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Fall Bundle No Harm Campaign Licensed Staff

Fall Bundle No Harm Campaign Licensed Staff. REPORTING of FALLS. Regulatory Agencies. Falls are reportable as a Sentinel Event per The Joint Commission and as endorsed by The National Quality Forum’s List of “Never Events ” Individual State Statutes, e.g. California Senate Bill 1301

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Fall Bundle No Harm Campaign Licensed Staff

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  1. Fall Bundle No Harm Campaign Licensed Staff

  2. REPORTING of FALLS

  3. Regulatory Agencies • Falls are reportable as a Sentinel Event per The Joint Commission and as endorsed by The National Quality Forum’s List of “Never Events” • Individual State Statutes, e.g. California Senate Bill 1301 • The Department of Health Care Services outlines the following: • Section 2702 of the Affordable Care Act directs States to develop and implement a plan that withholds Medicaid payments to hospitals for provider-preventable conditions (PPC) as defined in the regulation • In California the Department of Health Care Services (DHCS) has developed a State Plan Amendment (approved by CMS) to implement Section 2702 • Similar recommendations in Arizona and Nevada • CMS elected to enforce compliance as of July 1, 2012 even though the federal law took effect July 1, 2011

  4. Reporting of Falls CMS requires reporting of Hospital Care-Acquired Conditions (HCACs ) only in inpatient acute care hospitals. Related to falls and trauma, this includes: • Fractures • Dislocations • Intracranial Injuries • Crushing Injuries • Burns • Electric shock

  5. The Fall Bundle T-E-A-M

  6. No Harm Campaign - Fall Bundle

  7. T-E-A-M • T - Toileting (Hourly Rounding) • Round on patient/family every hour • Correct technique • Validation • Accountability • T – Teaching (Patient and Family: Teach Back Model) • Patient and family education. Put a process in place that includes giving a Fall Handout/brochure, utilizing teach-back techniques to verify patient understanding and document education • Education and communication of falls, risk across departments and disciplines (including attending physicians) will be provided • Utilize the Q-Tube customized Fall Prevention Bundle Video. This is found either on the Q-Tube site or Patient Safety SharePoint under the Fall tab

  8. T-E-A-M • E - Environmental • Bed Alarms/Chair Alarms • Floor Mat – ALL patients at high risk for falls (John Hopkins FRAT score > 13) shall have floor mat (new injury reduction intervention) and bed alarm (pre-existing fall risk reduction intervention) in place at all times. • Fall sign on door, yellow booties, and yellow magnet on patient’s board • Beds in lowest positions • Gain belts • Appropriate use of restraints • A – Assessment • Fall Risk Assessment tools (this includes the preliminary medication review) • Fall Injury Assessment (ABCs) • Application of Fall Matrix – The matrix will be used as an adjunct to the assessment tools. It is divided into four grids. Each grid recommends basic fall prevention strategies determined by the patient’s fall risk assessment and fall injury assessment score

  9. T-E-A-M • A - Assessment • Fall Huddles • Hand-off Methodologies (SBAR and Ticket to Ride) • Fall Debriefing Form (fall without injury) • RCA (Fall with injury) • M – Medication • Secondary medication review. Involve pharmacists and prescribing providers with the goal of eliminating or replacing unnecessary drugs that increase the risk of falls or the severity of fall-related injury

  10. Fall Risk Assessment Tools (FRAT)

  11. Fall Risk Assessment Tools

  12. Assessment Tools – Johns Hopkins Fall Risk

  13. Assessment Tools – Johns Hopkins Fall Risk

  14. Assessment Tools – Johns Hopkins Fall Risk

  15. Assessment Tools – Johns Hopkins Fall Risk

  16. Assessment Tools – Little Schmidy Fall Risk Assessment

  17. Assessment Tools – Little Schmidy Fall Risk Assessment

  18. Injury Risk Assessment

  19. Injury Assessment Tool (ABC’s) A: Age >65 years B: Bones susceptible to fracture C: Coagulopathies/risk for bleed S: Surgery (postoperative) Note: Use of critical thinking and clinical judgment should be used to override the result of any fall assessment tool assessment.

  20. Implementation Strategies CHSB is implementing strategies to identify patients who are high risk for falls and ways to prevent incidence/injuries related to falls. Every employee must be aware of the following strategies: • Use of YELLOWbooties • Use of YELLOW armband • Use of YELLOWgown • Use of YELLOWmagnet on patient’s board • Use of hip protectors • Use of bed alarms • Use of floor mats

  21. Implementation Strategies Use of YELLOW booties 3. Use of YELLOW gown 2. Use of YELLOW armband

  22. Implementation Strategies 4. Use of yellow magnet on patient’s board 6. Use of bed alarms 5. Use of hip protectors 7. Use of floor mats

  23. Post Fall Debriefing Tool

  24. ThankYou Please complete the Post Test after reviewing the module

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