Impatient Falls

4. All Patients should be rounded on ______ and monitored for the following: Pain, Position, Toileting assistance, Clear pathways to toilet, Possessions within reach, Bed and/or clip alarms on if indicated, Call, light within reach, Patient and family education.
8. All Falls _____ set of Vital Signs, with neuro check.Fifteen Unwitnessed or suspected head or neck injury –neuro checks every_____ minutes for one hour, and then hourly for four hours.
11. Complete a ______ Huddle, with the Nursing Supervisor.
12. Do not move the patient if the fall is _______, or suspected head or neck injury.
13. The RN should open fall risk _______ problems, on High Risk patients.
14. Complete a _____, Event Report.
15. High Fall Risk Patient interventions include: Non-skid slippers and 'high risk' yellow non-skid slippers, Falling Star _______ outside of patient room, Fall risk wrist band, Safety and environmental routine checks – rooms free of clutter, belongings within reach of patient, Bed or clip alarms, 1:1 sitter – companion.
17. Complete a new ______ assessment, and a new Fall assessment.
18. After patient has been assessed for injuries and if it is ______ that patient is safe to move, transfer them to comfortable location (bed, chair, stretcher, etc.)
20. The stretcher/bed wheels, when not in motion, will be ________ and side rails will remain up with high risk patients.

1. Family and patients will be properly instructed to call for assistance with ______, and/or toileting needs.
2. Notify the Nurse Supervisor (NS) for ALL falls, The NS will complete a Post-Fall ______ with the staff.
3. Every _______ should be exhausted before utilizing restraints, particularly when considering patient safety in relation to falls.
5. RN will use _______ judgment to determine which interventions are appropriate for the patient, and will ensure that the interventions are implemented.
6. Identify patients as a 'standard' or 'high fall risk', Individualize _______ and the nursing care plan.
7. _______the patient's provider, and family as soon as possible.
8. Document the ______, in the RN note.
9. _______, Vital Signs.
10. Call an RRT (Rapid Response Team) for suspected injury, known injury, or an _______ fall.
16. Complete a _____.
19. Complete a fall _______ upon admission, every shift and hand-off, upon mental or physical change, and upon change in care setting or following a fall.