Protocol For Responding To Falls

RODWELL FARM NURSING HOME - FALLS PROTOCOL
The Nurse-in-Charge must make an assessment of injury

using the Post Fall Assessment Checklist (Appendix 1)
prior to moving the resident
Slight/Minor
Minor/Injury
No apparent injury
No head injury
No complaints of
pain/discomfort
(verbal/nonverbal)
Mobility unaffected able to
move limbs on command or
spontaneously
No signs of bruising/
wounds
No signs of limb
deformity/shortening
rotation
Some bruising
Slight skin wounds
Slight discomfort
No mobility problems able to
move limbs on command and
spontaneously (within pre-fall
range of movement)
No head injury
No signs of limb deformity/
shortening/ rotation
Major/Injury
Loss of consciousness
Reduced consciousness
Signs of head injury
Airway/breathing problems
Haemorrhage / bleeding
Chest pain
Limb deformity
Pain/discomfort
Swelling
Extensive bruising
Unable to move limbs,
joints on command
Dizziness or vomiting
Any fall from height above
2 meters
Any other concerns by
assessor.
Any change in condition causing concern,

call GP or Emergency Care Practitioner on 999
Assist resident to a
comfortable place (using
hoist/handling aid as
required)
Write up Post Falls
Assessment in Residata
using Checklist in Appendix
2
Observe resident for 24
hours for pain/and write it
up in Residata
Complete a body map
(Appendix 2) and document
in Residata.
Administer first aid and assist

resident to a comfortable place
(using hoist/handling aid as
required)
Write up Post Falls
Assessment in Residata using
the Checklist in Appendix 2
Observe resident for 24 hours
for pain/and write it up in
Residata
Complete a body map
(Appendix 3) and document
the details in Residata.
Inform relatives and document
discussion in Residata
Inform GP (FAX print out of
Post Falls Assessment to
Practice) and ask to see
resident within next 5 days
(unless deterioration)
Inform Care Manager
Do not move
resident
Call 999 for
ambulance
Inform relatives
and document
discussion in
Residata
Complete incident form/record in accident book
APPENDIX 1
POST FALL - ASSESSMENT CHECK LIST
The following areas must be written up in Residata Care Notes
immediately after all falls
Date/Time of Fall
Level of Consciousness
(Check for head injury)
Select one option from:
Responsive (verbal/other)
Less responsive than usual
Unresponsive/unconscious (call 999)
Pain/ Discomfort
No evidence of pain/discomfort
Showing signs of pain (non verbal)
Complaining of pain (verbal)

Site of Pain (if any)
Injury/wounds
(check for open wounds,
haemorrhage)
No evidence of bleeding
Swelling/deformity
Bruising/bleeding
Site of Injury (if any)
Movement
(check for shortening or
rotation of limb)
Able to move limbs on command (within pre-fall

range of movement)
Able to move but with pain
Unable to move limbs on command or

spontaneously
Observations
(Before moving if injury
suspected)
Record the following:
Pulse
Blood Sugar
Blood Pressure
Mobility
Able to get up and weight bear
Able to assist but showing signs of discomfort
Unable to assist themselves up and requires hoist

or other handling equipment.
Major change in mobility and condition from pre-fall

status?
Conclusion, Clinical
assessment and judgment
Slight/Minor. If so,
o Document in Residata Care Notes
Minor/Injury. If so,
o Commence 24 hour observation
o Inform relatives and document in Residata
Care Notes
o Inform GP and ask to see within
o 5 days (FAX this form to surgery)
o Inform Care Manager
Major/Injury. If so,
o Suspected/confirmed injury, call 999
o Inform relatives and document in Residata
Care Notes
o First aid/resuscitate as appropriate
o Close observation until help arrives
o Provide ambulance staff with a copy of this
form
o FAX form to GP surgery
o Inform Care Manager
APPENDIX 2
Body Map Assessment of Injury
Residents Name: __________________________
Assessed by: _____________________________
(print name)
Marks or bruising on residents body (describe and mark on map above)
Date/Time _________________________________________________
Signature __________________________________________________

Protocol For Responding To Falls

Uploaded by

Copyright:

Available Formats

Protocol For Responding To Falls

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Protocol For Responding To Falls

Uploaded by

Copyright:

Available Formats

RODWELL FARM NURSING HOME - FALLS PROTOCOL

The Nurse-in-Charge must make an assessment of injury

Any change in condition causing concern,

Administer first aid and assist

Complete incident form/record in accident book

Select one option from:

Less responsive than usual

Unresponsive/unconscious (call 999)

Select one option from:

Showing signs of pain (non verbal)

Complaining of pain (verbal)

Select one option from:

Select one option from:

Able to move limbs on command (within pre-fall

Able to move but with pain

Unable to move limbs on command or

Record the following:

Select one option from:

Able to get up and weight bear

Able to assist but showing signs of discomfort

Unable to assist themselves up and requires hoist

Major change in mobility and condition from pre-fall

Select one option from:

Marks or bruising on residents body (describe and mark on map above)

You might also like