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Guideline
( ) N/A
( ) Newborns
( ) Pediatric
( ) Adult
DESCRIPTION/OVERVIEW
All patients, inpatient and outpatient, should be assessed for fall risk and have appropriate interventions
instituted. The Humpty Dumpty Falls Assessment Scale is a validated pediatric tool that can help
predict the possibility of a pediatric patient fall. It is based on a retrospective review of pediatric falls.
The most common elements involved in pediatric falls are included in the grading criteria of the tool.
The scoring is a cumulative calculation of defined categories.
REFERENCES
PC.01.02.08, 2012 Hospital Accreditation Standards, The Joint Commission, 2012.
http://www.jointcommission.org.
Miami Childrens Hospital Implementing a Humpty Dumpty Falls Assessment Scale and Fall
Prevention Program in Pediatric Patients 2009.
AREAS OF RESPONSIBILITY
All inpatient units and outpatient clinics including Behavioral Health and diagnostic areas should assess
patients and institute fall precautions on intake and continue them according to procedures in this
guideline.
GUIDELINE PROCEDURES
Adult Inpatient
1. On admission to an adult unit at UNMH, transfer to another unit, change in caregiver, change in
shift, or change in clinical condition, the patient will be assessed using the approved fall risk
assessment tool. Adolescent patients on an adult unit should be assessed using the approved fall risk
assessment tool for that adult unit.
2 If the patients fall assessment score is less than 3, the Standard Safety interventions to be
implemented include:
2.1 Hourly rounding;
2.2 Bed in low position;
2.3 Bed wheels locked;
2.4 Mobility support items readily available;
2.5 Night light utilized;
2.6 Non-skid footwear;
2.7 Personal items within reach;
2.8 Sensory aids within reach;
2.9 Traffic path in room free of clutter;
2.10 Patient and family education, including fall risk signage in room and handout of fall
education brochure.
3 If the patients fall assessment score is equal to or greater than 3, the Fall Risk interventions need to
be individualized to the patients needs and implemented. These will be in addition to the above
Standard Safety interventions implemented for all patients. The Fall Risk interventions included:
3.1 At risk for falls signage on door;
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928
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5.2 Approximately 6 months - 3 years (from time baby can sit to time child can be in adultstyle bed):
5.2.1 Young children able to stand while holding railings must have a covered crib
(jumper crib).
5.3 Approximately 3 years until school-aged:
5.3.1 Lock out side rail bed controls.
5.4 School-aged children and older:
5.4.1 Based on childs maturity level and mobility status: decide when to unlock side rail
bed controls.
5.4.2 Based on childs maturity level and mobility status: decide when family may assist
child out of bed.
5.4.3 Have personal care items, TV remote, eyeglasses, drinking cups, and ambulation
assists devices, etc. within reach of the bed.
6. Staff should document assessment and interventions other that age based interventions in the
nursing EMR or APC.
Behavioral Health Inpatient and Outpatient
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contribute to falls risk (such as an accident resulting in a lower limb castand/or with change in
psychotropic medications that may contribute to falls risk,
2. If the patient is considered at risk of falling, (score of 45 or greater on basic Morse Falls Risk
Assessment Tool) a Falls Prevention Treatment Plan is developed within the Multidisciplinary
Treatment Plan, and may include any of the following staff interventions as individualized to the
clients need:
2.1. Close supervision while ambulating in clinic or other outpatient program area
2.2. Avoid clutter in program areas
2.3. Provide adequate lighting for increased visibility
2.4. Educate client and family about risk factors that contribute to falls and how they can decrease
those risks in the home environment
2.5. Provide Center for Disease Control (CDC) fall prevention brochure and other relevant client
teaching tools as necessary.
3. For clients who are currently enrolled in behavioral health programs, a basic falls assessment
should be initially completed and then again as clinically appropriate using the Morse Falls Risk
Assessment Tool or other approved Falls Risk Tool:
3.1. If the clients score is 45 or greater on the Morse Falls Risk Assessment Tool, the complete
assessment will be done and a treatment plan completed as directed above.
Childrens Psychiatric Center Inpatient
All children and adolescents are assumed to be at a greater risk for falls secondary to their
developmental stage and developmental activities. Certain clients may be at higher risk for falls
secondary to their medical condition, medication regimen, and/or degree of sensorimotor integration
1. Age-based interventions to reduce the risk of falls in pediatrics should be implemented as
appropriate (based on cognitive, physical and sensorimotor development). Examples of such
interventions include but are not limited to:
1.1. Prevention guidance prior to and during therapeutic recreational activities
1.2. Client and family education regarding falls risks and prevention for children and adolescents
1.3. Removal of objects that could provide a small child with climbing access to elevated surfaces
1.4. Avoid unnecessary rearrangement of physical environment
1.5. Ensure that client wears shoes and /or slippers that fit properly, fasten securely and have nonskid soles
2. For those children and adolescents assessed to be at high risk for falls due to their medical
condition, medication regimen and/or degree of sensorimotor integration, the following
interventions may be added to the basic falls prevention interventions outlined above:
2.1. A Falls Prevention Treatment Plan is added to the clients Multidisciplinary Treatment Plan
which may include the following interventions as necessary:
2.1.1. Use of protective head gear or helmet as necessary
2.1.2. Use of other protective gear, such as knee guards or shin guards as necessary
2.1.3. Collaboration among members of the multidisciplinary health care team to minimize the
effects of medications that contribute to falling (for example, orthostatic hypotension
and unsteady gait)
2.1.4. Close supervision while ambulating as necessary
2.1.5. Provide assistance devices (for example, walker) as necessary
2.1.6. Lock wheels of wheelchair, bed, gurney during transfers
2.1.7. Instruct clients to call for assistance with movement as necessary
2.1.8. Provide elevated toilet seat as necessary
2.1.9. Provide a sleeping surface close to the floor as necessary
2.1.10. Provide the dependent client with a means of summoning help (bell or call light) when
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928
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2.9.5. Other age appropriate safety interventions are utilized for newborns and pediatric
patients as mentioned above in the inpatient guidelines.
3. Inpatients If patient is identified as being at continued risk for immediate risk of fall (reports acute
symptoms of high risk symptoms) prior to discharge from an inpatient setting, include this
information in handoff communication report prior to transfer of patient.
4. Outpatients If patient is identified as being at continued risk for immediate risk of fall (reports
acute symptoms of high risk symptoms) prior to discharge from an outpatient setting, contact
departmentally specified medical personnel for additional assessment and disposition.
5. All radiology patients, including all modalities, are considered a potential risk for falls.
5.1.All In and Out patients requiring the services of radiology are considered at risk for falls.
Patients entering the area may have multiple impairments; physical, mental and
pharmacological. The department has a standard process for all patients.
5.1.1 The front desk staff observes the patients upon entering the department. If a potential risk
is identified, the supervisor / charge technologist is immediately notified.
5.1.2 The supervisor / charge technologist will communicate with the patient/family to
establish what measures must be taken while in Radiology.
5.1.3 In the event a greater level of care is needed, a nurse will be requested to assess the
patient and in the event where a higher level of medical attention is required the patient
will be transported as follows:
5.1.3.1 Inpatient: the patient will be returned to the sending unit.
5.1.3.2 Outpatient: the patient will be taken to the Emergency Department.
5.1.3.3 Patients are escorted to the exam room by the technologist providing the
imaging service. If in the event more assistance is needed the technologist
will request it, i.e. lifting help, chaperone, requesting a wheel chair.
5.1.4 When the patient is pediatric or has special needs, the risk of falls from the imaging table,
stool or chair is of additional concern. The caregivers will be utilized to provide fall
safety for the patient.
5.1.5 Immobilization methods will be utilized at all times to include sandbags, gel rolls, and
caregiver holding procedures. These immobilization techniques will be utilized as
standard procedure.
5.1.6 The radiologic imaging specialist is responsible for any and all activities within the
imaging room. Prior to commencing any exam, the imaging specialist will provide
information to the caregiver and age appropriate information to the child regarding the
process. This information will include detail of what will be happening throughout the
exam as well as child safety instruction to the caregivers. These caregivers will be
instructed to maintain complete hands-on control of the patient at all times. Caregiver
instruction will be an integral part of the procedure.
5.1.7 The imaging specialist must secure any patient before exiting the procedure room. The
pediatric patient must be in the presence of a qualified caregiver, who will remain seated
in a chair or in attendance at the side of imaging table. Should a situation arise that
requires the imaging specialist to leave the room for any prolonged amount of time, the
patient and caregiver will be taken to a waiting area until that situation is resolved. The
imaging specialist must take every precaution to assure that the patient and caregivers are
in a safe environment.
5.1.8 In the event of a fall, the immediate action shall be to call Rapid Response Team. The
Radiologist will be called for initial assessment; however, the patient will not be moved
until the Rapid Response team deems it safe. All fall events must be reported using the
Patient Safety Net (PSN) system and reported to the direct Supervisor in charge.
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928
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5.1.9 Fall assessment verification is documented on the Radiology Information System (RIS).
DEFINITIONS
Fall A sudden, uncontrolled unintentional, loss of upright position that results in landing on the floor,
ground or onto an object or furniture. The fall may be witnessed or unwitnessed.
Fall Prevention Instituting special precautions with patients at risk for injury from falling.
SUMMARY OF CHANGES
Replaces Fall Prevention, last revision 10/2009.
Inclusion of Humpty Dumpty Fall Assessment Scales
RESOURCES/TRAINING
Resource/Dept
Clinical Education
Internet/Link
Contact
Date
Approval
Executive Director, Carrie Tingley Hospital, Inpatient Pediatric Areas, Outpatient
Ambulatory
Director, Diagnostic Center, Nursing Practice Coordinator, Behavioral Health
Unit Director Ambulatory Surgery
Nursing Practice PP&G Sub-Committee, Clinical Operations PP&G
Y
Committee, Pediatric Practice Council
Sheena Ferguson, MSN RN Chief Nursing Officer
Y
Sheena Ferguson, MSN, RN, CNO
Y
Official Signature
Date: 8/10/2012
Effective Date
Origination Date
Issue Date
8/10/2012
6/1997
8/16/2012
ar
ATTACHMENTS
Humpty Dumpty Scale-Emergency Department
Humpty Dumpty Scale-Inpatient
Humpty Dumpty Scale-Outpatient
Humpty Dumpty Falls Safety Protocol-Inpatient and Emergency Department
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
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Attachment A
_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
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_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928
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_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928
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_________________________________________________________________________________________________________________________
Title: Fall Precautions
Owner: Executive Director, Carrie Tingley Hospital
Effective Date: 8/10/2012
Doc. #2928
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