According to the Centers for Disease Control and Prevention (CDC), falls are the most frequent cause of accidental death in older adults; in 2020 more than 36,000 people aged 65 or older died as a result of fall-related injuries. Non-fatal injuries, such as hip fractures or head injuries, can lead to functional declines in mobility and other activities of daily living. Fear of future falls can also lead to self-imposed restrictions in mobility and other activities, increasing the risk of subsequent falls.
Most falls occur as a result of multiple contributing factors; therefore, managing the risk of falling begins with identifying the factors that contribute to fall risk. Some of the most relevant risk factors include:
- History of prior falls
- Chronic medical conditions
- Acute illness
- Impaired gait and balance, lower extremity weakness
- Cognitive impairment
- Changes in vision
- Certain high-risk medications and polypharmacy
Environmental factors can also increase the risk for falls, including:
- Inadequate lighting
- Uneven or damaged flooring
- Wet or slippery floors
- Missing or damaged handrails and grab bars
- Damaged or improperly fitted equipment, such as beds, wheelchairs, or walkers
- Improper use of assistive devices
- Inadequate supervision of the people living in the NF, including those who exhibit aggressive behaviors
A successful fall risk management program requires a thorough clinical assessment, with input from all members of the interdisciplinary team. Each person living in a nursing facility (NF) should be assessed for fall risk within 24 hours of admission, with an acute change in condition, and at least quarterly thereafter. When a fall occurs, the initial fall risk assessment should be repeated, along with a thorough investigation of the circumstances of the fall.
The care planning process requires development of person-centered interventions for minimizing fall risk and preventing fall-related injuries. Interventions should be based on the findings from the fall risk assessment and/or post-fall investigations, as well as the person’s preferences and goals. The use of any particular person-centered intervention should be based on the strength of the evidence provided by clinical evidence, such as best practice guidelines, clinical trials, or literature reviews. The care plan should also include interventions that are system-based, such as those that promote a safe environment (appropriate lighting, handrails, grab bars, etc.). The effectiveness of the interventions should be evaluated periodically, and the care plan revised as necessary to reflect changes in the fall risk assessment.
Implementing a fall risk management system using evidence-based best practice can reduce the prevalence of falls in the NF, while limiting the potential for fall-related injuries. The toolkit below includes evidence-based resources that will assist facility staff in developing effective systems for fall risk management.
Resources Created by HHSC
- Evidence-based Best Practice for Nursing Fall Risk Management (PDF) summarizes the key elements of an effective fall risk management program.
- Measuring Orthostatic Hypotension (PDF) provides instructions for measuring orthostatic vital signs and interpreting the findings.
- Fall Risk Management Care Plan Highlights (PDF) can assist facility staff in developing individualized care plans for fall risk management.
- Medications with Fall Risk Precautions (PDF) identifies medications that may contribute to an increased risk for falls.
Resources from Other Organizations
- Agency for Healthcare Research and Quality (AHRQ) Falls Management Program is a quality improvement initiative for NFs to develop more effective fall risk management systems.
- AHRQ On-Time Falls Prevention provides tools designed for use with electronic medical records that can help NF staff monitor fall risk and implement appropriate interventions for preventing falls.
- American Geriatrics Society (AGS) Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults provides access to the Beers Criteria and related resources. Note: Access to these resources requires registration at the AGS website.
- CDC Older Adults Fall Prevention provides resources for preventing falls in older adults.
- CDC Stopping Elderly Accidents, Deaths & Injuries (STEADI) Initiative provides clinical resources and tools developed for healthcare professionals to reduce risk for falls in older adults.
- VHA National Center for Patient Safety Falls Toolkit provides information for designing a system for fall risk management, along with interventions for preventing falls in high-risk individuals. The toolkit also includes educational information for residents, their families and facility staff on managing fall risk and preventing injuries.
- AMDA – The Society for Post-Acute and Long-Term Care Medicine Falls and Fall Risk Clinical Practice Guideline was developed by an interdisciplinary group of professionals providing care in the long-term care setting, using both clinical research and consensus-based approaches. The Falls and Fall Risk Clinical Practice Guideline is available for purchase.
- Registered Nurses’ Association of Ontario Prevention of Falls and Fall Injuries in Older Adults provides evidence-based resources for developing an effective fall risk management program for older adults.
- National Institute for Health and Care Excellence, Falls in Older People: Assessing Risk and Prevention is an evidence-based clinical practice guideline for reducing the risk of falls in older adults.