A fall is an unplanned descent to the floor (or extension of the floor, such as a trash can or other equipment) with or without injury. In the United States, falls are the most frequent cause of accidental death in older adults; more than 1,800 nursing facility residents die each year due to injuries sustained from falls. Around 5 percent of adults over the age of 65 live in nursing facilities, but account for nearly 20 percent of fall-related deaths in this age group. Up to 20 percent of residents who fall sustain serious injuries that can lead to a decline in functional ability and mobility impairment. Fear of future falls can 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 intrinsic and extrinsic factors that contribute to fall risk. A successful fall risk management program requires a thorough clinical assessment of residents and their environment, with input from all members of the interdisciplinary team. Each resident should be assessed for fall risk on admission and with an acute change in condition, as well as 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 resident-centered interventions for preventing falls and fall-related injuries, based on the findings of fall risk assessment and/or post-fall investigations. The use of any particular intervention should be based on the strength of the evidence provided by existing clinical trials or literature reviews. The effectiveness of fall risk management 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 nursing facility, 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.
Evidence-based Best Practice for Nursing Fall Risk Management (PDF)
This handout, developed by nurses from the Quality Monitoring Program, summarizes the key elements of an effective fall risk management program.
American Geriatrics Society. The 2012 American Geriatrics Society Updated Beers Criteria
Originally developed in 1991, the Beers Criteria identifies medications that may be inappropriate for use in older adults. In 2012, the American Geriatrics Society updated the Beers Criteria, using an evidence-based methodology.
The American Geriatrics Society (AGS) is a not-for-profit organization of more than 6,700 health professionals devoted to improving the health, independence and quality of life of all older people.
Centers for Disease Control and Prevention (CDC). Preventing Falls Among Older Adults
The National Center for Injury Prevention and Control (NCIPC) serves as the Injury Center for the Centers for Disease Control and Prevention (CDC). Their Preventing Falls Among Older Adults website section includes fact sheets, graphs, podcasts and brochures about falls and fall prevention for older adults.
Fall Prevention Center of Excellence
The Fall Prevention Center of Excellence is the home of a California Fall Prevention Initiative. The Center provides information to both consumers and professionals on various topics relating to falls and fall prevention.
National Center for Patient Safety 2004 Falls Toolkit
The 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.
Timed Up and Go Test
The Timed Up and Go (PDF) test is an assessment of mobility, used to identify individuals at risk for falls. Instructions for the Timed Up and Go test are similar to the Get Up and Go test, however the assessor times the individual as he or she completes the test. Times of 12 seconds or more indicate a high risk for falls.
Tinetti Assessment Tool
The Tinetti Assessment Tool (PDF) is used to evaluate gait and balance. The resident is asked to perform a number of specific tasks, and a score is assigned based on his or her ability to complete the task as instructed. The maximum total score is 28, with scores below 19 indicating the resident is at high risk for falls.
Berg Balance Scale
The Berg Balance Scale (PDF) is an evaluation of static balance and fall risk, with 14 separate tasks that are scored based on the resident's ability to complete the activity. The maximum total score is 56, and a resident with a score 20 or below is considered to be at high risk for falls. An eight point difference between any two assessments is considered a change in function.
Merck Manual for Health Care Professionals
First published in 1899, the Merck Manual is a medical reference covering a variety of medical topics. In 1990, the Merck Manual of Geriatrics was published, focusing on the care of older adults.
American Geriatrics Society. AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons 2010
This guideline, developed by the American Geriatrics Society and the British Geriatrics Society, is designed to assist health care providers in developing a system for fall risk management. Originally published in 2001, the recommendations in this update are based on an analysis of the most current evidence available.
American Medical Directors Association Clinical Corner: Falls and Fall Risk
The American Medical Directors Association (AMDA) is a professional association of physicians who practice in the long term care setting. The AMDA website includes resources for managing fall risk and reducing the incidence of falls in the nursing facility. The AMDA Falls and Fall Risk clinical practice guideline is available for purchase.
Registered Nurses' Association of Ontario (2005), Prevention of Falls and Fall Injuries in the Older Adult (revised). Toronto, Canada: Registered Nurses Association of Canada. Guideline Supplement May 2011
The Registered Nurses' Association of Ontario (RNAO) initiated their Nursing Best Practice Guidelines Program in 1999. This guideline provides recommendations for preventing falls and fall related injuries, using evidence gathered through systematic literature review and analysis.
Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Fall and Injury Prevention
Published by the Agency for Healthcare Research and Quality (AHQR) in 2008, this handbook (PDF) provides evidence-based recommendations for managing fall risk and preventing fall related injuries.
Best Practice System Summary/Technical Assistance Worksheet (PDF)
Developed by nurses from the Quality Monitoring Program, this checklist identifies key elements of an effective fall risk management system, and can be used by facility staff to identify opportunities for improvement.
Measuring Orthostatic Hypotension (PDF)
This handout, developed by nurses from the Quality Monitoring Program, provides instructions for measuring orthostatic vital signs and interpreting the findings.
Fall Risk Management Care Plan Highlights (PDF)
This handout, developed by nurses from the Quality Monitoring Program, can assist facility staff in developing individualized care plans for fall risk management.
Medications with Fall Risk Precautions (PDF)
This handout, developed by pharmacists from the Quality Monitoring Program, identifies medications that may contribute to an increased risk for falls.
Updated: March 3, 2014