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What is a post-fall assessment?

Every nursing home resident should have an individual care plan that identifies health conditions, medications, risk factors and more so that health care staff can help them live life to the fullest. Included in the risk factors are personal fall risks.

According to the Agency for Healthcare Research and Quality, if a resident falls, trained nursing staff should evaluate the care plan and the situation and create a post-fall assessment that can help prevent future falls. This is critical because falling itself is a major fall risk.

Assessing the resident

The immediate assessment of the resident’s condition includes taking vital signs, examining the body for injuries and pain, evaluating range of motion and doing a neurological check for changes in mental status. The nurse doing the assessment should also check the resident’s medication and care plan to see if there have been any changes that may have contributed to the fall.

Assessing the circumstances

Possibly, the issue was something as simple as an untied shoelace or a walker with a worn rubber grip. The assessing nurse should document the resident’s footwear, mobility devices, floor surfaces, and environmental changes such as rearranged furniture or a new rug.

If the resident should not have been out of a bed or chair, then restraint status such as bed rails or chair position may be relevant. Toileting status could be important if, for example, the resident called for help getting to the bathroom and did not receive a prompt enough response.

When nursing home staff understand why a resident could fall, it may help them prevent the fall. AHRQ notes that about half of all U.S. nursing home residents fall each year, many more than once. Comprehensive risk assessments could lower that figure.