Identifying Those at Risk of Falling in Hospitals
The possibility of trauma within the hospital is supposed to be a foremost concern on the minds of management and staff alike in all hospitals. Every Nursing Admission Assessment Form must contain a tool for identifying those at risk. Although the elderly are the most vulnerable, any age can be susceptible to falling.
Aside from the obvious vigil of keeping the floors free of liquid spills and loose clutter, the following are the risk factors of falling that the admitting nurse is required to look for:
confusion, agitation, or other aberrant behavior
physical impairment, such as with a history of stroke
balance impairment, as with inner ear inflammation
low blood pressure (postural hypotension)
history of fainting (syncope)
history of epilepsy
nonwalking persons of any age
age greater than sixty-five
frequent urge to urinate
history of falling
taking sedatives, hypnotics, narcotics, and the like
neurological diseases such as Parkinson's and multiple sclerosis
Family members need to make the nurse aware if any of these conditions exists. After such a report is made, it is vital to discuss with the nurse what the specific plan is for fall prevention. All nurses are required to write and update a care plan on their patients. Ask to see this plan. It would be interesting to see the responses if all consumers would ask the nurse to produce a copy of the care plan. The level of diligence would soar to new heights.
To start with, confusion, agitation, and other acting-out behaviors are serious management problems. Patients exhibiting such behaviors not only are prone to falling but are also at risk for hurting themselves and others by disrupting the rendering of care. This includes pulling out lines and tubes and attempting acts of violence against staff members and other patients. The patient who is obviously confused and given to bizarre and/or violent behavior is easy to identify, and there are specific prescribed actions that I shall discuss later in this chapter.
However, a more difficult problem exists with people who do not exhibit such behavior initially and become unpredictably confused at night. The elderly are especially vulnerable because they lack the ability to adjust to an unfamiliar environment. Confusion often sets in at night when the patient wakes up thinking that he or she is still at home. This often leads to the person getting out of bed without calling for help. This is particularly troublesome because nurses are often lulled into a false sense of safety from interacting with a patient who through the entire day has demonstrated lucidity and full cooperation with hospital routine. The onset of momentary confusion in such persons is unpredictable.
In the case of Esther M., she was seventy-four years old when she entered the hospital for a biopsy of a lump in her right breast. After the surgery, she was having trouble sleeping, so the doctor prescribed a mild sedative, which she took at 6 P.M. and again at 10 P.M. The night nurse made rounds regularly every hour. Although Esther was independent and ambulatory during the day, the nurse assessed her as being at moderate risk of falling due to her age being over seventy. The protocol was to keep two side rails up at night at the head of the bed and to frequently remind the patient to call for assistance before getting out of bed. About fifteen minutes after the night nurse made 1 a.m. rounds, Esther attempted to climb out of bed and fell, sustaining a fracture to her left hip.
According to current standards, the nursing staff did everything they were required to do. They made a reasonable assessment of the risk, they made rounds every hour, and they kept two of the four side rails up at night. Obviously, that was not enough to keep Esther from falling and fracturing her hip. There is a design defect in the standard. The question is, "What's missing?" The answer is surveillance. As mentioned previously, we need family involvement and consumer activism to upgrade the current standards. A standard by which the courts judge a health professional is nothing more than a consensus of like professionals opining that the injury was "unfortunate but unavoidable."
Assessing risk comes down to first observing whether an individual is prone to falling and then anticipating the likelihood that a person who is disposed to falling is going to attempt some form of movement with no one in attendance.
The question of being susceptible to falling is a matter of whether a person needs assistance with sitting up, standing, walking, transferring, and sitting in a chair or on a toilet seat. Even with those who are independent in such matters, there is also the question of balance and judgment as well as whether any conditions exist that cause fainting and/or dizziness. Those could be either an illness such as diabetes, heart block, low blood pressure, anemia, and panic attacks or side effects from medications.
A case in point is an incident involving Rachel, a thirty two year old female who entered a university medical center after suffering from a leaking aneurysm in the right side of her brain. Fortunately, the neurosurgeons were able to place a clip to seal off the blood leak. However, there was some residual damage from the blood collection. The clot left Rachel with residual strokelike left-sided partial paralysis. The advantage was that she was young and responded extremely well to physical therapy. Everyone involved, including the patient and her husband, expected a near-full recovery. However, this was not to be the case. Rachel had made a lot of progress but still needed assistance to walk to the bathroom, and she had some difficulty balancing herself on the toilet.
About three weeks after surgery, one of the nurses assisted Rachel in walking to the bathroom and helped her onto the toilet. The nurse, wanting to give Rachel some privacy, said, "I'll be right outside the door if you need me."
Moments later, Rachel fell over toward her left side and slammed her head on the floor. The nurse, who remained outside the bathroom door, was unable to prevent the injury. Shortly thereafter, Rachel was in the operating room with a neurosurgeon removing the blood clot from the left side of her brain. Following this, Rachel was now dealing with partial paralysis on both sides. The chances of her future recovery became remote. This terrible scenario could have easily been avoided, but not without the patient and her family being educated in the risks and taking a proactive role in risk prevention by engaging the nursing staff in a continuous dialogue regarding safety concerns with the hemiparesis (one-sided partial paralysis).