Fall Prevention in the Home

Falls are the leading cause of injury death in adults 65 and older. About one in four older adults falls each year, and about one in five falls causes a serious injury such as a broken bone or a head injury. You are in the home on every visit, so you see the wet floor, the loose slipper and the new dizziness before anyone else does. This guide covers how to prevent falls and what to do when one happens.

What You Will Be Able to Do

• Name personal and home risk factors for falls.
• Walk a home room by room and find hazards.
• Check for orthostatic hypotension when asked.
• Check that canes and walkers fit and are used safely.
• Respond to a fall without making an injury worse.
• Document a fall accurately.

How Nurses Score Risk

Nurses may use a scale such as the Morse Fall Scale or the Hendrich II Fall Risk Model. These scales look at things like past falls, the use of a walking aid, gait, confusion and dizziness. You do not score these yourself. You report what you see so the nurse 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 - one of the strongest predictors
• 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

These are the things in the home, and they are what you can change.

• Throw rugs
• 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

Walk the home on day one, and again after any change. The bathroom is the most dangerous room for many older adults, because wet, slippery surfaces, hard fixtures and tight spaces all combine.

Ask before you move a client's things. Report hazards you cannot fix, and report when the family will not fix them.

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.

Orthostatic hypotension is a drop that shows up within 3 minutes of standing:

• 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. The steps are 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

Your instinct will be to pick them up. Resist it. Moving someone with a hip fracture or a spine injury can make it much worse. Stay with them, stay calm and check first. Assess.

What to Check

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.
• Mechanical lift if one is 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 the person by hand from the floor.

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

Keep it specific and factual.

• 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.

What to Report to the Nurse

Call the nurse for every fall, even if the client says they are fine. Also report near-falls, new unsteadiness, orthostatic blood pressure drops, new dizziness or fainting, new fear of walking, a worn or broken walking aid and hazards the family will not address.

Any head strike in a client on a blood thinner, such as warfarin, apixaban or rivaroxaban, is a 911 call.

Common Mistakes

Check Your Understanding

1. You hear a thud and find Mr. Ortiz sitting on the bathroom floor rubbing his hip. He tells you to help him up. What do you do first?

Do not lift him. Check whether he is alert and breathing, ask about a head strike and look for neck or back pain, a deformed hip or leg, and bleeding. Call 911 if there is any red flag.

2. Sitting, a client's blood pressure was 138/78. After 3 minutes standing, it is 112/70 and she feels dizzy. What does this suggest?

Orthostatic hypotension, because the systolic pressure dropped by 26 points. Sit her down and report it to the nurse.

3. A client with a weak left leg holds his cane in his left hand. What should change?

He should hold it in his right hand, the strong side. Tell the nurse or therapist so it can be taught.

4. A client fell, is on apixaban and has a bump on his head. He says he feels fine. What do you do?

Call 911. A head strike on a blood thinner can cause bleeding that shows up later.

Key Takeaways

• Walk the home with fall hazards in mind, and start with the bathroom.
• A drop of at least 20 systolic or 10 diastolic within 3 minutes of standing is orthostatic hypotension.
• Canes go on the strong side.
• After a fall, check before you move anyone.
• Report every fall, and document it fully.