1. Jeff Reece, RN, MSN, MBA Chief Executive Office Chesterfield General Hospital

2. Patient Safety Concerns- injury to patient HAC’s became reality by the signing of the 2006 Deficit Reduction Act. Discharges occurring on/after October 1, 2008 in which one of the HAC’s were not present on admission, hospitals will not receive additional payment for those cases.

3. Purpose of the policy was to address: Targeted (Re) Assessment for identified patients at risk Targeted Interventions to prevent falls for patients identified as low or at risk for falls. Visually identify and effectively communicate hospital wide which patients are at risk to fall. Reduce falls Define Falls Reduce severity of injury related to falls Reduce repeat falls Educate staff, patient and family.

4. Any observed fall of patient from one surface level to another, i.e. bed to floor or chair to floor. Any fall reported by a patient Any patient found on the floor and there is a reason to believe the patient fell as opposed to sitting on his/her own accord. Any patient assisted to the floor by staff.

5. Department Managers held accountable to ensure staff compliance with the policy. Admitting RN will perform a fall risk assessment and implement nursing interventions The patients nurse to routinely reassess the patient for the need for appropriate intervention throughout the stay. A low risk patient is to be reassessed when there is a significant change in their mental status, gait or mobility, medications, etc not to exceed 24 hours. High risk is reassessed every shift.

6. The patient’s nurse should re-assess the patient when a change in the patient’s condition or environment changes. Interventions should be implemented, communicated and documented. It is the responsibility of all employees to observe and monitor patients identified at risk for falls.

12. An orange Leaf is placed on the door to remind staff that this patient is at risk for falls. Orange Non-skid socks are placed on identified at risk patients. Orange Dot is placed on patients medical record. Orange ID band is placed on patient to help those who may be transporting patient from unit to unit identify quickly of the patients fall risk status.

13. The care plan is updated to reflect the patients fall status as well as in the nursing notes.

14. Discussion? Questions? Thank You!