Fall Prevention in the Home

Falls are the leading cause of injury death in adults 65 and older. One in four older adults falls each year. Of those who fall, one in five sustains a serious injury such as a hip fracture or head trauma. The first hip fracture carries about a 20 to 30 percent one-year mortality rate. The second fall often comes within six months because of the "fear of falling" cycle: the patient moves less, loses strength and balance, and is more likely to fall again.

A home aide prevents more falls than any specialist the patient will ever see. You are in the home. You see the wet spot on the kitchen floor. You see the slipper with a torn sole. You walk with them to the bathroom at 2 a.m. This guide covers how to assess fall risk, how to walk a house room by room with a checklist in your head, how to check orthostatic blood pressure, how to fit and use canes, walkers, and rollators, proper footwear, and what to do when a fall happens anyway.

Assessment Tools the RN Uses

The RN may ask you to help gather information that feeds into a fall-risk scale. Two common ones:

Morse Fall Scale

Six items, each scored and summed. Higher score means higher risk.

| Item                   | Scoring                                                   |
|------------------------|-----------------------------------------------------------|
| History of falling     | No=0, Yes=25                                              |
| Secondary diagnosis    | No=0, Yes=15                                              |
| Ambulatory aid         | None/bed rest/nurse=0, crutches/cane/walker=15, furniture=30 |
| IV therapy/heparin lock| No=0, Yes=20                                              |
| Gait                   | Normal/bed rest/wheelchair=0, weak=10, impaired=20        |
| Mental status          | Oriented=0, forgets limitations=15                        |

A total above roughly 45 is high risk in most settings. The exact threshold varies by agency.

Hendrich II

Used more in hospital and some home settings. Eight items: confusion or disorientation, symptomatic depression, altered elimination, dizziness or vertigo, gender (male scores higher in some versions), antiepileptic medication use, benzodiazepine use, and the Get-Up-and-Go test (can the patient rise from a chair in one attempt without using arms, or do they need multiple attempts, or cannot rise). Higher score means higher risk. A score of 5 or more is high risk in most protocols.

You do not score these on your own. You report the observations cleanly so the RN can.

Intrinsic Risk Factors

Things about the patient that raise fall risk:

• Age (sharp rise after 75)
• Muscle weakness, especially quadriceps and hip abductors
• Balance and gait problems
• Vision impairment - cataracts, macular degeneration, bifocals on stairs
• Orthostatic hypotension (blood pressure drops on standing)
• Polypharmacy (five or more medications, or any of the fall-risk classes)
• Prior falls - the single strongest predictor
• Neuropathy in the feet
• Foot problems - bunions, hammertoes, thick nails
• Cognitive impairment - dementia, delirium
• Incontinence and the rush to get to the bathroom
• Depression (slowed movement, inattention)
• Fear of falling itself

Fall-risk medication classes to be aware of (the RN tracks these, but you should know the words): benzodiazepines, opioids, antipsychotics, antidepressants, sleep aids, antihypertensives, diuretics, anticonvulsants, anticholinergics, alpha-blockers.

Extrinsic (Environmental) Risk Factors

Things about the home. These are what you can change. Most falls happen because of the environment, not the patient.

• Throw rugs (the single most dangerous item in a senior's home)
• Poor lighting, especially hallways and stairs
• Wet floors, bathroom tile, kitchen spills
• Pets underfoot
• Electrical cords, phone cords, oxygen tubing across walk paths
• Uneven thresholds between rooms
• Ill-fitting footwear - floppy slippers, worn soles, socks on hardwood
• Clutter on the floor, stairs, hallways
• Broken or missing handrails
• Stairs without non-slip treads
• Low toilets and no grab bars
• High beds the feet cannot touch when sitting
• Reaching for items on high shelves - climbing chairs, stools

The Room-by-Room Walkthrough Checklist

Walk the house on day one. Walk it again after any change. Look at it through fall-prevention eyes, not housekeeping eyes.

| Room          | Check For                                                              |
|---------------|------------------------------------------------------------------------|
| Entryway      | No raised threshold to trip on, good lighting, handrail at steps,      |
|               | non-slip mat, keys reachable without stretching                        |
| Living room   | Clear walk paths, NO throw rugs, stable furniture for transfer points, |
|               | phone reachable from the floor, chair tall enough to rise from easily, |
|               | remote controls within reach                                           |
| Kitchen       | Non-slip mat at sink, daily dishes and cups in reachable cabinets so   |
|               | patient never climbs, step stool stored and labeled NOT FOR USE, spill |
|               | cloths handy, sharp knives in a block not loose in a drawer            |
| Bathroom      | Grab bars anchored to wall studs or with in-wall blocking (NOT         |
|               | suction cups - they fail), raised toilet seat if sit-to-stand is hard, |
|               | tub bench or shower chair, non-slip mat inside tub, non-slip rug       |
|               | outside tub, handheld shower head, night light, door that opens outward|
|               | so a fallen patient does not block it                                  |
| Bedroom       | Bed at right height - feet flat on floor when sitting on edge, night   |
|               | light, clear path to bathroom, phone at bedside, bedside commode if    |
|               | nighttime bathroom trips are risky, no clutter around bed, clock and   |
|               | lamp within reach                                                      |
| Stairs        | Handrail on BOTH sides, all the way top to bottom, non-slip treads or  |
|               | carpet, lit top and bottom, no items stored on steps, contrasting      |
|               | tread edges for low-vision patients                                    |
| Hallways      | Clear of clutter, night lights, rugs tacked down or removed, no cords  |
|               | across                                                                 |
| Laundry/      | Good lighting, non-slip floor, step stool NOT used, items accessible   |
| Basement      | without climbing                                                       |

Orthostatic Blood Pressure Check

Orthostatic hypotension means the blood pressure drops when the patient stands up, which causes dizziness, blurred vision, and falls. The RN may ask you to perform and report an orthostatic check. The procedure:

1. Patient lies flat (supine) for 5 minutes. Take blood pressure and pulse. Record.
2. Stand the patient up. Support them. Wait 1 minute standing. Take blood pressure and pulse again. Record.
3. Continue standing for another 2 minutes. At the 3-minute mark, take blood pressure and pulse again. Record.

Positive finding (orthostatic hypotension):

• Systolic drops by 20 mmHg or more, OR
• Diastolic drops by 10 mmHg or more, OR
• Heart rate rises sharply (often over 30 bpm increase) suggesting a compensatory response.

Report any positive finding, symptoms during the test (dizziness, lightheadedness, grayed-out vision), and the numbers. A positive orthostatic is a big deal. Common causes include dehydration, blood loss, heart medications, antihypertensives, Parkinson disease, autonomic dysfunction. The care plan may need to change.

If the patient becomes dizzy or about to pass out during the test, STOP, sit them down, and document what happened.

Assistive Devices

Cane

For minimal support, usually for one-sided weakness.

• Hold on the STRONG side. Classic rule: cane goes on the opposite side of the weak leg. This is unintuitive. It works because the cane and the weak leg move forward together, sharing load.
• Height: the top of the cane at the wrist crease when the arm hangs relaxed at the side. When the patient holds it, the elbow bends about 15 to 20 degrees.
• Tip: rubber tip intact, not worn flat. Replace when the tread disappears.
• Gait pattern: cane and weak leg move forward together, then the strong leg steps through.
• Stairs: up with the strong leg first, then the weak leg and cane together. Down with the weak leg and cane first, then the strong leg. "Up with the good, down with the bad."

Walker (Standard, Four-legged, No Wheels)

For bilateral weakness or significant balance impairment.

• Height: same rule - wrist crease at the top of the grip when the arm hangs relaxed.
• Use: lift and place the walker ahead, then step into it. Not a jog, not a shuffle. Lift, place, step.
• Rubber tips on all four legs intact.
• Never climb stairs with a standard walker. Use a transfer technique or a different device.

Two-wheel Front, Two-rubber-tip Back Walker

Compromise device. Wheels glide, rubber tips prevent it from rolling away. Common in home care. Same height rule.

Rollator (Four wheels, hand brakes, seat)

For patients with endurance limits rather than stability limits. The seat is for resting, not for transport.

• Four wheels roll freely. Good for distance.
• Hand brakes engaged fully when sitting on the seat. Otherwise it rolls out from under.
• Not for patients with severe balance problems - a rollator rolls away if they lean on it wrong.

Proper Footwear

The cheapest fall prevention is a good pair of shoes.

• Closed heel - no backless clogs, no mules, no slides.
• Non-slip sole with intact tread.
• Well-fitting - not too big, not too tight. Feet change size with age and swelling.
• Thin, firm sole is often better than thick cushiony sole for proprioception in older adults.
• Velcro or elastic laces if the patient cannot tie well - better than untied laces dangling.
• No bare feet on any surface. Ever. Not on carpet, not at 3 a.m.
• No socks on hardwood or tile - socks slide.
• No floppy slippers - they slip off, they catch on rugs, they roll under the foot.
• Replace worn shoes promptly. A worn-out sole is a fall waiting to happen.

When a Patient Falls: The Post-Fall Sequence

A fall happens. What you do in the next 60 seconds matters.

First: Do NOT Rush to Lift

The instinct is to scoop them up. Resist it. Lifting a patient with a hip fracture makes the fracture worse. Lifting a patient with a head injury without protecting the spine can paralyze them. Pause. Assess.

Assessment (stay with the patient)

1. Level of consciousness. Are they responsive? Are they talking? Do they know where they are?
2. Breathing and airway. Normal? Labored?
3. Head injury signs. Did they hit their head? Is there a cut, a lump, bleeding from the nose, mouth, or ears? Are the pupils unequal? Any vomiting?
4. Neck or back pain. Do not move them if yes.
5. Hip or leg position. A leg that is shortened and externally rotated (foot turned out) is a classic hip fracture presentation.
6. Pain. Where? How bad?
7. Bleeding. Controlled? Apply pressure.
8. Vitals if you can safely - pulse, breathing rate, general color.

Call 911 For

• Loss of consciousness, even briefly.
• Suspected head injury, especially on a blood thinner.
• Severe pain in hip, back, or neck.
• Visible deformity of a limb.
• Shortened, rotated leg (suspected hip fracture).
• Inability to move a limb or numbness.
• Confusion that was not there before.
• Heavy bleeding you cannot control.
• Patient cannot get up safely with help.
• Chest pain, shortness of breath, stroke signs.

If Safe to Help Them Up

Only if the patient is alert, has no red flags, reports no severe pain, can move all limbs, and the agency/care plan allows an aide to assist recovery. Even then:

• Use a gait belt around the patient's waist.
• Two-person lift is safer. Call for help if you are alone and unsure.
• Hoyer lift if available and you are trained.
• Chair recovery method: have the patient roll to their side, push up to hands and knees, crawl to a sturdy chair, place hands on the chair seat, bring one leg forward, push up to sitting on the chair. Takes time. That is fine.
• Never lift with your back. Your back will be the next agency problem.

If you cannot safely help them up, do not keep trying. Keep them warm with a blanket, offer a pillow for the head, stay with them, and call 911 or the supervisor.

After the Recovery

• Take vitals.
• Observe for 30 minutes minimum even if the fall looked minor. Delayed symptoms of head injury and internal injury show up later.
• Call the RN case manager. Every fall. No exceptions.
• Complete the agency incident report.

Documenting a Fall

Detailed, specific, factual. Agencies get sued over falls. Clean documentation protects everyone.

• Date and exact time of the fall.
• Location - kitchen, specific spot.
• Activity at the time of the fall - walking to bathroom, reaching for cup, getting out of bed.
• Mechanism as described by the patient in their own words if possible.
• Witnesses - were you present, was anyone else present.
• Observed injuries - describe, measure if you can (a 2-inch cut above the right eyebrow, a golf-ball-size lump on the back of the head, bruising on the left hip).
• Vitals pre-fall if you happen to have them, and post-fall vitals.
• Level of consciousness at the time of finding them.
• Notifications - RN called at 10:14, family notified at 10:18, 911 called at 10:21.
• Follow-up plan - ED transport, X-ray ordered, care plan change, environmental fix (throw rug removed from hallway).
• Agency incident report completed and submitted per policy.

Call the RN When / Escalate When

Call the RN case manager for:

• Any fall, even if the patient says they are fine.
• Near-falls or new unsteadiness.
• Positive orthostatic BP findings.
• New dizziness, blurred vision, or fainting episodes.
• New fear of falling or refusal to ambulate.
• Worn or broken assistive device.
• Environmental hazards the family will not address.

Call 911 for:

• Loss of consciousness at any point.
• Suspected head injury with altered mental status.
• Suspected hip fracture (shortened, rotated leg).
• Severe pain or deformity.
• Patient cannot be safely moved.
• Any fall in a patient on a blood thinner (Coumadin, Eliquis, Xarelto) with any head strike.

Falls are preventable. The best work happens before they happen. Walk the house. Fix the rugs. Fit the shoes. Fit the cane. Do the orthostatic when asked. Report what you see. That is how the one-in-four number gets better on your caseload.