and fractures.
chlordiazepoxide-amitriptyline (Limbitrol) Short- and intermediate-acting benzodiazepines are preferred if a
clidinium-chlordiazepoxide (Librax), diazepam benzodiazepine is required.
(Valium), quazepam (Doral), halazepam
(Paxipam), and chlorazepate (Tranxene)
Disopyramide (Norpace and Norpace CR) Of all antiarrhythmic drugs, this is the most potent negative inotrope and High
therefore may induce heart failure in elderly patients. It is also strongly
anticholinergic. Other antiarrhythmic drugs should be used.
Digoxin (Lanoxin) (should not exceed _0.125 Decreased renal clearance may lead to increased risk of toxic effects. Low Low
mg/d except when treating atrial arrhythmias) Short-acting dipyridamole (Persantine). Do not consider the long-acting
dipyridamole (which has better properties than the short-acting in older adults)
except with patients with artificial heart valves. May cause orthostatic
hypotension.
Methyldopa (Aldomet) and methyldopa- May cause bradycardia and exacerbate depression in elderly patients. High
hydrochlorothiazide
(Aldoril)
Reserpine at doses _0.25 mg May induce depression, impotence, sedation, and orthostatic hypotension. Low
Chlorpropamide (Diabinese) It has a prolonged half-life in elderly patients and could cause prolonged High
hypoglycemia. Additionally, it is the only oral hypoglycemic agent that causes
SIADH.
Gastrointestinal antispasmodic drugs: GI antispasmodic drugs are highly anticholinergic and have uncertain High
dicyclomine (Bentyl), hyoscyamine (Levsin and effectiveness. These drugs should be avoided (especially for long-term use).
Levsinex), propantheline (Pro-Banthine),
Page 2 of 4
belladonna alkaloids (Donnatal and others),
and clidinium-chlordiazepoxide (Librax)
Anticholinergics and antihistamines: All nonprescription and many prescription antihistamines may have potent High
chlorpheniramine (Chlor-Trimeton), anticholinergic properties. Nonanticholinergic antihistamines are preferred in
diphenhydramine (Benadryl), hydroxyzine elderly patients when treating allergic reactions.
(Vistaril and Atarax), cyproheptadine
(Periactin), promethazine (Phenergan),
tripelennamine, dexchlorpheniramine
(Polaramine)
Diphenhydramine (Benadryl) May cause confusion and sedation. Should not be used as a hypnotic, and when High
used to treat emergency allergic reactions, it should be used in the smallest
possible dose.
Ergot mesyloids (Hydergine) and cyclandelate Have not been shown to be effective in the doses studied. Low Low
(Cyclospasmol) Ferrous sulfate _325 mg/d Doses _325 mg/d do not dramatically increase the
amount absorbed but greatly increase the incidence of constipation.
All barbiturates (except phenobarbital) except Are highly addictive and cause more adverse effects than most sedative or High
when used to control seizures hypnotic drugs in elderly patients.
Meperidine (Demerol) Not an effective oral analgesic in doses commonly used. May cause confusion High
and has many disadvantages to other narcotic drugs.
Ticlopidine (Ticlid) Has been shown to be no better than aspirin in preventing clotting and may be High
considerably more toxic. Safer, more effective alternatives exist.
Ketorolac (Toradol) Immediate and long-term use should be avoided in older persons, since High
a significant number have asymptomatic GI pathologic conditions.
Amphetamines and anorexic agents These drugs have potential for causing dependence, hypertension, angina, and High
myocardial infarction.
Long-term use of full-dosage, longer half-life, Have the potential to produce GI bleeding, renal failure, high blood pressure, and High
non–COX-selective NSAIDs: naproxen heart failure.
(Naprosyn, Avaprox, and Aleve), oxaprozin
(Daypro), and piroxicam (Feldene)
Daily fluoxetine (Prozac) Long half-life of drug and risk of producing excessive CNS stimulation, sleep High
disturbances, and increasing agitation. Safer alternatives exist.
Long-term use of stimulant laxatives: bisacodyl May exacerbate bowel dysfunction. High
(Dulcolax), cascara sagrada, and Neoloid
except in the presence of opiate analgesic use
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Amiodarone (Cordarone) Associated with QT interval problems and risk of provoking torsades de pointes. High
Lack of efficacy in older adults.
Orphenadrine (Norflex) Causes more sedation and anticholinergic adverse effects than safer High
alternatives.
Guanethidine (Ismelin) May cause orthostatic hypotension. Safer alternatives exist. High
Guanadrel (Hylorel) May cause orthostatic hypotension. High
Cyclandelate (Cyclospasmol) Lack of efficacy. Low
Isoxsurpine (Vasodilan) Lack of efficacy. Low
Nitrofurantoin (Macrodantin) Potential for renal impairment. Safer alternatives available. High
Doxazosin (Cardura) Potential for hypotension, dry mouth, and urinary problems. Low
Methyltestosterone (Android, Virilon, and Potential for prostatic hypertrophy and cardiac problems. High
Testrad)
Thioridazine (Mellaril) Greater potential for CNS and extrapyramidal adverse effects. High
Mesoridazine (Serentil) CNS and extrapyramidal adverse effects. High
Short acting nifedipine (Procardia and Adalat) Potential for hypotension and constipation. High
Clonidine (Catapres) Potential for orthostatic hypotension and CNS adverse effects. Low
Mineral oil Potential for aspiration and adverse effects. Safer alternatives available. High
Cimetidine (Tagamet) CNS adverse effects including confusion. Low
Ethacrynic acid (Edecrin) Potential for hypertension and fluid imbalances. Safer alternatives available. Low
Desiccated thyroid Concerns about cardiac effects. Safer alternatives available. High
Amphetamines (excluding methylphenidate CNS stimulant adverse effects. High
hydrochloride and anorexics)
Estrogens only (oral) Evidence of the carcinogenic (breast and endometrial cancer) potential Low
of these agents and lack of cardioprotective effect in older women.
Page 4 of 4
Appendix A Risk factors for falls and
fall-related injuries
Biological / Medical Behavioural

■ Advanced age ■ Multiple medications
■ Female gender ■ Use of:
■ Chronic illness/disability: -Tranquillizers
-Stroke -Antidepressants
-Parkinson’s disease -Antihypertensives
-Heart disease ■ Excessive alcohol
-Incontinence/frequency ■ Risk-taking behaviour
-Depression ■ Lack of exercise
■ Acute illness ■ Previous fall/recurrent falls
■ Cognitive impairment ■ Fear of falling
■ Gait disorders ■ Inappropriate footwear
■ Poor balance ■ Lack, inappropriate use or improper use
■ Postural sway of mobility aids
■ Muscle weakness ■ Poor nutrition or hydration
■ Poor vision
■ Impaired touch and/or proprioception
Social / Economic
■ Low income
Environmental ■ Lack of education
■ Poor building design and/or ■ Illiteracy/language barriers
maintenance ■ Poor living conditions
■ Inadequate building codes ■ Unsafe housing
■ Poor stair design ■ Poor social environment
■ Lack of: ■ Living alone
-Handrails ■ Lack of support networks and social
-Curb ramps interaction
-Rest areas
-Grab bars
■ Poor lighting or sharp contrasts
■ Slippery or uneven surfaces
■ Obstacles and tripping hazards
■ Assistive devices
Adapted by V. Scott (2005) from: Federal/Provincial/Territorial inventory of Canadian programs for the prevention of
falls among seniors living in the community, 2001.
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Universal Fall Precautions
The following constitute the minimum level of care to prevent falls in older adults. The
corresponding acronym is “SAFE”
S
Safe Environment
At least one bedrail down unless assessed otherwise
Clutter-free pathways
Bed brakes applied
Adequate lighting
A
Assist with Mobility
Safe and regular toileting
Documented transfer and mobility status
Mobility aid within resident’s reach
F
Fall Risk Reduction
Call bell within reach
Bed in lowest position for resident’s need
Personal items within reach
Proper footwear in use
E
Engage Resident and Family
Discuss fall risk factors
Communicate mutual plan
Three Questions Before Exiting a Resident’s Room:
1. Do you need to use the toilet?

2. Do you have any pain or discomfort?
3. Do you need anything before I leave?
Asking these simple questions can:
 Decrease the chance of a fall

 Decrease the use of the call bell
 Increase resident satisfaction
Adapted from: Fraser Health Authority / Vancouver Island Health Authority (2009)
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Common Medications and Substances Associated with
Increased Falls in the Elderly
Psychotropics
Very high risk – especially benzodiazepines
Antidepressants Benzodiazepines Antipsychotics

Citalopram (Celexa) Long-acting: Atypical:
Fluoxetine (Prozac) Chlordiazepoxide (Librium) Clozapine (Clozaril)
Fluvoxamine (Luvox) Clonazepam (Rivotril) Olanzapine (Zyprexa)
Paroxetine (Paxil) Diazepam (Valium) Quetiapine (Seroquel)
Sertraline (Zoloft) Flurazepam (Dalmane) Neuroleptics:
Venlafaxine (Effexor) Intermediate-acting: Chlorpromazine (Largactil)
Amitriptyline (Elavil) Alprazolam (Xanax) Haloperidol (Haldol)
Bupropion (Wellbutrin) Lorazepam (Ativan) Hydroxyzine (Atarax)
Clomipramine (Anafranil) Nitrazepam (Mogadon) Lithium
Desipramine (Norpramin) Oxazepam (Serax) Loxapine (Loxapac)
Doxepin (Sinequan) Temazepam (Restoril) Methotrimeprazine (Nozinan)
Imipramine (Tofranil) Short-acting: Perphenazine (Trilafon)
Mirtazapine (Remeron) Triazolam (Halcion) Prochlorperazine (Stemetil)
Moclobemide (Manerix) Midazolam (Versed) Risperidone (Risperdal)
Nortriptyline (Aventyl) Thioridazine (Mellaril)
Trazodone (Desyrel) Trifluoperazine (Stelazine)
Anticonvulsants Antihistamines/Antinauseants Alzheimer’s Drugs
Carbamazepine (Tegretol) Dimenhydrinate (Gravol) Donepezil (Aricept)
Gabapentin (Neurontin) Diphenhydramine (Benadryl) Galantamine (Reminyl)
Lamotrigine (Lamictal) Meclizine (Bonamine) Rivastigmine (Exelon)
Phenobarbital Metoclopramide (Maxeran)
Phenytoin (Dilantin) Prochlorperazine (Stemetil)
Topiramate (Topamax) Promethazine (Phenergan)
Valproate (Depakene) Scopolamine patch (Transderm-V)
Vigabatrin (Sabril)
Antiparkinsonian Agents
Risk of postural hypertension increases when used with antihypertensives
Amantadine (Symmetrel) Levodopa/Benserazide (Prolopa) Pramipexole (Mirapex)
Bromocriptine (Parlodel) Levodopa/Carbidopa (Sinemet) Selegiline (Eldepryl)
Entacapone (Comtan) Pergolide (Permax)
Alcohol
The most commonly used substance by seniors
The best practice when taking medications is to abstain. Liquid medications may contain ethanol
There is no such thing as a trivial fall – the next one might be devastating.
Adapted from Niagara Health System Falls Prevention Program, Regional Niagara Public Health Department (2004).
Original Concept from Baycrest Centre for Geriatric Care Fall Risk Assessment (1996).
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Common Medications and Substances Associated with
Increased Falls in the Elderly
Antihypertensives
Angiotensin II Receptor Beta Blockers Diuretics
Antagonists
Candesartan (Atacand) Acebutalol (Sectral) Amiloride/HCTZ (Moduret)
Eprosartan (Teveten) Atenolol (Tenormin) Furosemide (Lasix)
Irbesartan (Avapro) Bisoprolol (Monocor) Hydrochlorothiazide
Losartan (Cozaar) Carvedilol (Coreg) Triamterene/HCTZ
Telmisartan (Micardis) Labetalol (Trandate)
Valsartan (Diovan) Metoprolol (Lopressor)
Propranolol (Inderal)
Sotalol (Sotacor)
Timolol (Blocadren)
ACE Inhibitors Calcium Channel Blockers Vasodilators
Benazepril (Lotensin) Amlodipine (Norvasc) Isosorbide (Isordil)
Captopril (Capoten) Diltiazem (Cardizem) Hydralazine (Apresoline)
Perindopril (Coversyl) Felodipine (Plendil) Nitroglycerine (Nitro-Dur)
Cilazapril (Inhibace) Nifedipine (Adalat) Terazosin (Hytrin)
Ramipril (Altace) Verapamil (Isoptin)
Lisinopril (Prinivil, Zestril)
Quinapril (Accupril)
Fosinopril (Monopril)
Narcotics
Acetaminophen-Codeine-Caffeine (Tylenol 1/2/3) Meperidine (Demerol)
Codeine Morphine (MOS, MS Contin, M-Eslon)
Fentanyl Oxycodone (Percocet/Percodan, OxyContin)
Hydromorphone (Dilaudid, Hydromorph Contin) Pentazocine (Talwin)
Over the Counter

OTCs may contain medications identified in this resource. Medications with line-extensions, e.g.
(Tylenol-Cold) contain more than one substance.
Allergy medications Cold remedies Muscle relaxants Some herbal and
Antinauseants Cough preparations Painkillers alternative remedies
Sleeping pills
There is no such thing as a trivial fall – the next one might be devastating.
Adapted from Niagara Health System Falls Prevention Program, Regional Niagara Public Health Department (2004).
Original Concept from Baycrest Centre for Geriatric Care Fall Risk Assessment (1996).
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Prevention of Falls and Fall Injuries in the Older Adult
Summary of Recommendations
General Principles:
1. The client’s perspective, individual desires and needs are central to the application of the guideline.
2. The over-arching principle that guides the intervention choices is the principle of maintaining the
highest quality of life possible while striving for a safe environment and practices. Risk taking, autonomy,
and self-determination are supported, respected, and considered in the plan of interventions.
3. Individuals, their significant other(s) and the care team engage in assessment and interventions through
a collaborative process.
RECOMMENDATION *LEVEL OF +GRADE

OF
EVIDENCE RECOMMENDATION
Practice Recommendations
Assessment 1.0 Assess fall risk on admission. Ib B
1.1 Assess fall risk after a fall. Ib B
Intervention
Tai Chi 2.0 Tai Chi to prevent falls in the elderly is recommended Ib B
for those clients whose length of stay (LOS) is greater
than four months and for those clients with no history
of a fall fracture. There is insufficient evidence to
recommend Tai Chi to prevent falls for clients with
LOS less than four months.
Exercise 2.1 Nurses can use strength training as a component Ib I

of multi-factorial fall interventions; however, there
is insufficient evidence to recommend it as a
stand-alone intervention.
Multi-factorial 2.2 Nurses, as part of the multidisciplinary team, Ia B

implement multi-factorial fall prevention
interventions to prevent future falls.
Medications 2.3 Nurses, in consultation with the health care team, IIb B
conduct periodic medication reviews to prevent falls
among the elderly in health care settings. Clients taking
benzodiazepines, tricyclic antidepressants, selective
serotonin-reuptake inhibitors, trazodone, or more than
five medications should be identified as high risk.
There is fair evidence that medication review be
conducted periodically throughout the institutional stay.
Hip Protectors 2.4 Nurses could consider the use of hip protectors to Ib B
reduce hip fractures among those clients considered
at high risk of fractures associated with falls;
however, there is no evidence to support universal
use of hip protectors among the elderly in health
care settings.
* For a discussion of Levels of Evidence see p. 11.
+ For a discussion of Grades of Recommendation see p. 12.
8
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Nursing Best Practice Guideline

OF
Vitamin D 2.5 Nurses provide clients with information on the IV

benefits of vitamin D supplementation in relation
to reducing fall risk. In addition, information on
dietary, life style, and treatment choice for the
prevention of osteoporosis is relevant in relation
to reducing the risk of fracture.
Client Education 2.6 All clients who have been assessed as high risk for IV
falling receive education regarding their risk of falling.
Environment 3.0 Nurses include environmental modifications as a Ib

component of fall prevention strategies.
Education Recommendations
Nursing Education 4.0 Education on the prevention of falls and fall injuries IV
should be included in nursing curricula and on-going
education with specific attention to:
■ Promoting safe mobility;
■ Risk assessment;
■ Multidisciplinary strategies;
■ Risk management including post-fall follow-up; and
■ Alternatives to restraints and/or other restricted devices.
Organization & Policy Recommendations

Least Restraint 5.0 Nurses should not use side rails for the prevention III I
of falls or recurrent falls for clients receiving care in
health care facilities; however, other client factors
may influence decision-making around the use of
side rails.
6.0 Organizations establish a corporate policy for IV

least restraint that includes components of physical
and chemical restraints.
Organizational Support 7.0 Organizations create an environment that supports IV

interventions for fall prevention that includes:
■ Fall prevention programs;
■ Staff education;
■ Clinical consultation for risk assessment
and intervention;
■ Involvement of multidisciplinary teams in case
management; and
■ Availability of supplies and equipment such
as transfer devices, high low beds, and bed
exit alarms.
9
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OF
Medication Review 8.0 Implement processes to effectively manage IV

polypharmacy and psychotropic medications
including regular medication reviews and
exploration of alternatives to psychotropic
medication for sedation.
RNAO Toolkit 9.0 Nursing best practice guidelines can be successfully IV

implemented only where there are adequate
planning, resources, organizational and administrative
support, as well as appropriate facilitation.
Organizations may wish to develop a plan for
implementation that includes:
■ An assessment of organizational readiness and
barriers to education.
■ Involvement of all members (whether in a direct
or indirect supportive function) who will contribute
to the implementation process.
■ Dedication of a qualified individual to provide
the support needed for the education and
implementation process.
■ Ongoing opportunities for discussion and
education to reinforce the importance of
best practices.
■ Opportunities for reflection on personal
and organizational experience in implementing
guidelines.
In this regard, RNAO (through a panel of nurses,
researchers and administrators) has developed the
Toolkit: Implementation of Clinical Practice Guidelines
based on available evidence, theoretical perspectives
and consensus. The Toolkit is recommended for
guiding the implementation of the RNAO guideline
Prevention of Falls and Fall Injuries in the Older Adult.
10
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Nursing Best Practice Guideline
Interpretation of Evidence
Levels of Evidence
This RNAO guideline is based on scientific evidence related to prevention of falls and fall-related injuries
among the elderly in health care settings. To this end, a literature review of relevant studies was conducted.
Where available, studies characterized by good methodologic quality and rigorous scientific design such as
systematic reviews, meta-analyses and randomized controlled trials (RCT) were identified as the goal for
inclusion within the guideline. Where high quality studies were unlikely to be found due to the nature of
the intervention of interest such as risk screening, other levels of evidence were considered including
cohort and case-control studies. The following evidence rating taxonomy provides the definitions of the
levels of evidence and the rating system used in this document. All studies included in the literature review
in support of this guideline were assigned a level of evidence in accordance with the classification system
outlined in Table 1.
Table 1: Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials.
Ib Evidence obtained from at least one randomized controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomization.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as

comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of
respected authorities.
11
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Grades of Recommendation
In addition to levels of evidence, recommendations generated as a result of the literature review were also
assigned a grade. The grade associated with each recommendation reflects the strength of the evidence
supporting it as well as the direction of the effect. For example, if a large body of literature of good
methodological quality and design suggests the effectiveness of a given therapeutic intervention, it is likely
the resultant recommendation would receive an “A” grade, meaning there is good evidence to include the
intervention. The grade of recommendation classification system has been adopted from the Canadian
Task Force on Preventive Health Care (CTFPHC, 1997). See Table 2.
Table 2: Grades of Recommendation
A There is good evidence to recommend the clinical preventive action.
B There is fair evidence to recommend the clinical preventive action.
C The existing evidence is conflicting and does not allow making a recommendation for or against
use of the clinical preventive action; however other factors may influence decision-making.
D There is fair evidence to recommend against the clinical preventive action.
E There is good evidence to recommend against the clinical preventive action.
I There is insufficient evidence (in quantity and/or quality) to make a recommendation, however
other factors may influence decision-making.
Reference: Canadian Task Force on Preventative Health Care (CTFPHC). (1997). Quick tables by strength of evidence.
Available: http://www.ctfphc.org
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11.0 Appendices
11.6 – 11.11
Fall Risk Assessment Tools & Hazard
Checklists
11.6 Morse Fall Scale and Checklist for Residents Assessed
Based on Level of Risk
11.7 Identification of Falls Risks and Intervention for Falls
and Injury Reduction Tool
11.8 NPS Medication Review Form
11.9 General environmental checklist
11.10 Environmental Hazards Checklist
11.11 Equipment safety checklist
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APPENDIX A: Morse Fall Scale
Fall Risk is based upon Fall Risk Factors and it is more than a Total Score. Determine Fall Risk Factors
and Target Interventions to Reduce Risks. Complete on admission, at change of condition, transfer to a
new unit, and after a fall.
Variables Score Admission Review Review

Date Date Date
History of No 0
Falling Yes 25
Secondary No 0
Diagnosis Yes 15
Ambulatory None/bedrest/nurse assist 0

Aid
Crutches/cane/walker 15
Furniture 30
IV or IV No 0
access Yes 20
Gait Normal/bedrest/wheelchair 0
Weak 10
Impaired 20
Mental Knows own limits 0

Status
Overestimates or forgets limits 15
Total
Signature & Status
To obtain the Morse Fall Score add the score from each category.
Morse Fall Score
High Risk 45 and higher
Moderate Risk 25-44
Low Risk 0-24
Note: Complete checklist for resident assessed based on level of risk (See Appendix B).
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APPENDIX B: Checklist for Residents Assessed Based on Level of Risk
*Care Plan Indicate Referrals Made to an

Initiated/ Interdisciplinary Team Member
Updated
Yes No
Low/Moderate Has the resident been oriented to the unit/ward,
Falls Rate room and mechanisms for assistance, e.g., call bell?
Ƒ Yes Ƒ No
Is the resident using visual and/or hearing aides?
Do they need reviewing? Ƒ Yes Ƒ No
Is the resident’s environment uncluttered?
Is the resident’s bed at the correct height?
Ƒ Yes Ƒ No
Have the resident and family/visitors been given
basic information on safety and risks
(verbal/written)? Ƒ Yes Ƒ No
Are the resident’s medications appropriate?
Ƒ Yes Ƒ No
Is the resident’s footwear safe? (Refer to Appendix
C for footwear guidelines.) Ƒ Yes Ƒ No
Are mobility aids appropriate and accessible?
Ƒ Yes Ƒ No
Is there appropriate supervision of resident when
transferring/walking? Ƒ Yes Ƒ No
Are regular toilet times scheduled for the resident?
Ƒ Yes Ƒ No
High Falls Communicate falls risk to all staff (verbal and

Rate written) Ƒ Yes Ƒ No
Staff education conducted Ƒ Yes Ƒ No
Conduct environmental rounds Ƒ Yes Ƒ No
Has the resident been oriented to unit/ward, room

and mechanisms for assistance, e.g., call bell?
Ƒ Yes Ƒ No
Is the resident using visual and/or hearing aides?
Do they need reviewing? Ƒ Yes Ƒ No
Have the resident and family/visitors been given
basic information on safety and risks
(verbal/written)? Ƒ Yes Ƒ No
Is the resident’s footwear safe? (Refer to Appendix
C for footwear guidelines.) Ƒ Yes Ƒ No
Is the resident’s dietary intake appropriate?
Ƒ Yes Ƒ No
Review the need for hip protector and application.
Ƒ Yes Ƒ No
Review the need for bedrail use. Ƒ Yes Ƒ No
Are the resident’s mobility aids appropriate and

accessible? Ƒ Yes Ƒ No
Does the resident require assistance or supervision
when transferring/walking? Ƒ Yes Ƒ No
Is the resident involved in an exercise program?
Ƒ Yes Ƒ No
Does the resident have incontinence problems?
Ƒ Yes Ƒ No
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*Follow Interventions/Strategies to Reduce Risks for Falls and including the following:
Safety Factors
• Maintain bed in low position, bed alarm when needed
• Call bell, urinal and water within reach. Offer assistance with elimination routinely.
• Buddy system
• Wrist band identification
• Ambulate with assistance
• Do not leave unattended for transfers/toileting
• Encourage resident to wear non-skid slippers or own shoes
• Lock bed, wheelchairs, stretchers, and commodes
Assessment
• Assess resident’s ability to comprehend and follow instructions
• Assess resident’s knowledge for proper use of adaptive devices
• Need for siderails: up or down
• Hydration: monitor for orthostatic changes
• Review meds for potential fall risk
• Evaluate treatment of pain
Family/Resident Education
• PT consult for gait techniques
• Family involvement with confused residents
• Sitters
• Instruct residents/families for assistance with out-of-bed activities
• Exercise, nutrition
Environment
• Room close to nurses’ station
• Orient surroundings, reinforce as needed
• Room clear of clutter
• Adequate lighting
• Consider the use of technology (non-skid floor mats, raised edge mattresses)
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APPENDIX B
GUIDELINE FOR USE OF IDENTIFICATION OF FALL RISKS AND

INTERVENTION FOR FALLS AND INJURY REDUCTION TOOL
Identification of Fall Risks and Intervention
for Falls and Injury Reduction Tool
When to complete the tool:

x On admission, every resident is assessed for fall risks by reviewing the health records for a
history of falls and fall risks.
x If fall risk identified as a focus of care, the Identification of Fall Risks and Intervention for
Fall and Injury Reduction Tool will be initiated and completed within the first 2 weeks of
admission.
x In addition, when there is a change of condition, any fall incident and before Care
Conference, the Identification of Fall Risks and Intervention for Fall and Injury Reduction
Too will be initiated and completed.
How to complete the tool:

x Identification of Fall Risks and Intervention for Fall and Injury Reduction Too is used to
assess Fall Risks by asking the Assessment Questions. Then follow the instructions below –
If Yes or No, implement the Interventions.
x Results of the Identification of Fall Risks and Intervention for Fall and Injury Reduction Tool
will be summarized on the Interdisciplinary Progress Record.
Re-assess resident with falls at least quarterly or when a fall incident occurs.
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Patient Data
APPENDIX B- IDENTIFICATION OF FALLS RISKS AND INTERVENTION FOR
FALLS AND INJURY REDUCTION TOOL
Bar Code Area
Date: ___/___/____ Signature: _______________________
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Bar Code Area
ADDI000001A Rev: Oct. 31/07 Page: 1 of 2
Risk Factors (5.3) Assessment Questions- indicate intervention to be Client-Centered Interventions

RAI-MDS section implemented
History of Falls Did client have a fall in the last 6 months? No Yes Develop Care Plan to support client’s routines and preferences, yet provide measures to
Section J4 reduce falls with consideration to the identified fall risk
If YES, implement interventions ___________________________________________________________
Impaired balance, Is client having difficulty walking from bed to the toilet? No Yes Refer PT/OT for consultation
mobility, muscle Is client having difficulty walking from bedroom -dining No Yes
weakness, co- room?
Promote walking program, if appropriate
ordination e.g. use Does client need supervision or help when transferring? No Yes Ensure non-pharmacological and appropriate pharmacological pain interventions to reach
of mobility aid the client’s desired comfort level (FH, 2006)
Section G/ J2 & 3 If any above is YES, implement interventions _________________________________________
Impaired safety Does client understand why he/she has fallen? No Yes Instruct and demonstrate to client and family how to call for assistance
awareness – lack of Does client understand his/her limitations? No Yes
insight/judgment Is client willing and/or able to ask for assistance? No Yes
Implement alternatives to Least Restraint measures appropriate for the client, e.g. which rail
to be in the lowest position, height of bed, exit system to be in place, drop mat(FH , 2007a)
Risk taking behavior Does client follow instructions? No Yes
Section B _____________________________________________
Section C If any above is NO, implement interventions
Cognitive impairment Is client’s MMSE score above 15 or CPS above 3 No Yes Review Behaviour Pattern Record to implement interventions (FH 2007b)
Section B Is client able to use the follow items safely?
Section C call bells toilet wheelchair walker No Yes
Develop Care Plan to support client’s routines and preferences, yet provide measures to
reduce falls with consideration to the identified fall risk
Section G Is client able to dress / toilet safely? No Yes
Is client able to make his / her needs known? No Yes Utilize bed/chair check, movement alarm, client wandering system, or motion detector
when appropriate and available
If any of the above is NO, implement interventions ______________________________________________________
Agitation and Is client easily frustrated? No Yes Review Behaviour Pattern Record to implement interventions (FH, 2007b)
restlessness Does client pace? No Yes
Section E Is there a change in behaviour? No Yes
Decrease environmental stimuli and provide quiet times during the day
If any above is YES, implement interventions _________________________________________________________
Sleep disturbance Is client getting enough sleep? No Yes Review Sleep Pattern Record (Appendix F) & implement sleep promotion measures
Section E1 If NO, implement interventions _____________________________________________________________
Syncope and Is there a difference in blood pressure – lying and standing of No Yes Educate client when appropriate on how best to transfer and change position
dizziness 20 mmHg or more in the systolic?
Section J1
Review orthostatic hypotension, hypertension, dehydration and vestibular problems
Refer to Pharmacist, Physician & other members of the interdisciplinary team
If YES, implement interventions __________________________________________
Use of restraints Is a restraint used? No Yes Implement alternatives to Least Restraint measures appropriate for the client, e.g. which rail
Section P4 Which bed rail is down: Right ______ Left ________ to be in the lowest position, height of bed, exit system to be in place, drop mat (FH, 2007a)
If YES, implement interventions ___________________________________________
APPENDIX B- IDENTIFICATION OF FALLS RISKS AND INTERVENTION
FOR FALLS AND INJURY REDUCTION TOOL Patient’s name
Patient’s unit number

Page: 2 of 2
Risk Factors (5.3) Assessment Questions - indicate intervention to be Client-Centered Interventions

RAI-MDS section implemented
Fear of falling Is client afraid of walking and falling? No Yes Assess for style and size of hip protector. Encourage use of hip protectors.
Does client want to walk? No Yes
Is client restricted in activity? No Yes
Ensure appropriate mobility device – correct height and in working order, especially
brakes
If any above is YES, implement interventions
Promote walking program, if appropriate
____________________________________________________
Medication – Is client taking a medication that may have a side effect of Ensure medications are appropriate - dosage and medication form are easily taken
dosage/ recent dizziness or loss of balance? No Yes
Consult with Pharmacist or Physician
changes Any recent change of medication or health status? No Yes
Section O and P If any above is YES, implement interventions ____________________________________________________
Dehydration/ Is client drinking less than1500cc of fluid per day? No Yes Promote at least 1500cc’s of fluid per day
Malnourishment If YES, implement intervention Consult the Pharmacist or Dietician on supplements (Vit. D etc.)
Section K, J and I
Bladder/Bowel – Does client have a history of urinary tract infections No Yes Review Voiding Record/Bowel Record to establish regular bladder/bowel routine, if
urgency & frequency Does client frequently want to go to bathroom? No Yes possible have client sit on toilet
Section H Does client have difficulty initiate a void? No Yes
Section I2 Is client on diuretic medication? No Yes
Ensure the client is able to safely toilet self or have care team follow routine
Does client have irregular bowel elimination? No Yes Promote a healthy diet with increased protein and fiber
If any above is YES, implement interventions _____________________________________________________
Poor proprioception Is client’s depth perception accurate? No Yes Modify living environment to accommodate the client’s abilities and likes
and tactile sensation Is client aware of objects in his/her environment? No Yes
e.g. feet Is client aware of where his / her feet are? No Yes
______________________________________________________
If any above is NO, implement interventions
Hearing/visual Is client able to hear normal conversation? No Yes Encourage use of hearing aids, if applicable. Ensure batteries are working
impairment Is client able to see objects in the bedroom / bathroom? No Yes
Section C and D
Encourage the use of clean glasses with current prescription
If any above is NO, implement interventions Improve lighting in the room, according to the client’s need, e.g. motion sensitive lighting
Inappropriate use or Is the mobility aid appropriate? No Yes Ensure appropriate mobility device – correct height and in working order, e.g. brakes
type of mobility Is the mobility aid working properly? No Yes
aid/wheelchair Is client able to operate the mobility aid safely? No Yes
Refer to Physiotherapist/Occupational Therapist for consultation
If any above is NO, implement interventions _________________________________________________________
Footwear – improper Does client have improper fitting shoes? No Yes Socks and shoes in correct size, secure, easy to apply e.g. velcro straps & non-slip sole
fit and slippery sole Does client get up at night without shoes/non-slip socks? No Yes
Non-slip socks may be worn in bed if client is at risk for getting up on his own
If any above is YES, implement interventions
Physical environment Is the pathway clutter free for client to walk? No Yes Modify living environment to accommodate the client’s abilities and likes
- uncomfortable and (door to bed and bed to bathroom)
At least one bottom rail is to be down so the client may get out of bed safely. Upper side
unsafe for the client Is the pathway from bed to bathroom well lit? No Yes
rail on the same side left up for support,
Can client get off the bed or toilet safely? No Yes
Is the pathway from bedroom to dining room clutter free? No Yes Provide non-slip, beveled edge, dense drop mat on the side of the bed the client tends to
get up when available and applicable
If any of the above is NO, implement intervention Provide non-slip, non-glare floor surface, consider safety tape in high risk areas
Provide contrasting colour to create a path to bathroom, behind toilet or on toilet seat
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_________________________________________________________
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Date: __________________________________________ Medical record/file no: __________________________
Patient name: _______________________________________________________________________________ Medication Review Form N P S
Medication History Medication Problems Plan of Action
Medication Prescribed dose/ Actual dose/ Treatment goal Actions/instructions to patient eg:
(generic/brand frequency frequency/ (reason for medication) Tick those that apply dose change, cease, new medication,
name and strength) method of use medication counselling, compliance aids
none contraindications no change

not aware of medication adverse effects action
continuing need drug interaction
dose/frequency/ serum levels/
formulation biochemistry required
duplication compliance
other____________________________________________________________

other____________________________________________________________

other____________________________________________________________

other____________________________________________________________

other____________________________________________________________
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Medication Review N P S
Instructions for using this form Patient Details
This form (consisting of two pages, this page and overleaf ) is to assist with the Date of review: ___________________________________________________________________________________________________________________________________________________________________
process of a medication review.The form is made up of 5 rows, one row for each
Patient name: __________________________________________________________________________
medication. Photocopy this form as many times as is needed for each
patient. Age: ________________________________________ Weight: ________________________________
▲ Complete Patient Details Allergies: ______________________________________________________________________________
Fill in the date of review, patient name and medical history in the space History of adverse drug reactions: ________________________________________________
provided in the box opposite and at the top of the form overleaf. ______________________________________________________________________________
▲ Medication History ______________________________________________________________________________
Take a medication history with the patient, then complete the four sections Alcohol and tobacco use: _______________________________________________________________________
on the form, as outlined below. Renal function:
1.‘Medication’: list all medications currently used regularly or Serum creatinine: _____________________ Estimated Cl cr*: ____________________________
intermittently. Include all prescription drugs prescribed by you and other Liver function: ___________________________________________________________________________________
doctors, over-the-counter medicines and complementary medicines
(herbal, alternative and vitamin perparations) as well as medications not
5
previously recorded on your medical records. *Calculating an Estimate of Renal Function
2.‘Prescribed’: record dose and frequency of medication as prescribed Renal function declines with age. The estimated creatinine clearance rather than the
serum creatinine indicates renal function. Use a formula such as Cockcroft - Gault to
(if applicable) e.g. 10mg at night.
estimate renal clearance, especially in the elderly who may have a normal serum
3.‘Actual’: record dose and frequency of medication taken by patient creatinine
eg: 10 mg at night prn when symptoms occur. Creatinine clearance Cl cr (mL/min) (males) = (140 – age ) x (body weight (kg))
4.‘Therapeutic goal’: record the desired clinical outcome 815 x serum creatinine (mmol/L)
e.g. target blood presure level, pain control. (females) = 85% of above
▲ Medication Problems - Creatinine clearance <10 mL/min - - renally excreted drugs may be contraindicated
Tick any which apply, for ‘other’, specify problems. - Creatinine clearance 10-25 mL/min - significant dosage adjustment will be
necessary for renally excreted drugs
▲ Plan of Action - Creatinine clearance 25-50 mL/min - most renally excreted drugs will need
Record action plan e.g.reduce dose, order biochemistry. dosage adjustment
Note this formula is invalid in severe renal insufficiency or with rapidly changing renal
function.
For further assistance or information please contact the National Prescribing
Drug Interactions: See www.nps.org.au for information on interactions with the
Service on (02) 9699 4499 or refer to the Prescribing Practice Review No. 7, on
top 10 drugs used on PBS.
Medication Review.
Other resources: Australian Medicines Handbook;Therapeutic Guideline series
"QQFOEJY&(FOFSBMFOWJSPONFOUBMDIFDLMJTU
Surname: _________________________________
First Name: _________________________________
U.R.No: _________________________________
General Environmental Checklist
Date of Birth: / /
(Please affix Patient ID Label here if available)
Client Location: Bed/Room No:
Bathroom and Toilets Please tick Appropriate Box Yes No N/A

Grab rails are appropriately positioned and secured in the toilet, shower and bath
Floors are non slip
Baths/showers have non-slip treatment and/or mats
Are areas immediately around the bath and sink marked in contrasting colours?
Raised toilet seats are available
Toilet surrounds and/or grab rails are available in toilets
Soap, shampoo and washers are within easy reach and do not require bending to
reach
Do all shower chairs have adjustable legs, arms and rubber stoppers on the legs?
Is there room for a seat in AND near the shower?
Is the shower base without steps? (not necessary for most patients)
Are call buttons accessible from sitting position in shower area?
Are doors lightweight and easy to use?
Furniture Please Tick Appropriate Box Yes No N/A
Is furniture secure enough to support a client should they lean on or grab for
balance?
Are bedside lockers or tables available to clients so they can put things on safely
without undue stretching and twisting?
Are footstools in good repair and stoppers in good condition?
Is space available for footstool when required?
Floor Surfaces Please Tick Appropriate Box Yes No N/A
Are carpets low pile, firmly attached and a constant colour rather that patterned?
Are walls a contrasting colour to the floor?
Is non-skid wax used on wooden and vinyl floors?
Do floors have a matted finish which is not glary?
Are ‘Wet Floor’ signs readily available and used promptly in the event of a
spillage?
Do steps have a non-slip edging in contrasting colour to make it easier to see?
Is routine cleaning of floors done in a way to minimise risk to residents eg. Well
signed, out of hours?
Lighting Please Tick Appropriate Box Yes No N/A
Is lighting in all areas at a consistent level so that patients are not moving from
darker to lighter areas and vice versa?
Do staircases have light switches at the top and bottom of them?
Do patients have easy access to night lights?
Are the hallways and rooms well lit (75 watts)?
There is minimal glow from furniture/floorings
Are all switches marked with luminous tape for easy visibility?
Passageways Please Tick Appropriate Box Yes No N/A
Are all passageways kept clear of clutter and hazards?
Are firm and colour contrasted handrails provided in passageways and stairwells
Is there adequate space for mobility aids?
Is there adequate storage space for equipment?
Are ramps/lifts available as an alternative to stairs?
Do steps have a non-slip edging in contrasting colour?
Is there enough room for two people with frames/wheelchairs to pass each other
safely?
QBHF99/153
Passageways Please Tick Appropriate Box Yes No N/A
Are all passageways kept clear of clutter and hazards?
Are firm and colour contrasted handrails provided in passageways and stairwells
Is there adequate space for mobility aids?
Is there adequate storage space for equipment?
Are ramps/lifts available as an alternative to stairs?
Do steps have a non-slip edging in contrasting colour?
Is there enough room for two people with frames/wheelchairs to pass each other
safely?
Lifts Please Tick Appropriate Box Yes No N/A
Do doors close slowly?
Are buttons easily accessible to avoid excessive reaching?
Are floor signs at eye level to prevent stretching the neck?
Are handrails available?
External Areas Please Tick Appropriate Box Yes No N/A
Are pathways even and with a non-slip surface?
Are pathways clear of weeds, moss and leaves?
Are steps marked with a contrasting colour and non-slip surface?
Are there handrails beside external steps and pathways?
Are there any overhanging trees, branches and shrubs?
Are sensor lights installed?
Are there sufficient numbers of outdoor seats for regular rests?
Security of Environment Please Tick Appropriate Box Yes No N/A
Are all exits from the facility secured to prevent confused patients leaving?
Are there clear walking routes both inside and outside where patients can wander
safely without becoming lost?
Does the layout of the facility, or allocation of rooms, allow staff to monitor high
risk patients?
Remedial actions that need to be taken:
Completed by: __________________________________ Date: _____________________________

This tool was adapted from CERA – ‘Putting Your Best Foot Forward” Preventing and Managing Falls in Aged Care Facilities, by staff at the
rehabilitation unit, Bundaberg Base Hospital, Bundaberg Health Service District, as part of the Queensland Health Quality Improvement and
Enhancement Program.
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QBHF
APPENDIX E: Environmental Hazards Checklist
Ground Surfaces: Chairs:

• Highly polished or wet • Low seat height or cushions lacking firmness
• Thick pile carpets, area rugs • No arm rests
• Curbs, cords, cluttered pathways • Colour distinguishable – e.g., legs blend into
• Irregular surfaces carpet
• Outdoor walks with poor footing or irregularities • Tipping when back used for support
• Position of waste baskets • No back support
Lighting: Stairs:
• Poor lighting • Lighting
• Location and visibility of switches • No handrails
• Glare • Treads
• Sudden changes in light intensity • Overhang
Beds: Doors:
• Too high or too low • Narrow doorway
• Sagging mattress, mattress that slides on bed • Round door knobs (greater strength required to
• Polished floor beside bed open door)
• Wheels • Locks requiring 2 hands to operate
• Space/placement • Backroom locks that open from the inside only
• Bedrails • Thresholds not visible
• Handles left out • Bathroom doors obstructing
Bathroom: Assistive Devices:
• Space • Mechanical fault
• Lack of rails/grab bars or poorly located • Improper utilization
• Toilet seat too low, too high • Brakes, foot plates on wheelchairs
• Tub slips • Improper length, worn rubber tips on canes
• Sharp edges
Shelves: Restraints:
• Too high or too low • May actually increase falls
• Complications from use
Shoes: Elevators:
• No slip resistant sole • Close too quickly
• Heels too high or worn/no backs • Poor leveling
• Lack of fit or deformity • Start or stop abruptly
(Adapted from Tideiksarr, 1989)
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"QQFOEJY&&RVJQNFOUTBGFUZDIFDLMJTU
Equipment safety checklist:
Wheelchairs Please 9
Brakes Secure chair when applied _______
Arm rest Detaches easily for transfers _______
Leg rest Adjust easily _______
Foot pedals Fold easily so that patient may stand _______
Wheels Are not bent or warped _______
Anti-tip devices Installed, placed in proper position _______
Electric Wheelchairs/Scooters
Speed Set at the lowest setting _______
Horn Works properly _______
Electrical Wires are not exposed _______
Beds
Side rails Raise and lower easily _______
Secure when up _______
Used for mobility purposes only _______
Wheels Roll/turn easily, do not stick _______
Brakes Secures the bed firmly when applied _______
Mechanics Height adjusts easily (if applicable) _______
Transfer Bars Sturdy, attached properly _______
Over-bed table Wheels firmly locked _______
Positioned on wall-side of bed _______
IV Poles/Stand
Pole Raises/lowers easily _______
Wheels Roll easily and turn freely, do not stick _______
Stand Stable, does not tip easily (should be five-point base) _______
Footstools
Legs Rubber skid protectors on all feet _______
Steady—does not rock _______
Top Non-skid surface _______
Call Bells/Lights
Operational Outside door light _______
Sounds at nursing station _______
Room number appears on the monitor _______
Intercom _______
Room panel signals _______
Accessible Accessible in bathroom _______
Within reach while patient is in bed _______
Walkers/Canes
Secure Rubber tips in good condition _______
Unit is stable _______
Commode
Are weighted and not ‘top heavy’ when a person is sitting on it _______
Brakes Secure commode when applied _______
Chairs
Chair Located on level surface to minimize risk of tipping _______
Brakes Applied when chair is stationary _______
Secure chair firmly when applied _______
Footplate Removed when chair is placed in a non-tilt or non-reclined position _______
Removed during transfers _______
Positioning Chair is positioned in proper amount of tilt to prevent sliding
or falling forward _______
Tray Secure _______
Completed by: ___________________________________ Date: _______________________________
2EPRODUCEDWITHPERMISSIONFROM6!.ATIONAL#ENTREFOR0ATIENT3AFETY&ALLS4OOLKITPAGE
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QBHF
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11.0 Appendices
11.12 – 11.16
Post-Fall Resources
11.12 Fraser Health Post Fall Flowchart
11.13 Fall Report
11.14 Post Fall Investigation
11.15 Post Fall Assessment Tool
11.16 Notifying the Family That a Fall has Occurred
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APPENDIX D – Post Fall Flowchart
IDENTIFICATION OF FALL RISKS AND
INTERVENTIONS FOR FALLS AND INJURY REDUCTION
FALL
Witnessed Unwitnessed
Nurse will complete Neurological Vital Sign

x Physical exam (Head to toe assessment) including vital Chart – Appendix I
signs
x Provide comfort measures such as 1 to 1, reassurance,
pillow under head only if there is no suspected
head/neck injury x Inform the physician and family
x Assess pain/discomfort level (use FH Pain Assessment tool, members during waking hours
A di D) (0900 to 1700), unless otherwise
indicated, if hospitalization is not
required.
x Use mechanical lift from the floor +
2 staff to raise the client
Serious
injury? x Initiate or review the RAI MDS 2.0
No or Identification of Risk Factors
and Interventions for Falls and
Injury Reduction Tool (Appendix
B), Behaviour Pattern Record
(Appendix C)
Yes x Initiate post fall interventions and
follow-up
Suspect neck/head injury

xDo not move client
xDo not put pillow under head
Suspect xImmobilize head and neck Laceration
fracture? xDo assessment immediately and for requiring
48 hours after fall using the sutures?
Neurological Vital Sign Chart
Appendix E
x Leave client on the floor

x Call Physician to discuss condition
x Arrange transport to Emergency, if
appropriate
x If needed, assist Paramedics with lift
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Fall Report© Place client label here OR complete (Addressograph on rear):
Client Name: _________________________________
Modified June 02, 2008
Entered in data base _______________ (dd/mm/yy)
MRN/PHN: ______________________________________
Age: _____________ Gender: ________________
A fall is defined as unintentionally coming to rest on the ground, floor or other lower level, whether
or not the faller is injured. Complete a separate form for each fall.
Complete & attach copy to Incident Reporting Form for all incidents involving a client fall.
1. Name of person completing form: ______________________ Date completed: (dd/mm/yy)______

2. Fall Witnessed/Observed: □ No □ Yes, by ________________ Date of fall: (dd/mm/yy)_________
3.Time of fall: □Unknown □7:00am-12:59pm □1:00pm-6:59pm □7:00pm-12:59am □1:00am-6:59am
4. Location of fall (check one only) □ Unknown

□ Bedroom □ Stairs □ Yard or surrounding outdoor area
□ Bathroom □ Kitchen □ Public outdoor area e.g. sidewalk
□ Hallway □ Laundry/utility area □ Public building, e.g. store, clinic
□ Dining/living area □ Transition area, e.g. doorway □ Other ______________________
5. Activity at time of fall (check one only) □ Unknown

□ Walking □ Bathing □ Carrying/lifting an object □ Climbing (eg. on/off
□ Turning □ Using toilet □ Getting in/out of bed ladder/stool/chair, etc)
□ Bending/Reaching □ Dressing/Undressing □ Standing up/Sitting down from seat □ Other ____________
6a. Fall description and contributing factors if known: Briefly give your impressions of why this fall
happened, e.g. had flu; was rushing to toilet; tripped over phone cord __________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
_________________________________________________________________________________________
6b. Additional Information: (check all that apply): □ Client used call bell or personal alarm to call for help
□ Client called for assistance □ Client found on the floor □ Client wearing hip protector at time of fall
7a. Does resident report, or appear to have, pain or injury from the fall? □ Yes □ No
If “Yes”, briefly describe injury. Indicate which injuries are suspected OR confirmed, e.g., confirmed bruise to
right arm above the elbow OR suspected fracture to left wrist: ______________________________________
____________________________________________________________________________________
7b. Location and Type of Injuries (Using the letter codes A to G 7c. Actions Taken (check all that apply)
(see below), mark the exact location of all suspected or □ Comfort measures only
confirmed injuries □ First Aid e.g. ice pack, wound dressing
A. Pain □ Notified Manager/supervisor
B. Cut/Scrape/Abrasion □ Notified physician
C. Bruise □ Notified other health professional
D. Bump/Redness/Swelling
□ Notified family
E. Sprain/Strain/Dislocation
□ Phone call to BC Nurse Line
F. Fractured bone
G. Concussion □ Visit from health professional
□ Visit to /or from physician
Indicate if following □ Ambulance or Fire Dept. visit without
injuries were confirmed:
transfer to Emergency Dept.
□ Sprain/Strain/Dislocation
□ Taken to Emergency Dept.
□ Fractured bone
□ Concussion □ Care Plan reviewed for prevention
Front Back □ Other (specify): _________________
8. Recommendations and follow-up actions (see on reverse) ___________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. H&CC: If report linked to client’s calendar, circle X to indicate a Falls Report has been completed for this fall □ Done
© Fall Report 2008. Permission for use given to B.C. Health Authorities only. For more information contact lead author, Dr. Vicky Scott at
109/153
1
[email protected]).
INSTRUCTIONS ON USING AND COMPLETING THE FALL REPORT FORM:
Fall Report forms to be printed on goldenrod paper to distinguish from other forms.
The cover page of this form may be copied onto the back of an existing in-house incident reporting
system - it is recommended that goldenrod paper be used for the new 2-sided form.
Complete a Fall Report form for every fall, regardless of where the fall occurred; whether or not it
was witnessed, and whether or not there was an injury.
Completed Fall Reports must be copied and original linked to client record for prevention planning.
In Home & Community Care, original is given to health professional(s) caring for client/patient.
Use Regional protocols regarding where copies of the Fall Report are sent, for example copied are
typically not forwarded to Quality and Patient Safety.
A data entry program is available to be used to track trends/patterns of falls over time, within, or
across sites. This is important for site-wide or region-wide falls prevention planning.
1. Name of person completing form: Name of person who completed the form
2. Fall Witnessed/Observed: Indicate if the fall was witnessed by person completing the form, or if not,
state if it was witnessed by the, family member or other.
3. √ Time of fall: Select the closest time category.
4. Location of fall: Note the exact location of the fall. Check one location only.
5. Activity at time of fall: Note the activity at the time of fall. If fall was not witnessed, gather
information to judge the exact activity at the time of fall. Check one activity only.
6. Fall description and additional information:
a. Fall description: Use this section to provide additional information NOT covered in the other
sections such as a detailed description of the fall or factors that may have contributed to the fall.
b. Additional Information: Check all applicable.
7. Injury due to fall and all Interventions:
a. Pain or injury: Ask about any obvious new injuries and complaints of pain. Describe if these are
suspected injuries or confirmed (obvious or diagnosed injury, e.g. Open wound).
b. Location(s) and Type(s) of Injury: Mark the exact location of the injury on the diagram with
the letters (A – G) from the type(s) of injury list given.
c. Actions Taken: Mark all actions (by staff, client, family)
8. Recommendations and follow-up actions: Give your ideas of how the fall could have been
prevented and follow-up actions to reduce the risk of future falls, such as having a urinal or commode by
the bed if fall happened at night while rushing to the bathroom.
Possible Recommendations and Follow Up Actions:

Use the time of day response to determine behavior patterns that may contribute to risk, e.g., if client
falls during the night, ask about toileting habits at night, check lighting and use of nightlights, review
sleep medications.
For frequent fallers, review prior fall reports and for patterns that contribute to falls in order to tailor
prevention strategies.
If possible, have the client show you where the fall occurred. Inspect the location for contributing
factors such as scatter rugs, electrical cords, clutter, inaccessible call bell etc. For Home & Community
Care: Refer to the Checklist and Action Plan for recommended actions.
Use the activity information to suggest interventions, e.g., if the client fell while walking, they may
need a mobility aide, or training in using the mobility aid correctly, or may need to increase muscle
strength and balance through exercise. If they fell while getting out of a bed or a chair, ask them to
demonstrate how they do this to look at the risk, e.g., the bed or chair may be the wrong height. If
the fall happened while bathing, check to make sure grab bars are in place and are being used.
Transfer this information to a care plan.
ADDRESSOGRAPH INFORMATION
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© Fall Report 2008. Permission for use given to B.C. Health Authorities only. For more information contact lead author, Dr. Vicky Scott at 2
[email protected]).
Fall Report© Place client label here OR complete (Addressograph on rear):
Client Name: _________________________________
Modified June 02, 2008
Entered in data base _______________ (dd/mm/yy)
MRN/PHN: ______________________________________
Age: _____________ Gender: ________________
A fall is defined as unintentionally coming to rest on the ground, floor or other lower level, whether
or not the faller is injured. Complete a separate form for each fall.
Complete & attach copy to Incident Reporting Form for all incidents involving a client fall.
1. Name of person completing form: ______________________ Date completed: (dd/mm/yy)______

2. Fall Witnessed/Observed: □ No □ Yes, by ________________ Date of fall: (dd/mm/yy)_________
3.Time of fall: □Unknown □7:00am-12:59pm □1:00pm-6:59pm □7:00pm-12:59am □1:00am-6:59am
4. Location of fall (check one only) □ Unknown

□ Bedroom □ Stairs □ Yard or surrounding outdoor area
□ Bathroom □ Kitchen □ Public outdoor area e.g. sidewalk
□ Hallway □ Laundry/utility area □ Public building, e.g. store, clinic
□ Dining/living area □ Transition area, e.g. doorway □ Other ______________________
5. Activity at time of fall (check one only) □ Unknown

□ Walking □ Bathing □ Carrying/lifting an object □ Climbing (eg. on/off
□ Turning □ Using toilet □ Getting in/out of bed ladder/stool/chair, etc)
□ Bending/Reaching □ Dressing/Undressing □ Standing up/Sitting down from seat □ Other ____________
6a. Fall description and contributing factors if known: Briefly give your impressions of why this fall
happened, e.g. had flu; was rushing to toilet; tripped over phone cord __________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
_________________________________________________________________________________________
6b. Additional Information: (check all that apply): □ Client used call bell or personal alarm to call for help
□ Client called for assistance □ Client found on the floor □ Client wearing hip protector at time of fall
7a. Does resident report, or appear to have, pain or injury from the fall? □ Yes □ No
If “Yes”, briefly describe injury. Indicate which injuries are suspected OR confirmed, e.g., confirmed bruise to
right arm above the elbow OR suspected fracture to left wrist: ______________________________________
____________________________________________________________________________________
7b. Location and Type of Injuries (Using the letter codes A to G 7c. Actions Taken (check all that apply)
(see below), mark the exact location of all suspected or □ Comfort measures only
confirmed injuries □ First Aid e.g. ice pack, wound dressing
A. Pain □ Notified Manager/supervisor
B. Cut/Scrape/Abrasion □ Notified physician
C. Bruise □ Notified other health professional
D. Bump/Redness/Swelling
□ Notified family
E. Sprain/Strain/Dislocation
□ Phone call to BC Nurse Line
F. Fractured bone
G. Concussion □ Visit from health professional
□ Visit to /or from physician
Indicate if following □ Ambulance or Fire Dept. visit without
injuries were confirmed:
transfer to Emergency Dept.
□ Sprain/Strain/Dislocation
□ Taken to Emergency Dept.
□ Fractured bone
□ Concussion □ Care Plan reviewed for prevention
Front Back □ Other (specify): _________________
8. Recommendations and follow-up actions (see on reverse) ___________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. H&CC: If report linked to client’s calendar, circle X to indicate a Falls Report has been completed for this fall □ Done
© Fall Report 2008. Permission for use given to B.C. Health Authorities only. For more information contact lead author, Dr. Vicky Scott at
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1
[email protected]).
10.What mechanical devices were in use?
Mechanical Device Yes No Was the mechanical device Yes No
in good repair?
None
Personal Alarm
Bed Alert
Bed Rail(s) Circle number
used: 0 1 2 3 4
Hi-Lo bed, at lowest level
11.What assistive devices were in use?

Assistive Device Yes No Was the assistive device in Yes No
good repair?
Cane
Straight Quad
Crutches
Walker: Standard
2-wheeled 4 -wheeled
Wheelchair
Broda Chair
Other:
12. Mental Status of Resident: (check all that apply)

Prior to the fall Following the fall
Alert
Able to follow directions
Confused / Disoriented
Change in behaviours
Other:
13.Physical Status of Resident at time of fall: (check all that apply)

Incontinence Change in BP
Weakness / fatigue Recent weight loss / gain
Unsteady gait Decrease in fluid intake
Recent acute illness Recent change in lab values
Specify: (Hgb, blood sugar)
Pain Recent cough / cold
Visual impairment Glasses on
Hearing impairment Hearing aid on & working
Dizziness
14.Environmental status at time of fall: (check all that apply)

Call bell within Resident’s reach Call bell on at time of fall
Bed locked Room light on
Wheelchair locked Night light on
Throw rugs Floor wet
Uneven floor surface Power / phone / TV cords
Other:
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15. List all new medications or dosage / time changes or prn medications prescribed / administered to the
resident within the past 48 hours:
Date Medication
16. Did fall result in transfer to hospital? Yes No

If yes, Ministry of Health Unusual Occurrence Form initiated? Yes
Complete WRH Risk Monitor Pro Yes
17. Executive Director notified (at ext. 75450) of resident transfer to hospital Yes No
Date & Time: ___________________
18. Physician notified? Yes No Date & Time: _________________________
19. Family notified Yes No Date & Time: _________________________
20. Is there a need to re-educate the resident, family and staff? Yes No
Summary: Factors contributing to fall
Action Plan(s)
Post Fall Follow Up

Activity Date
Fall documented in progress notes
Fall entered in Incident Log
Post Fall Investigation summary documented in progress notes
Fall Risk Assessment Tool completed
Fall Prevention Care Plan reviewed
Assessment completed by:
Name (print) ______________________________
Signature ______________________________
Date ______________________________
Submitted to management on: _____________________

Date and Time
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Providence Manor Site
Post-Fall Assessment Tool (PFAT)

Date of Fall: ________________________
Time of Fall: ________________________
Date of 1st Assessment: ________________________
Location of Fall: ________________________
Falling Star: Yes No
MMSE: ________________________ Date: ________________________
New Admission: Yes No
Date Family Notified: ________________________ POA: ________________________
RAI: ________________________ (Ext. 3159 or 3149)
Using SPLATT Assess Risk Factors:
S: Symptoms/ Health Conditions Apparent at Time of Fall

Agitation/Aggression
Foot Problem (ulcer, bunion)
Urinary Incontinence
Urinary Tract Infection (UTI)
Balance/Galt Problem
Dizziness
Urinary Urgency
Bowel Incontinence
Bowel Urgency
Other (please specify):
P: Previous Falls
a) Fell in past 30 days
b) Fell in Past 31-180 days
c) Hip fracture in last 180 days
d) Other fracture in last 180 days
For C & D specify time frame
c) _____________ d): _____________
L: Location (Where did the fall occur? Bedroom, bathroom, hallway, dining room?)
____________________________________________________________________
PFAT Page 1 of 2
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A: Activity & Environment
a) What was the resident doing at the time of the fall?
_____________________________________________________________________
b) Was he or she walking or transferring from the bed, chair, wheelchair, or toilet?
_____________________________________________________________________
c) Was the resident going to the bathroom?
_____________________________________________________________________
d) Was he or she bending down to pick something off the floor or reaching for
something, such as a call bell? __________________________________________
e) Other Possible Causes

Causes: YES NO
Poor fitting shoes
Poor lighting
Obstructed hallways
Cluttered room
Wet floor
Inadequate assistive device
Malfunctioning bed alarm
Equipment failure
Side rails as per care plan
T: Time
a) What time of the day did the fall occur? ___________________________________
b) What day of the week? ________________________________________________
T: Trauma
None
Scrapes or abrasions
Bumps, swelling, or bruises
Skin cuts or lacerations
Bumps or bleeding from the head
Fracture of the hip
Other fracture(s): Where?
• Fall risk assessment reviewed: _________________

• Medication reviewed for changes in the last 24 hours: _____________________
• Logo updated: _______________
• Care plan updated: ___________
• Person completing this report (name all team members present):
__________________________ __________________________
__________________________ __________________________
Signature of RN or RPN: __________________________________________

Copy to NFCLTC Team Leader Copy to RN Manager Original copy to Medical Report
PFAT Page 2 of 2
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Notifying the Family That a Fall has Occurred
When a resident falls, the family should be notified as soon as possible.
1. State the facts of exactly what happened, including how the resident was found and what they
were doing at the time.
2. If the reason for the fall is known, share this information.
3. If the reason for the fall is not known, outline the steps the team is taking to identify the
contributing factors to the fall.
4. State the injuries that were sustained and the treatments, including pain or comfort
management.
5. Inform the family of the type of monitoring that will occur after the fall (e.g. neuro checks) and
how this information will be communicated to staff on the next shifts.
6. Share strategies for preventing future falls and ensure the family that this information is being
communicated to the rest of the care team.
Adapted from: Wagner, L., & Mafrici, N. (2007). Resident falls; how staff and families can improve
communications. The Long-Term Care Magazine. Ontario Long-Term Care Association, June/July, 2007.
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11.0 Appendices
11.17 – 11.20
11.17 A Guide for Preventing Falls and Related Injuries
11.18 Footwear Guidelines
11.19 Safe shoe checklist
11.20 Hip Protectors; Always on your Side Info Sheet
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APPENDIX C: Footwear Guidelines
The features outlined may assist in the selection of an appropriate shoe.
Heel • Have a low heel (e.g., less than 2.5 cm) to ensure stability and better
pressure distribution on the foot. A straight through sole is also
recommended.
• Have a broad heel with good round contact.
• Have a firm heel counter to provide support for the shoe.
Sole • Have a cushioned, flexible, non-slip sole. Rubber soles provide better
stability and shock absorption than leather soles. However, rubber soles do
have a tendency to stick on some surfaces.
Weight • Be lightweight.
Toebox • Have adequate width, depth, and height in the toebox to allow for natural
spread of the toes.
Fastenings • Have buckles, elastic or Velcro to hold the shoe securely onto the foot.
Uppers • Be made from accommodating material. Leather holds its shape and
breathes well however many people find walking shoes with soft material
uppers are more comfortable.
• Have smooth and seam free interiors.
Safety • Protect feet from injury.
Shape • Be the same shape as the feet, without causing pressure or friction on the
foot.
Purpose • Be appropriate for the activity being undertaken during their use. Sports or
walking shoes may be ideal for daily wear. Slippers generally provide poor
foot support and may only be appropriate when sitting.
Orthoses • Comfortably accommodating orthoses such as ankle foot orthoses or other

supports if required. The podiatrist/orthotist or physiotherapist can advise the
best style of shoe if orthoses are used.
This is a general guide only. Some people may require the specialist advice of a podiatrist for the
prescription of appropriate footwear for their individual needs.
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11.0 Appendices
11.21 – 11.28
Quality Improvement
11.21 Check sheet: Activities at Time of Fall
11.22 Check sheet: Factors Contributing to Falls
11.23 Check sheet: Location of Fall
11.24 Check sheet: Fall Injuries
11.25 Safer Healthcare Now National Falls Collaborative Indicators
11.26 Ontario Health Quality Council – LTC Quality Indicators
for Public Reporting: Falls
11.27 Monitoring Indicators NWLHIN Falls Project
11.28 Injury Severity Rating Scale
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Analyzing Circumstances of Falls
Check sheet:
Activities at Time of Fall
Audit timeframe: ___________________ to ___________________
Audit area (unit / facility): __________________________________________
Total # of falls in audit timeframe: ___________
Activity at Time of Fall # of Falls % of total falls
Transfer to/from bed

Transfer to/from chair
Transfer on/off toilet
Other transfer
Ambulating
Commode
Shower
Other bathroom
Faint/dizziness
After meal
Other (list):
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Check sheet:
Factors Contributing to Falls
Fall # No No Medic- Foot- Balance/ Incont- Restraints/ Cognition Mobility Vision Obstacle
risk envir ations wear gait inence Bedrails aid /glasses room or
assess assess hallway
Totals:
% total
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Check sheet:
Location of Fall
Location of Fall # of falls % of total falls

Bedroom
Bathroom –toilet
Bathroom – other
Hallways
Other areas (list):
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Check sheet:
Fall Injuries
Fall Injury # of injuries % of total

fall injuries
No Harm No injury
Minor Bruising
Abrasion
Moderate Laceration
Fracture minor
Serious/Critical Fracture major
Death
Other (list):
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Safer Healthcare Now
National Falls Collaborative
Indicators
Indicator Goal Numerator Denominator Calculation

Falls per Reduce by Total # of falls Total # of resident days for the unit or Falls per 1000 Resident Days:
1000 40% within facility this month (num / denom) X1000
resident year
days
Percentage Reduce by Total # of falls requiring medical Total # of falls for the facility or unit this Percentage of harmful falls:
of harmful 40% within intervention month (num / denom) X100
falls year
Percentage 100% Total # of residents admitted this Total # of residents admitted this month Percentage of newly-admitted residents
of residents month or quarter with a completed or quarter with Fall Risk Assessment completed:
with fall risk assessment (num / denom) X 100
completed
fall risk
assessments
Percentage 100% Total # of residents this month or Total # of residents this month or quarter Percentage of residents post-fall or
of risk quarter experiencing a fall or experiencing a fall OR significant post-change in status with Fall Risk
assessments significant change in status who change in status (add) Assessment Completed:
following had a fall risk assessment (num / denom) X 100
status performed following the fall or
change change in status
Percentage 100% Total # of residents in denominator Total # of current residents (baseline) or Percentage of “at-risk” residents with a
of at risk with an implemented falls new admissions or residents with an fall prevention intervention:
residents prevention intervention this month anniversary of admission identified as (num / denom) X 100
with or quarter “at risk” on a fall risk assessment this
intervention month or quarter
plans
Restraint 0% Total # of residents on the unit or in Total # of residents on the unit or in the Percentage of residents on the unit or in
use the facility with restraints applied at facility being audited this month the facility with restraints applied at the
the time of the audit this month time of the audit this month:
(num / denom) X 100
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Long Term Care Quality Indicators for Public Reporting (November 2009)
Ontario Health Quality Council
Exclusion Risk Adjustment (Individual

Theme Indicator Technical Technical Definition Criteria Covariates) Source
Numerator: Number of residents who had falls in the last 30 Not totally dependent in transferring
Incidence of fall in the Excludes the
Avoidance days on most recent assessment. Denominator: All residents locomotion problem, PSI: Subset 2 non-
past 30 days prior to initial MDS-RAI
of falls on most recent assessment (excluding admission assessment diagnoses, any worsening unsteady
assessment assessment
and those who went to the hospital) gait/cognitive impairment, Age less than 65
Emergency dept visits Numerator: Number of residents who went to emergency

Avoidance NACRS:
for falls per 100 departments for falls. Denominator: Number of residents in None None
of falls ICES
resident years by LHIN long term care homes in a year
Numerator: Number residents who were physically

Avoidance Prevalence of daily
restrained daily on the most recent assessment (including:
of use of physical restraint (based None None MDS-RAI
trunk, limb, chair prevents rising).Denominator: Number
restraints on last 7 days)
residents in facility on most recent assessment
Numerator: Number residents restrained at least once over

Avoidance Prevalence of restraints
the past 7 days (using the quarterly assessment) on most
of use of use at least once over None None MDS-RAI
recent assessment. Denominator: Number residents in
restraints past 7 days
facility in last 7 days on most recent assessment
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Monitoring Indicators – Northwest LHIN Falls Prevention Project
Outcome Measures:
All Participant Organizations:
1. Falls Rate for Patients/Residents/Clients/ of an Organization
‐ Form: Fall Rate Measurement Form
‐ Definition “A fall is defined as “an event that results in a person coming to rest
inadvertently on the ground or floor or other lower level”. (RNAO, 2005,
Prevention of Falls and Fall Injuries in the Older Adult (Revised))
‐ Numerators: # of people who had a fall this past month, # of inpatients who fell:
# of outpatients who fell, # ER Visitors who fell
‐ Denominators: # of people who were eligible to fall. # of inpatients, outpatients
and ER visitors who were eligible to fall
‐ Calculation (# of falls/# of Bed Days) * 1000

2. Fall Injury Rate for Patients/Residents/Clients of the Organization
‐ Form: Fall Injury Rate Measurement Form
‐ Total number of falls
‐ Definition: No harm event ‐ No injury or negative outcome nor was temporary
monitoring required to ensure there was no negative outcome, no loss of public
confidence. Direct care examples: slip from bed to floor with no injury.
‐ Definition: Minor Injury Minor self‐limiting injury or impairment in which
function may be altered temporarily and/or temporary monitoring and/or
diagnostic investigations are required to assess full effects of incident, minimal
potential for loss of public confidence. Direct care examples: skin tear; abrasion;
fall causing bumps or bruising.
‐ Definition: Moderate/Serious or Critical Injury ‐ Injury or impairment in
which function is altered longer term and require medical intervention, breach
of security or safety that impacted client care, equipment, failure that may
jeopardize provision of client care, potential for loss of reputation or public
confidence OR serious injury (loss of function, limb or life). Direct care
examples: Falls resulting in serious injury ‐ laceration requiring suturing; minor
fracture or dislocation, major fracture such as hip; sustained loss of
consciousness; higher levels of care, or death.
‐ Numerators ‐ # of falls resulting in injury (minor and serious) this past month
‐ Denominator ‐Total # of falls with injury
‐ Calculation (# of patients injured/# of patients who fell)*100 (per month)

3. Falls Injury Transfer Rates:
‐ Form: Fall Injury Hospital Transfer Rate Measurement Form
‐ Definition: Number of Transfers of Clients/Patients/Residents/Tenants from
LTC/Home to Hospitals for Falls Injuries (NW LHIN)

4. Falls Injury Hospitalization Rate:
‐ Definition: Number of hospitalizations/admissions for falls injuries for people
over age 65 years. (NW LHIN)

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5. Falls Injury Emergency Room Visits:
‐ Definition: Number of Emergency Room visits for falls injuries for people over
age 65 years. (NW LHIN)

Process Measures

6. Tracking of Plan/Do/Study/Act Cycle
‐ Form: PDSA Tracking Sheet in Excel Spread Sheet 4 ‐Measurement Tools

7. Falls Prevention Education Sessions
‐ Education Session: tracking sheet
‐ Definition: Any educational sessions that relate to a fall risk factor –
medications, restraints, exercise, frailty, environmental hazards, occupational
risks, visions, hearing, incontinences, osteoporosis, falls, alcohol or other at risk
‐ # of participants
‐ # of health care providers,
‐ # of family members and residents.
‐ Optional: Participant Satisfaction of sessions (NW LHIN) (Use Participant Form)

8. Assessments of Patients/Residents/Clients
‐ Form: Percentage of Patients/Residents/Clients with Completed Fall Risk
Assessment on Admission ‐ Measurement Worksheet Excel Sheet 1
‐ Definition: The percentage of patients/residents/clients for whom a fall risk
assessment has been completed on admission. Baseline data should be collected
on all new admissions on a monthly or quarterly basis depending on volume. A
"Fall" is defined as: An event that results in a person coming to rest
inadvertently on the ground or floor or other lower level. (National Falls
Collaborative)
‐ Numerator: Total number of patients/residents/clients admitted in #1 with a
Fall Risk Assessment completed this month or quarter
‐ Denominator: Total number of patients/residents/clients admitted this month
or quarter
‐ Calculation: Percentage of newly admitted patients/residents/clients with Fall
Risk Assessment completed. Divide Numerator by Denominator. Multiply by
100.

9. Interventions for “At Risk” Patients/Residents/Clients
‐ Form: Percentage of "At Risk" Patients/Residents/Clients with Falls
Prevention/Protection Intervention Implemented ‐ Measurement Worksheet
Excel Sheet 2
‐ Definition: The percentage of residents for whom a Fall Risk Assessment has
identified them as "At Risk" and for whom a Falls Prevention and/or Protection
intervention e.g. hip protectors have been implemented. Baseline data should be
collected on all current residents and then subsequent data collected on new
admissions and on the resident's anniversary of admission on a monthly or
quarterly basis depending on volume. (National Falls Collaborative)
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‐ Numerator: Total number of patients/residents/clients in #1 with an
implemented "Falls Prevention and/or Protection Intervention this month or
quarter.
‐ Denominator: Total number of current patients/residents/clients (baseline) or
new admissions / patients/resident/client's with an anniversary of admission
identified as "At Risk" on a Fall Risk Assessment this month or quarter.
‐ Calculation: Percentage of "At Risk" patients/residents/clients with a Fall
Prevention or Protection intervention. Divide # Numerator by # Denominator.
Multiply by 100.
Balancing Measures
Long Term Care Homes/Hospitals:
10. Percentage of Residents with Restraints
‐ Form: Percentage of Patients/Residents with Restraints ‐ Measurement
Worksheet (National Falls Collaborative) Excel Spread Sheet #3
‐ Definition: The percentage of patients/residents with physical restraints
applied on the day(s) of audit.
‐ Numerator: Total number of patients/residents on the unit or in the
organization being audited (#1) with physical restraints applied at the time of
the audit
‐ Denominator: Total number of residents/patients on the unit or in the
organization being audited this month.
‐ Calculation: Percentage of patients/residents on the unit or organizations with
physical restraints applied at the time of the audit this month. Divide numerator
by denominator. Multiply by 100.

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Injury Severity Rating
1) No harm event - No injury or negative outcome nor was temporary monitoring

required to ensure there was no negative outcome, no loss of public confidence, no
loss or damage to property.
Direct care examples: minor delay in giving medication with no harm to client; verbal abuse;
smoking on unit; slip from bed to floor with no injury
2) Minor - Minor self-limiting injury or impairment in which function may be altered

temporarily and/or temporary monitoring and/or diagnostic investigations are required
to assess full effects of incident, minimal potential for loss of public confidence, loss or
damage less than $100.
Direct care examples: minor variation in dose of medication but results in no harm; skin tear;
abrasion; fall causing bruising
3) Moderate - Injury or impairment in which function is altered longer term and required
medical intervention, breach of security or safety that impacted client care, equipment
failure that may jeopardize provision of client care, potential for loss of reputation or
public confidence, theft or damage between $100 to $2000.
Direct care examples: medication error with adverse effect and/ or requiring transfer to acute
care; laceration requiring suturing; minor fracture or dislocation
4) Serious or Critical - serious injury (loss of function, limb or life), attempted suicide,
illegal act (assault, threat with a weapon), serious breach of security (e. bomb
threat), serious potential for loss of reputation or public confidence, theft of items or
damage over $2000.
Direct care examples: major fracture such as hip; sustained loss of consciousness; admission
to intensive care unit due to medication error
(St. Joseph’s Care Group, Thunder Bay, Ontario, 2009)
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11.0 Appendices
11.29 – 11.30
Medical Directives
11.29 Medical Directive: Bone Mineral Density
11.30 Medical Directive Template: Bisphosphonates
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Medical Directive: Bone Mineral Density
Purpose:
Allow the nurse practitioner (NP) to order a bone mineral density (BMD) test to evaluate
for osteoporosis or to re-evaluate effectiveness of prescribed medication.
Criteria:
 Age 65 years or older
 Vertebral compression fracture
 Fragility fracture after age 40
 Family history of osteoporotic fracture (especially maternal hip fracture)
 Systemic glucocorticoid therapy > 3 months
 Malabsorption syndrome
 Primary hyperparathyroidism
 Propensity to fall
 Osteopenia apparent on x-ray film
 Hypogonadism
 Early menopause
Contraindication:
 Resident or SDM do not wish to have BMD testing
Procedure:
1. Assess resident’s status, condition and medication.
2. Assess resident’s recent radiography or last bone density results.
3. If BMD indicated, resident or SDM to be contacted to obtain consent.
4. NP to order BMD on order sheet as MDO (Medical Directive Order) with
physician’s name / RNEC’s name.
5. Physician will co-sign order upon next visit to the home.
6. The Registered nursing staff will process orders as per Fairmount Home’s policy
and procedures.
7. Registered staff to book appointment and arrange transportation.
Responsibilities:
MD:
 Availability to the NP in a reasonable time when clarification is needed.
 Co-sign orders on next visit to facility.
NP:
 Understand and aware of potential problems that could be related to exposure to
test for resident.
 Assess the resident’s condition and the staff’s concern.
 Call the SDM or delegate to RN to obtain consent.
 If unsure consult with MD according to CNO standards for RN(EC).
 Maintain up to date standards, education and proficiency.
Reproduced with permission from Fairmount Home, Medical Directives (no date)
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Follow-up results and consult with the physician and resident /SDM to initiate
pharmaceutical therapy if indicated.
References:
Brown JP et al. (2002). Clinical practice guidelines for the diagnosis and management
of osteoporosis in Canada. CMAJ, 167, 10 supplement, S1-S34.
College of Nurses of Ontario. Medical Directives, revised 2000
____________________________ ____________________________
Authorizing physician Date
____________________________ ____________________________
Registered nurse in Extended Class Date
____________________________ ____________________________
Administrator Date
Review every two years.
Review Date:
Review Date:
Review Date:
Review Date:
Reproduced with permission from Fairmount Home, Medical Directives (no date)
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Medical directive: Insert name of bisphosphonate here
Purpose:
Allow the nurse practitioner (NP) to order insert name of bisphosphonate here, which is
a medication out scope of practice, for resident living at this facility with osteoporosis.
Criteria:
Resident been diagnosed with osteoporosis
Contraindication:
Resident / SDM does not consent to treatment
Residents with known hypersensitivity to insert name of bisphosphonate here
Procedure:
Review BMD test, if + for osteoporosis – consult resident/SDM for treatment
consent and then order name of medication, dose, frequency on order sheet as
Medical Directive Order (MDO) signed MD/RNEC and physician to co-sign on
next visit to facility.
Responsibilities:
MD:
Availability to the NP in a reasonable time when consultation is needed.
Co-sign order on next visit to the facility.
NP:
Resident’s risk factor’s, radiography or bone density results, condition, status and
medications need to be reviewed.
Medication need to be reviewed with resident.
Maintain up to date standards, education and proficiency.
Consultation with MD according to CNO standards for RN(EC)
Follow-up of resident.
Signatures:
______________________________ ___________________________
Authorizing Physician Date
______________________________ ___________________________
Registered nurse in Extended Class Date
______________________________ ____________________________
Pharmacist Date
______________________________ ___________________________
Administrator Date
References:
College of Nurses of Ontario. Medical Directives, Revised (2000)
Ontario Program for Optimal Therapeutics (2000). Ontario Guidelines for the prevention
and treatment of osteoporosis.
153/153

Preventing Falls and Injuries in Long-Term Care (LTC) : Bridges To Care Resource Manual

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Bridges to Care Resource Manual

Preventing Falls and

1.0 Introduction: Falls and Injuries in Long Term Care 3

Section 11.0 Appendices 67

11.12 Fraser Health Post Fall Flowchart 107

11.17 A Guide for Preventing Falls and Related Injuries 121

11.21 Check sheet: Activities at Time of Fall 131

11.29 Medical Directive: Bone Mineral Density 151

Deanna Abbott-McNeil Dr. John Puxty

BC Injury Research and Prevention Unit - Dr. Vicky Scott

Exposure to environmental hazards account for approximately 27% of all falls in

Fall-related hospital admissions, by place of occurrence of fall, age 65+, 1998-2003

(Adapted from PHAC, 2005)

It is important that osteoporosis, fracture prevention, and falls are recognized as a

Adapted from Seniors Health Research Transfer Network (2008)

Decreased life expectancy:

Adapted from OOSLTC 2009 © Copyright CSAH 2009

Deterrents to Assessment and Treatment of Osteoporosis in LTC

© Copyright CSAH 2009

Efficacy of Calcium, Vitamin D, and Bisphosphonates in LTC:

Fear of falling is common in new admissions to long-term care. Research suggests

Individualized, Multifactorial Care Plans

Severe injury (from a fall):

(Adapted from Earthy, 2009a)

In about one-third of falls, a single potential cause can be identified; in two-thirds,

1. Biological / Medical Risk Factors

Adapted from Statistics Canada © Copyright CSAH 2009

• Parkinson’s disease: characterized by rigidity, postural instability, and fear

• Cardiovascular diseases: conditions such as orthostatic hypotension,

• Bowel and bladder problems: associated with incontinence, urgency,

• Foot disorders: deformities, corns, bunions, and hammertoes can lead to

Gait disorders and poor balance:

Adapted from Statistics Canada © Copyright CSAH 2009

Previous fall or recurrent falls:

Lack of mobility aids, or improper use:

Poor nutrition or hydration:

Adapted from Statistics Canada © Copyright CSAH 2009

Fall hazards specific to long-term care homes include:

Risk of Falls in Long-Term Care

Risk of Injury from a Fall in Long-Term Care

The risk factors most highly associated with injury are:

Other risk factors for hip fractures:

Strategy Components Processes Section

Assessment of Risk Assessment Tool (RAI or other) Assessment

Medical Optimize health status and remediable conditions Interventions

Immediate Assisting to floor Post-fall

(Adapted from RNAO, 2005)

The following evidence-based recommendations and clinical practice guidelines regarding

1. Prevention of Falls and Fall Injuries in the Older Adult

1. Those who report a fall or recurrent falls, or demonstrate abnormalities of gait

3. Prevention of Falls in Long-Term Care Facilities

1. Residents should be assessed on admission and re-assessed after a fall.

Three Basic Categories of Fall Risk Assessment Tools

Assessment tools are classified as either quick screening tools or in-depth

Recommended Fall Risk Assessment Tools:

4. Morse Fall Scale**

RAI item Description Rationale as risk factor

(Adapted from CIHI, 2005)

RAI item Description Rationale as risk factor