Anatomy of a Fall: A Nurse’s Perspective


Fall Risk Expert Witness

The prevalence of falls among the elderly represents a major public health problem.  According to The Joint Commission, a non-profit organization that accredits healthcare facilities and programs, falls resulting in serious injury are among the top ten unanticipated events reported to their database, with about sixty-three percent resulting in death.

Any event such as a fall is examined through the lens of one’s profession.  The legal perspective of an attorney differs from the healthcare perspective of a nurse.  Perspectives tend to inform the questions asked in regards to a particular event.  Therefore it is important to know which questions to ask in order to determine what did or didn’t happen.

While all healthcare personnel are concerned with patient safety, nurses have particular responsibilities— to ensure the implementation of all interventions to ameliorate fall-risk, inform improvement efforts, and prevent falls.  One of the ways that nurses accomplish this is to conduct what can be thought of as a post-mortem of the event: a post-fall huddle (PFH).   The format of PFHs can serve as a guideline for attorneys to formulate the correct questions regarding the circumstances of a fall.

PFHs are immediate evaluations of the circumstances surrounding a fall.  The PFH is recommended by The Joint Commission as a strategy to review fall and injury risk factors with the ultimate goal of prevention.  While PFHs are confidential and therefore off the medical record, they provide a template to examine any unanticipated event in a healthcare setting.

Individuals involved in a PFH include the care team with knowledge of the patient/resident and event, and if possible, the individual and his/her family.  The format of a PFH tends to follow a communication tool commonly known among healthcare personnel— Situation, Background, Assessment, Recommendation, or SBAR.  Each section of the PFH provides further clarification of the event as well as the facility’s protocols, policies, and procedures.

The Situation – What Happened?

It is important to assemble all individuals who possess knowledge of the incident— including the patient/resident, if possible— within 30 minutes of the fall to gain the most systematic picture.  First, the PFH members must establish a timeline of events, determining what time the incident occurred and witnesses, if any.  The following questions must then be answered: did the fall occur during a shift change?  Was there full staffing as per facility policy?  If the shift was understaffed, how many staff were absent or unavailable, and why (on break, another emergency on unit, etc.)?

After determining the staffing pattern, PFH members must establish the location of the fall— in the hallway, bathroom, room, nurse’s station, etc.— and examine the environment in which the fall occurred.  First, they must identify whether a method of communication was available to the patient/resident to summon help— was a call light, a call bell, or any other method detailed by facility policy accessible and in reach?  If the fall occurred in the patient/resident’s room, were commonly needed items also in reach— tissues, phone, food tray, trash bin; and any assistive devices such as cane, walker, glasses, or hearing aids?  Was there a clear, unobstructed path to the bathroom?  If appropriate, were bed rails in place— if so, how many?  Identify any possible trip hazards in the area— tubes, cords, clothing, shoes, etc.  If out of bed, was the individual wearing non-skid footwear?  Was the floor slippery or freshly washed?  If so, was proper signage in place?  If appropriate, was the bed or wheelchair alarm in place and turned on?  Was the all the equipment functional?  If the individual had been designated as at-risk for a fall, were all the hospital/facility fall prevention policies in place and followed?

The final step is determining what the patient/resident was doing at the time of the fall.  If unwitnessed and if the patient/resident can’t communicate or recall the circumstances leading up to the fall, PFH members must look at the whole picture— was the patient/resident reaching for something?  Trying to get to the bathroom?  Attempting to transfer from a wheelchair, or leaning on something for support that gave way?  It’s also important to determine the last person to see the individual, and what were they were doing at the time.  Finally, it is important to ask the patient/resident if there was anything different from any other instance in which he/she performed this activity in the past.

The Background – What do we Know?

This section addresses the specific fall-risk factors, medication management, and medical/nursing assessments.   Most facilities use the Morse Fall Scale, a standardized risk assessment tool, upon admission of a patient/resident.  The Morse Fall Scale details common risk factors and predicts a patient/resident’s fall potential.  Members of a PFH must detail the particular factors that may have increased fall-risk including impairment to any of the following— mobility, mentation, bowel and/or bladder patterns, communication, cognition, and vital signs.  Further considerations include age, prior fall history, administration of any medications known to affect balance or judgment prior to the fall (i.e. anti-seizure medication, tranquilizers, anti-anxiety, anti-depressants), and any change in medications over the prior two days.  Any medical/nursing diagnosis must be taken into account, including dementia, mental illness, low blood pressure, low blood sugar, Parkinson’s Disease, Diabetes, withdrawal from alcohol or drugs, or any other significant condition that could impact the physical or mental ability of the patient/resident.

Any recent laboratory and diagnostic results (12-hours prior to fall) and nursing, physician, and any other healthcare professional notes should be attached to the PFH.  The same fall-risk scale should be repeated post-fall and a comparison of pre- and post-fall scores reviewed and recorded in the medical record.

The Assessment – Was There Any Injury?

Post-fall but prior to the arrival of EMTs and treating physicians, a thorough nursing assessment is performed to evaluate any potential injury.  First the nurse will check for any injury with the potential to be life-threatening, focusing on circulation, airway, and breathing.  This is followed by an evaluation of any mobility injuries, neurological deficits, and pain.  Vital signs (blood pressure, heart and respiratory rates, pain and oxygen level) are taken and recorded.  All elements of the assessment are documented in the medical record.

The Recommendations – What Did we Learn?

After examining the entire event, revisions to plans of care or even facility policy and procedures may be the next logical step.  Were all facility policies and procedures followed and documented?  Were they appropriate to the situation?  For instance, some acute care hospitals include inpatient psychiatric units.  Is the facility applying the same fall-risk policy to the entire hospital?   Were preventive measures in place and documented; if not, why?

Implementation of any further interventions or care plan modifications should include prevention strategies based on the finding of the PFH or, at the very least, the nursing post-fall assessment.  What were the post-fall physician orders, including diagnostic tests?  Were they appropriate and implemented?  What was the post-fall follow-up?  Was it documented?

Finally, communication post-fall is key, including a hand-off report to the next shift and notification of the patient/resident’s family or legal guardian, his/her primary care care or attending physician, and the facility administration.  All communications should be documented in the medical record.

A post-fall huddle is an immediate evaluation of the circumstances preceding and occurring in the aftermath of a fall.  The huddle is usually comprised of an interdisciplinary group of individuals caring for the patient/resident, that have knowledge of the event and includes the individual and his/her family, if possible.  The actual huddle document is privileged and confidential, but all objective information is contained in the medical record.  The huddle format provides an attorney with a guideline to develop relevant questions concerning the situation, background, assessment, and recommendations in regards to an unanticipated fall.

Expert Author E-076044

Expert E-076044This extremely qualified expert of Nursing obtained her Basic Certificate in Gerontology, her AA in General Studies, and her AAS in Nursing from North Harris College, she obtained her BS in Nursing from Prairie View A&M University, her MS and her Post-Masters in Nursing from The University of Texas Health Science Center at Houston, and her DNP in Nursing from the University of South Alabama. She is a Certified Registered Nurse in Texas and is a member of the American Psychiatric Nurses Association. She has 15 Publications and is currently an Advanced Practice Nurse at a local Health Center.

Basic Certificate, Gerontology, North Harris College
AA, General Studies, North Harris College
AAS, Nursing, North Harris College
BS, Nursing, Prairie View A & M University
MS, Nursing, The University of Texas Health Science Center at Houston
Post-Masters, Nursing-Addictions Focus, The University of Texas Health Science Center at Houston
DNP, Nursing, The University of South Alabama
Certified, Registered Nurse
Member, American Psychiatric Nurses Association
Published, 5 Articles, 10 Abstracts
Former, Registered Nurse-Geropsychiatry, Columbia Parkview Center
Former, Charge Nurse-Geropsychiatry, Tenet Park Plaza Hospital
Former, Charge Nurse-Geropsychiatry, West Oaks Hospital
Former, Registered Nurse-Geropsychiatry/Psychiatric Intensive Care, Memorial-Hermann Behavioral Health Center
Former, Consultant, Advanced Practice Clinician, The University of Texas Houston Health Science Center on Aging
Former, Community Health Coordinator, Wolfe Center, Seven Acres Jewish Senior Care Services
Former, Clinical Instructor, Psychiatric/Mental Health Nursing, The University of Texas Health Science Center at Houston School of Nursing
Former, Psychotherapist, The University of Texas
Former, Advanced Practice Clinician, The University of Texas – Houston Recovery Campus
Former, Primary Clinician/Nurse Manager – HOPE Unit, The Menninger Clinic
Former, Clinical Team Leader – Tobacco Treatment Program
Former, Domiciliary Chief, Veteran’s Affairs Medical Center-Houston
Former, Clinical Manager, Memorial Hermann Southwest
Former, Director Patient Care, Memorial Hermann Southwest
Former, Director of Behavioral Health, Memorial Hermann Southwest
Former, Advanced Practice Nurse, Memorial Hermann Medical Group
Current, Advanced Practice Nurse, Health Center