Skip to content
Andrew Pollack-Gray

Nursing Notes

Fall Risk

3 min read

Patient Needs

Prevent falls and injuries while maintaining independence, mobility, and dignity.
Common risk factors:

  • Physical: Weakness, poor balance, fatigue, muscle atrophy, neuropathy.
  • Medical: Orthostatic hypotension, new illness, dizziness.
  • Sensory: Impaired vision or hearing.
  • Medication: Side effects, sedation, or drug interactions.
  • Environmental: Clutter, spills, poor lighting, improper footwear.
  • Fall History: Previous falls, especially recurrent falls.
  • Changes in Condition: New confusion, changes in mobility, acute illness, or increased assistance needs.

What Should I Assess?

  • Changes in balance, strength, and mobility.
  • Dizziness or weakness when standing.
  • Ability to follow instructions and use assistive devices.
  • Appropriate footwear and working mobility equipment.
  • Environmental hazards and access to the call light.
  • Assistance level specified in the care plan.

How Do I Provide Care?

Fall Prevention:

  • Keep walkways clear, dry, and well-lit.
  • Ensure appropriate nonslip footwear.
  • Respond promptly to toileting and assistance requests.
  • Encourage safe mobility and prescribed exercise.
  • Ensure walkers, wheelchairs, and grab bars are accessible.
  • Use gait belts and mechanical lifts as directed.
  • Encourage use of glasses and hearing aids when needed.
  • Follow individualized fall-prevention interventions.
    If a Resident Begins to Fall:
  1. Do not attempt to keep the resident upright by force.
  2. If trained and safe, use the approved assisted-fall technique to guide them toward the floor.
  3. Protect the head as much as possible without endangering yourself.
  4. Call for assistance immediately.
    After a Fall:
  5. Stay with the resident and provide reassurance.
  6. Do not move the resident until assessed or directed, unless necessary for immediate safety.
  7. Notify the nurse immediately and activate emergency response when indicated.
  8. Observe for pain, bleeding, injury, confusion, or changes in consciousness.
  9. Follow nurse directions for vital signs, monitoring, and transfer.
  10. Document observations and care according to facility policy.

Safety & Precautions

  • Never attempt unsafe lifting or catching of a falling resident.
  • Do not independently lift a resident off the floor after a fall.
  • Use the approved method and equipment for recovery when directed.
  • Bed and chair alarms alert staff but do not independently prevent falls.
  • Restraints are not routine fall-prevention devices and may increase injury risk.
  • Follow the care plan for assistance levels and safety equipment.
  • Report sudden changes in mobility or balance.
  • A resident may have an injury after a fall even when there are no obvious external signs.
  • Report all falls immediately, including unwitnessed falls and falls without visible injury.
  • Observe and communicate the resident’s responsiveness, complaints of pain, apparent injuries, and circumstances of the fall.
  • Follow nurse directions for post-fall observation and monitoring. CNAs do not independently determine that a resident is uninjured or safe to mobilize.
  • Report new or worsening symptoms promptly, even if the resident initially appeared well.

What Should I Report?

  • Every fall, including those without visible injury.
  • New dizziness, weakness, or loss of balance.
  • Head injury, bleeding, severe pain, or suspected fracture.
  • Confusion, altered consciousness, or neurological changes.
  • Increased assistance needs.
  • Environmental hazards or malfunctioning safety equipment.

Sources

Flashcards

Why does fall prevention need individualized plans?03-application / patient-care
Answer

Mobility, cognition, medications, and environmental risks differ.

Why is a resident's history of previous falls important?03-application / patient-care
Answer

Previous falls are a strong predictor of future falls.

Should a CNA lift a resident immediately after a fall if no injury is visible?03-application / patient-care
Answer

No. Obtain nursing assessment and follow the approved recovery procedure.

Graph View

Backlinks