A: Patient characteristics.

1.    Dementia associated with "sundowner" syndrome - nighttime confusion is a most common occurrence. In this situation, a patient wakes up in the middle of the night, not knowing where he/she is, experience a drop in blood pressure from arising too quickly, have a momentary dizzy spell or loss of consciousness and fall.
2.    Visual disturbance where a patient cannot see well enough to guide his/her steps.
3.    Arthritis and other orthopedic problems that compromise gait capacity.
4.    Old strokes associate with weakness, partial paralysis and loss of balance.
5.    Multiple medications that cause drops in blood pressure, lack of positional compensation when arising, medications which cause sleepiness, lack of awareness & balance and diabetic medication, which cause low blood sugars are also causes.

B: Environmental Factors.

Such things as slippery floors, uneven surfaces, blind corners, insufficient lighting and improperly placed beds and rails are specific factors in the SNF environment.

Incident reporting is an essential element in preventing falls.
Assessment of the causative factor for each fall must be recorded for
each individual patient and also noted in aggregate terms for the whole
facility. Patients who are frequent fallers must be carefully assessed
for underlying causes as noted above and a risk assessment made.

In addition, simple precautions, such as anti-skid strips around beds
and bathrooms, need to be implemented. Beds should be lowered at night
and bed rails raised. Mobility and balance evaluations are important
methods of assessing individual risks and point to specific, patient-
oriented interventions.

Ameliorating the potential severity of effects of falls in certain
patients should also be undertaken with consultation from the attending
physician. This would include such things as wearing hip protectors in
high fall risk patients and having patients who are on anticoagulants
and at high risk for falling wear crash helmets to prevent the most
disastrous complication of intracranial hemorrhage. Treating
osteoporosis is also important so bones are less likely to break with
minimal or moderate trauma.

Whereas not all falls are preventable even in the best of circumstances
with this group of patients, each SNF must have written protocols and
policies reflecting the principles outlined above for dealing with falls
in its facility. These policies must include ongoing monitoring and
evaluation by nursing and physician staff, physio and occupational
therapists and careful attention to prompt triage and treatment for
injured patients. Regular staff training and updating of policies are
the only way that an SNF can adequately fulfill its duty and standard of
care to its long term patients.