APPENDIX 1
FALLS RISK ASSESSMENT
1
Inpatient Admission Assessment
On admission or transfer to Older People’s Mental Health wards, Community
Rehabilitation wards or the Hospice all patients will have a multifactorial risk
assessment competed within 12 hours. It will be the responsibility of the
admitting nurse/named nurse to ensure that this is completed and any
immediate risks addressed.
Following completion of the assessment a care plan will be completed
Patients with certain diagnosis/treatment will be considered a high risk of falls
or harm from falls. These include;
o
o
o
o
o
o
o
1.1
Patients with a diagnosis of osteoporosis or osteopenia
All patients with a recent hip replacement
Patients with cognitive impairment or dementia/delirium
Patients with significantly impaired mobility
Patients with recent history of recurrent falls
Patients with a history of falls or fear of falling
Patient who are unsafe but who try to walk alone
Assessment Learning Disability
All patients within In-Patient settings and community homes must have an up
to date risk assessment with any needs identified within care plans.
1.2
Assessment Forensic Services/ Adult Mental Health/ Drug and Alcohol
Services
The Multifactorial In-Patient Falls Risk Assessment and Guidance must be
completed for patients who have mobility problems, history of previous falls,
medical or physical conditions which may predispose them to falls. It will be
the responsibility of the clinician co-ordinating the care to ensure, when
indicated, that the assessment is completed.
1.3
Hospice
The falls risk assessment will be completed on admission. However its review
and actions may differ to other services due to the patient group. The
frequency and process of review of risk assessment will be dependent on the
needs of the individual patient at that time and their presenting condition.
2
Actions as part of initial assessment;
2.1
Identify any information relating to history of falls
This Information is vital to identify patient’s levels of risk.
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2.2
Identify with patient/carers/family regarding




2.3
Position of bed at patients home e.g. side of bed they normally get out of
Any patterns patient may have when getting up at night
Mobility aids used
Preferred night time lighting
Avoid commencing sedating prn medication/night sedation until sleep
assessment completed
There is increased risk associated
polypharmacy. (See Appendix 11)
with
certain
medications
and
Studies have found that around two-thirds of hospital patients who fell had
received at least one medication that affects the central nervous system in the
24 hours prior to their fall. New medications should not be commenced unless
a clear need has been identified through assessment.
2.4
Ensure appropriate footwear ( see Appendix 13)
Patients may be admitted without bringing slippers or shoes, or their footwear
may not be suitable, safe, or may not fit. Attempts should be made as soon as
possible to obtain appropriate footwear for the patient. In emergency slipper
socks may be utilised if indicated.
2.5
Ensure Call bell within reach
All patients who are able to use the call bell should have it within sight and
within reach if appropriate.
Every patient must be shown how to use the call bell system. Patients must
be reassured and encouraged to use the call bell.
If a patient has cognitive impairment, communication problems and/or lacks
capacity to use a call bell, there must be a documented alternative plan to
ensure patients individualised needs and requirements are met.
2.6
Urinalysis
Will be completed as part of admission assessment Results will be analysed
and appropriate treatment commenced if indicated
2.7
The use of a walking aid
Will be identified on assessment (see Appendix 11)
If the patient has brought in their own walking aid this will be clearly marked
and within reach
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If the patient uses a walking aid but has not brought it with them, a walking aid
will be provided on admission if nursing staff are trained or as soon as
possible by the Physiotherapist
If a walking aid is issued by a member of nursing staff, this will be reviewed by
the Physiotherapist as part of their initial assessment
2.8
A Bed rails assessment
Will be considered on admission (see Appendix 3) If immediate risks of falls
from bed are identified a bed rails assessment will be completed.

2.9
This will also be reviewed as further information is obtained e.g. how the
patient sleeps
Items within reach
Staff will ensure that all patient’s items will be placed within reach
2.10
Lying and standing blood pressure
Will be completed as part of the initial assessment. Any postural deficits to be
discussed with Doctor/ Nurse Practitioner.
3
Within 48 hours (Mon – Fri) of admission patient will be seen for a
Physiotherapy Assessment ( except in the hospice where this may not
be indicated)
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


4
Establish falls history
Review falls assessment
Review/prevision of walking aids
Mobility care plan/care goal
Reviewing risk assessments and care plans (all areas)
All identified falls risk factors and care needs must be addressed and
reviewed regularly as part of the continuous multi-disciplinary (MDT) care
planning process.
The decision as to how often multi factorial risk assessments are reviewed
should be based on clinical judgement/MDT decision making and related to
the individual’s specific needs.
All patients should be medically assessed for risks of falls against their
pathology and medications.
If staff require advice they should discuss further with senior colleagues, other
members of the Multidisciplinary Team (MDT) or they can contact the Trust
Falls Leads for advice.
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Risk assessment must always be reviewed following a fall or a near miss.
Following a fall a full MDT reassessment and review should be
undertaken.

Patients who have fallen will require interventions to reduce their likelihood
of further falls. These interventions will be decided upon during the review
of the service user’s care post fall, e.g. as part of care planning, Care
Programme Approach (CPA) review, MDT meetings. Any actions taken
and/or referrals made regarding such interventions will be clearly recorded
in the patient’s care plan.

If patients have recurrent falls then the Ward Manager/ Modern Matron will
discuss the case with staff and if necessary will themselves lead further
review of the falls prevention risk assessments and care planning
6
Community Patients (see Appendix 13)
6.1
All patients over the age of 65, and those aged 50-64 who are judged by a
clinician to be at a higher risk of falling because of an underlying condition,
should have a multifactorial assessment completed and a person centred care
plan developed for any identified risks. This may include referral to other
services.
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CARE PATHWAY FOR IN PATIENTS IDENTIFIED AS AT RISK OF FALLING
Patient admitted onto ward
Falls risk assessment completed within 12 hours; bedrails risk tool to be completed for patients who are at risk of rolling/ falling from bed
Create an appropriate MDT care plan and regularly review
Involving patient and carer
History of
Falls
Identify any
previous falls;
including falls
from bed
Consider bed
alarm, bed rails
Physiotherapy/
Falls prevention
programme
Previous Fracture
Medical
Medication
Mental Health
Mobility
Physical Health
Environment
Identify any
previous fractures –
discuss these with
Dr or physio,
Check
glasses/hearing
aids
Medication review
Consider bed
alarm
Consider hip
protectors, bed
alarm
MUST/Dietetic
referral
Check lying
standing BP
Monitor side
effects of
medication
Consider
lighting,
signage, trip
hazards,
seating height,
bed height and
position.
Consider hip
protectors/bed
alarm/bed rails
Consider risks
associated with
bone health.
Medical review
Psychiatric
review/
observation/
sleep chart
Chiropody
referral/
appropriate
footwear
Re orientate to
surroundings/
Continence
assessment
Medical
assessment to
rule out physical
cause
Review use of
PRN medication
Ensure pain
assessment and
pain relief
Review
prescribing
Signs/ nursing
following fall Page 5 of 9 observation
Follow BPSD Nice
guideline around
prescribing
Physiotherapy
assessment
Consider 1:1 if
indicated
Ensure clear
signs
Referral for
alcohol
counselling
Health
promotion
advice
Multifactoral Risk Assessment
Multifactorial Falls Risk Assessment
Name:
DOB:
Name of Professional:
Address:
Signature:
Date:
Designation:
Contact no.
Ward:
Hospital no.
NHS No.
History of Falls:
How many falls in last 6 months?
Activity at time? When? Where? Pattern?
Unexplained – further assessment required
Explained – and further assessment required
Date
History
History of falls out of bed
History of fractures including wrist/shoulder.
Diagnosis of Osteoporosis or on bone health
medication
Y/N
Y/N
Y/N
Y/N
Cardio Vascular
Postural Hypotension/dizziness from lying standing
History of dizziness/blackouts/collapse
History of stroke or Cardiovascular problems
Symptomatic on standing?
Y/N
Y/N
Y/N
Y/N
Medication
2 medicines or more
PRN medication
Benzodiazepines/ prn medication
Night time risk
History of falls out of bed
Gets up during the night
Cognitive Impairment:
Any memory problems?
Any delirium symptoms or overlay?
Vision:
Wears glasses?
Any change in vision?
Has related pathology?
Hearing:
Wears hearing aid (s)?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
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Review records, discuss with family.
Discuss in MDT
Consider further osteoporotic
screening
Check medication regime re bone
health
Follow hip protectors protocol
Carry out blood pressure assessment
(baseline and lying/standing BP)
Refer to doctor
Discuss in MDT
Consider assistance required/times it
required
Consider impact on falls risk
Medication review with Consultant/GP
MDT review
Avoid unnecessary night sedation
Consider night-time toileting needs and
ensure plan in place
Consider bed rails assessment
Consider observation
Bed alarm
Carry out further cognitive assessment
Consider impact on falls risk
Consider assistance required/times it
required
Check glasses are clean.
Carry out basic visual check
Consider Ophthalmology
Check hearing aid works.
Check for ear wax.
Ref to Audiology if required
Name: …………………………………………………………………………. DOB……………………. NHS No……………………………………………………….
Continence
Is there a problem? Day / Night
Have appropriate aids?
Access to toilet / night light?
Y/N
Y/N
Y/N
Hydration
Any signs of dehydration?
Any dizziness?
Any UTI?
Y/N
Y/N
Y/N
Alcohol
Is intake above recommended units?
Y/N
Feet / footwear
Problem with nails / bunions / oedema?
Suitable, supportive, well-fitted shoes worn?
Y/N
Y/N
Pain
Is pain affecting mobility?
Where is the pain?
Y/N
Functional ability
Problem with mobility?
Poor balance
Reporting a fear of falling
Difficulty getting out of chair/ transfer problems
Additional Information:
Y/N
Y/N
Y/N
Y/N
Toileting needs assessment and plan in
place
Consider if urinary / faecal continence
assessment needed:Refer to nurse or specialist service
Recommend 8 (250mls) glasses of water
per day.
Review in MDT
Consider MSU
Provide sensible drinking advice.
Consider ref to local specialist support
service if required
Ref to Podiatry services if indicated
Consider referral to Orthotics if required
Provide info re suitable shoes.
Involve family as appropriate
Check analgesics taken correctly.
Ref to Doctor for analgesia review.
Physiotherapy assessment
Physiotherapy assessment
Make sure has suitable walking aid and
That walking aid within reach
Agree level of assistance needed and
ensure mobility plan in place
Risk Formulation / Risk Management Plan
Multifactorial Assessment completed on Date: …………………………
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Signature: …………………………………………….
FALL RISK ASSESSMENT TOOL (FRAT)
Notes for users:
1) Complete the assessment form below. The more positive factors, the higher the risk for falling.
2) If there is a positive response to three or more of the questions on the form, then please see the
guidance for further assessment, referral options and interventions for the different risk factors. If
trained and competent complete the falls template on System One.
3) Some users of the guidance may feel able to undertake further assessment and appropriate
interventions at the time of the assessment.
Name:
Date of Birth
NHS Number:
YES
1
Is there a history of any fall in the previous year?
How assessed? Ask the person.
2
Is the patient / client on four or more medications per day?
How assessed? Identify number of prescribed medications.
3
Does the patient / client have a diagnosis of stroke or
Parkinson's Disease?
How assessed? Ask the person.
4
Does the patient / client report any problems with his/ her balance?
How assessed? Ask the person.
5
Is the patient/client unable to rise from a chair of knee height?
How assessed? Ask the person to stand up from a chair of knee height
without using their arms.
Page 8 of 9
NO
Guidance for further assessment, referral options and interventions
Risk factor present
1) History of falling in
the previous year
2) Four or more
medications per day
3) Stroke or
Parkinson’s disease
4) Balance and gait
problems
5) Is the
patient/client unable
to rise from a chair of
knee height?
Postural hypotension
(low blood pressure)
Further assessment
Review incident(s),
identify factors which may
have caused or contributed
to the fall. Check medical
records, ask relatives if
present.
Identify types of
Medication prescribed –
ask patient, check actual
medication if patient has
them present, check
medical records, ask GP.
Ask about symptoms of
dizziness.
Recent/old stroke?
Functional decline?
Medically stable?
Confusion?
Can they talk while
walking?
Do they sway significantly
on standing?
Referral Options
Occupational Therapy
Physiotherapy
Falls Clinic/CICT
Interventions
Discuss fear of falling and realistic
preventative measures.
General Practitioner
Falls Clinic
Pharmacist
Review medications, particularly
sleeping tablets (see
www.bhps.org.uk/falls for more
information on medication and
falls).
Discuss changes in sleep patterns
which could be normal with ageing.
Occupational Therapy
Physiotherapy
Falls Clinic/CICT
Review medications, particularly
Parkinson’s medication.
Occupational Therapy
Physiotherapy
Falls Clinic/CICT
Teach about risk. And how to
maneuver safely, effectively and
efficiently.
Physiotherapy evaluation for range
of movement, strength, balance
and/or gait exercises.
Transfer exercises.
Evaluate for assistive devices.
Consider environmental
modifications to compensate for
disability and to maximize safety, so
that daily activities do not require
stooping or reaching overhead.
Discuss why they cannot rise
If not, can they rise using
hands?
Physiotherapy.
Falls clinic.
GP
Three readings taken
1) After rest five
minutes supine (laying
down, or sitting if this
cannot be done)
2) 1 minutes later
Standing
3) 3 minutes after standing
Drop in systolic BP greater
than 20mmHg and or drop
in diastolic greater than
10mmgHg
District Nurse
Practice nurse
General Practitioner
Falls Clinic
Offer extra pillows or consider
raising head of bed if severe.
Review medications.
Teach to stabilize self after
changing position and before
walking.
Avoid dehydration