THO-NW NSQHS Standard 10 - Patient Falls Audit v1

• Document No.

• Conducted on

  Date

• Hospital

  MCH

  NWRH

  King Island

  Queenstown

  Smithton

• Ward

  Select Medical Surgical ICU HDU Paediatric Maternity / Neonate Rehabilitation Palliative Aged Care

  • Medical
  • Surgical
  • ICU
  • HDU
  • Paediatric
  • Maternity / Neonate
  • Rehabilitation
  • Palliative
  • Aged Care

• Bed number

• Acknowledgement: Based on the Queensland Health paper tool available at www.health.qld.gov.au

• This audit collects patient level data on a ward/unit. Start a new audit for each patient audited.
  
  If an unwanted media field opens, tap the relevant question to close it.
  
  Please maintain patient confidentiality at all times.

Observational audit - patient

• Which type of bed rail is present on the bed? (Note: only check where a patient is present.)

  Select N/A Bed not present No bed rail Split - both rails up Split - half rail up Rails up Rails midway Rails down

  • N/A
  • Bed not present
  • No bed rail
  • Split - both rails up
  • Split - half rail up
  • Rails up
  • Rails midway
  • Rails down

• Is the nurse call system within reach of the patient?

  Yes

  No

  N/A

• Is the bed control (if bed has a control) within reach of the patient?

  Yes

  No

  N/A

• Is the patient's bed at the appropriate height? Note: Appropriate height is the level that the patient can sit and touch the floor with their feet, with their legs at 90 degrees.

  Yes

  No

• Are the patient's bed brakes locked on?

  Yes

  No

• Is the patient's chair at the appropriate height?

  Yes

  No

• Is the patient's room free of clutter / other hazards?

  Yes

  No

• Is the patient's tray table within reach?

  Yes

  No

• If the patient has sensory aids (eg glasses, hearing aid) are they within reach?

  Yes

  No

  N/A

• Does the patient have appropriate footwear? (Eg non-slip / well fitting / low heel)

  Yes

  No

  N/A

• If patient is at risk of falling, are they within view of and close to the nursing station? (Risk is determined below.)

  Yes

  No

  N/A

• If "no" responses are obtained, advise Nurse so that the problem can be promptly rectified.

Documentation audit - patient

• Is there documented evidence at the bedside that the patient was screened for a history of falling on admission?<br>(Note: screening identifies if the patient is at increased risk of falling and then should be assessed at admission.)

  Yes

  No

  Incomplete

• Is there documented evidence at the bedside that the patient was assessed for risk of falling on admission?

  Yes

  No

• What is the patient's documented risk of falling?

  Low risk

  Medium risk

  High risk

• What type of bed is the patient in?

  Standard bed

  Mid Low bed

  Low Low bed

• If the patient is at risk of falling, have they been reviewed by the Physio / OT?

  Yes

  No

• Which one?,

  Physio

  OT

• Is there documented evidence at the bedside that there is a multifactorial falls prevention plan (FPP)?<br>(Ie documented actions corresponding to identified risk factors.)

  Yes

  No

• What type of bed is the patient in?

  Standard bed

  Mid Low bed

  Low Low bed

• Is there documented evidence at the bedside of the level of supervision / assistance required for mobilisation in the patient's care plan? (Red dot system.)<br>(N/A for patients that can mobilise independently.)

  Yes

  No

  N/A

• Is there documented evidence at the bedside that the patient's care plan includes the use of a mobility aid?<br>(N/A for patients that can mobilise independently.)

  Yes

  No

  N/A

• Is the mobility aid within arms reach of the patient? (Patient refuses to use aid = PRTUA)

  Yes

  No

  Patient refuses to use aid

• Does the patient have documentation at the bedside (ie in the care plan) that an assessment has been undertaken for continence and continence aid requirements?

  Yes

  No

• Has the discharge process commenced?

  Yes

  No

• Have referrals to appropriate primary health providers / community services been organised?

  Yes

  No

• To whom - select all applicable options

  Select Physio OT Dietitian Nutritionist AH Asst Nursing Home Placement HACC Other

  • Physio
  • OT
  • Dietitian
  • Nutritionist
  • AH Asst
  • Nursing Home Placement
  • HACC
  • Other

• Specify what other referrals have been made.

• Is there evidence that the patient has experienced a fall while in hospital?

  Yes

  No

• Is there evidence the incident has been entered into the incident management system (EIMS)?

  Yes

  No

• Report to NUM to ensure incident is recorded.

Patient Questions

• Patient Q: We're you shown around the bed area, room and ward/unit facilities on admission?

  Yes

  No

• Patient Q: Did you have an education session with a staff member on how you can prevent falls?

  Yes

  No

  N/A

• Which form of education did you receive?

  Select Patient education brochure Safe recovery workbook Viewed DVD Discussed with staff member Other - specify below

  • Patient education brochure
  • Safe recovery workbook
  • Viewed DVD
  • Discussed with staff member
  • Other - specify below

• Patient Q: Were you involved in the development of plans to prevent you falling while in hospital?

  Yes

  No

  N/A

• If you have identified a patient risk related to bed or surrounds, please photograph here (do not include any patient faces in the photo).

  Media

• Auditor please enter your name and sign off here

  Sign