1. Allyson Grutter, RN PCCN Ferris State University
Preventing Falls
Allyson Grutter, RN PCCN
Ferris State University

2. Definition
A fall is an unexpected event in which the participant comes to rest on the ground, floor, or lower level
(Grey-Miceli, 2008)

3. Risk Factors Cognitive impairments Vision loss Balance impairment
High risk medications
Urinary incontinence
Use of assistive devices
Inappropriate Footwear
Slippery floors
Poor lighting

4. Basic Fall Assessment
Assess the patient and the patient care environment on admission and routinely for possible risk factors and take appropriate corrective action if able
Use standard or empirically tested Fall Risk tools in addition to other assessment tools such as the Tinetti Test or the Timed Get up and Go test
Include patient’s family and interdisciplinary team in identifying and reducing risk factors based on your assessments
(Grey-Meceli, 2008)

5. Tinetti Assessment Tool Get up and Go Test
Have the person sit in the chair with their back to the chair and their arms resting on the arm rests
Ask the person to stand up from a standard chair and walk a distance of 10 ft.
Have the person turn around, walk back to the chair and sit down again
The patient is given 1 practice and then 3 trials with the average time taken from them
Seconds Rating
<10 Freely mobile
<20 Mostly independent
20-29 Variable mobility
>20 Impaired mobility
A minute test based on the ability of the patient to follow specific tasks related to gait and balance
0 = Most impairment
2 = Most independent
Scoring system:
19 or less = high risk for falls
20-24 = risk for falls
Maximum score is 28
(Tenetti Assessment Tool: Description, n.d.)
(Hamilton County Fall Prevention Task Force, n.d.)

6. Try This: A Best Practice Approach to Fall Prevention
Fall Risk Assessment for Older Adults

7. Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model
Developed by nurses
Intended for use in the acute care setting to identify adults at risk for falls
Screens for primary prevention of falls and is integral in post-fall assessments for secondary prevention of falls

8. Hendrich II Fall Risk Model
Designed for quick administration and
based on the following 8
independent risk factors:
Confusion, disorientation, impulsivity
Symptomatic depression
Altered elimination
Dizziness, vertigo
Gender (being male proves to be an independent risk factor and automatically scores a 1)
Administration of antiepileptics (includes dosage changes or cessation)
Administration of benzodiazepines
Poor performance in the “Get-Up- and-Go” test of rising from a seated position

9. Hendrich II Fall Risk Assessment Scoring
Patients with a score of 5 or greater are at high risk for falling and will require precautionary interventions
A score of 16 is the highest
As risk factors change, so will the score thus continual assessments on the patient are necessary
A video with Ann Hendrich, MSN, RN, FAAN, that further discusses assessment scoring can be found online at
(Hendrich, 2007)

10. Hendrich II Fall Risk Assessment
Protocol Trial
Performed on 84 year old woman with multiple hospitalizations over past 2 years
Hendrich II Fall Risk Assessment:
Hendrich II Fall Risk Assessment
Risk Factor
Scale
Score
Confusion, disorientation, impulsivity
Yes 4
Symptomatic depression 2
Declining health, unable to perform ADL’s independently, loss of control
Altered elimination 1
Frequent UTI’s, unable to walk to bathroom alone,
Dizziness, Vertigo, Sway path, Loss of balance
Male Gender No
Any prescribed antiepileptics
Any prescribed benzodiazepines
Ativan and Zanax for anxiety r/t social phobias
Get up and Go test
Unable to rise without assistance during test
Total Score 13

11. Score Interpretation
Patient score = 13; Equates to High Risk for Falls
Interventions:
Due to altered elimination, regular toileting patterns will be established of every 2 hours
Discuss with interdisciplinary team any alternatives to pain control since Fentanyl and Vicodin can cause dizziness and/or loss of balance and patient is on both medications
Ensure pathways in room are clear of debris and cords
Fall risk arm band placed on patient and sticker placed outside of patients door for other staff to know she is a fall risk

12. Fall Risk Assessment at Metro Health Hospital
Risk Factor
Scale
Score
History of Falls
Yes No 25
Secondary diagnosis 15
Ambulatory Aid
Furniture
Crutches/Cane/Walker
None/Bedrest/Wheelchair/Nurse 30
IV/Saline lock 20
Gait/Transferring
Impaired
Weak
Normal/Bedrest/Immobile 10
Mental Status
Forgets Limitations
Oriented to own ability
RN to assess patient fall risk at time of admission using the Morse Fall Risk Assessment
A re-assessment is warranted when there is any change in the patient’s status (surgery, progression of disease, fall, etc)
Patients at high risk for falls receive a yellow arm band and wear yellow socks; a falling star magnet is placed outside of door to alert other staff of fall risk
Risk
Total Score
High Risk
45 and higher
Moderate risk
25-44
Low Risk
0-24
(Metro Health Hospital, 2011)

13. “Try This” Protocol vs. Metro Health Protocol
The Hendrich II Fall risk assessment is designed to be administered quickly
This assessment focuses on 8 key factors where the Morse fall risk only uses 6 factors
It takes into account that being male increases the likelihood of falls; possibly due to the fact that men are more likely to take risks than are women

15. Is Change needed at Metro??
I think the Hendrich II Fall Risk Assessment would be an excellent alternative to the Morse Fall Risk as it is more in depth yet can also be administered quickly
While studies on this fall risk are limited, the initial reports have been positive and hundreds of hospitals have converted to it
This assessment can also be
built into an electronic health
record as EPIC is used at all
Metro Health facilities

16. Determining Success of the new “Try This” protocol at Metro Health
Data Collection at 3, 6, & 12 months
Number of Falls
Number of patients labeled “At Risk” for falls
Number and circumstances of patients that fell who were not deemed “At Risk”
Is further Nursing education required?
Does the Hendrich II Fall Risk let some patients who are truly “at risk” fall through the cracks?
Compare with data over the previous year statistics when we were using Morse Fall Risk Assessment

17. References
Gray-Miceli, D. (2007). Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model. try this: Best Practices in Nursing Care to Older Adults, (8), . Retrieved February 8, 2012, from
Gray-Miceli, D. (2008). Nursing Standard of Practice Protocol: Fall Prevention. Retrieved February 9, 2012, from
Hamilton County Fall Prevention Task Force. (n.d.). Timed Get up and Go Test. Retrieved from
Hendrich, A. (2007). Predicting Patient Falls: Using the Hendrich II Fall Risk Model in clinical practice. American Journal of Nursing, 107(11), Retrieved from
Metro Health Hospital. (2011). Fall/Injury Prevention Policy.
Tenetti Assessment Tool: Description. (n.d.). Retrieved from