6.1 Fall Prevention, Fall Response, and Post-Fall Assessment

Fall Prevention, Fall Response, and Post-Fall Assessment

Quick Answer: Falls are the most common accident in long-term care. The CNA's job is to PREVENT falls, respond correctly when one happens, and monitor the resident afterward. After a fall: stay with the resident, assess for injury, call for help, notify the nurse, and document. Never leave a fallen resident to go get help alone — use the call light or call out for someone nearby.

Why Falls Matter

Falls are the leading cause of injury and injury-related death in older adults. A fall can cause hip fractures, head injuries, and a downward spiral of fear, immobility, and decline. Under OBRA and Indiana 410 IAC 16.2, every facility must have a fall-prevention program, assess every resident for fall risk on admission and after any fall, and implement interventions. The CNA is the front line of fall prevention because you are with residents more than any other team member.

Fall Risk Factors

Know these risk factors — the exam lists them in answer choices and you must pick the ones that apply.

Resident-Related Risk Factors

• Age 65 and older — balance, vision, and reflexes decline
• Impaired mobility — weakness, gait problems, need for assistive devices
• Cognitive impairment — dementia, Alzheimer's, confusion, poor judgment
• Medications — sedatives, tranquilizers, antihypertensives, diuretics, hypnotics cause dizziness, drowsiness, or orthostatic hypotension
• Sensory deficits — poor vision, hearing loss, neuropathy (numb feet)
• Postural hypotension (orthostatic hypotension) — blood pressure drops when standing, causing dizziness
• History of previous falls — the single strongest predictor of a future fall
• Incontinence — rushing to the bathroom, wet floors
• Dehydration — weakness, dizziness
• New admission or transfer — unfamiliar environment

Environmental Risk Factors

• Wet or slippery floors — spills, urine, bathroom water
• Poor lighting — especially at night
• Clutter and obstacles — furniture, cords, trash, shoes in walkways
• Improper footwear — slippery socks, ill-fitting shoes, walking barefoot
• Bed too high — resident cannot reach the floor safely
• Unlocked wheels — bed, wheelchair, or stretcher rolls away
• Call light out of reach — resident tries to get up alone
• Loose rugs or mats — trip hazards
• Equipment in the path — IV poles, oxygen tubing, catheter tubing

Fall-Prevention Interventions

Environmental Safety

1. Keep the bed in the lowest position when the resident is in it, unless ordered otherwise. This minimizes the distance of a fall.
2. Lock the bed wheels and wheelchair brakes before transfer or when the resident is sitting.
3. Keep the call light within reach at all times — the single most important intervention. A resident who cannot call for help will try to get up alone.
4. Provide nonskid footwear — nonskid socks or well-fitting shoes with nonslip soles. Never let a resident walk in slippery socks or barefoot.
5. Keep the path to the bathroom clear and well-lit. Nightlights in the room and bathroom. Remove clutter, cords, and obstacles.
6. Use bed alarms for high-risk residents — the alarm sounds if the resident tries to get out of bed, alerting staff to assist.
7. Place personal items within reach — glasses, hearing aids, water, phone. A resident who reaches for something out of reach may fall.
8. Use side rails appropriately — only when ordered and when they do not create an entrapment risk (see Section 6.4). Side rails are NOT a substitute for supervision.
9. Provide a gait belt for transfers and ambulation. Never transfer a weak resident without one unless contraindicated.
10. Answer call lights promptly. The longer a resident waits, the more likely they are to try getting up alone.

Resident-Centered Interventions

• Toileting schedules — offer toileting every 2 hours; many falls happen on the way to the bathroom.
• Exercise and ambulation — maintain strength and balance with regular walking (with assistance).
• Proper footwear and assistive devices — walker, cane, as ordered.
• Review medications with the nurse — identify drugs that cause dizziness.
• Orient confused residents — tell them where they are, what you are doing.
• Encourage use of the call light — remind the resident to call before getting up.

Trap callout: Side rails are NOT a restraint unless they prevent a resident from voluntarily getting out of bed. If the resident can lower the rail and get out, it is an assist device. If they cannot lower it, it is a restraint and requires a physician order and time limit (see Section 6.4). Do NOT use all four side rails as a fall-prevention method — that is a restraint and is a violation of resident rights.

What to Do After a Fall

This sequence is heavily tested. Memorize it.

Step-by-Step Fall Response

1. STAY with the resident. Do not leave them alone to get help — they could move, worsen an injury, or lose consciousness.
2. Call for help. Use the call light, call out loudly, or send another resident or visitor to get the nurse. If alone, yell for help.
3. Assess the resident before moving them.
   • Check level of consciousness — are they awake, responsive, confused?
   • Check for pain — ask where it hurts. Do not move a resident who reports hip, back, neck, or head pain.
   • Check for deformity, swelling, bruising, or shortening of a leg (signs of hip fracture).
   • Check for bleeding, especially from the head.
   • Check pupils for unequal size (sign of head injury).
   • Check skin for tears or bruising.
4. Do NOT move the resident if you suspect a fracture, spinal injury, or head injury. Moving them can cause paralysis or worse injury. Wait for the nurse and the lift team.
5. If the resident is alert, not in pain, and has no obvious injury, you may help them up slowly and carefully per facility protocol — usually with a gait belt and a second staff member. Some facilities require the nurse to assess the resident before they are moved.
6. Notify the nurse immediately. The nurse must assess the resident, check vital signs, and determine if the resident needs to see a doctor or go to the ER.
7. Report to the nurse using SBAR: Situation (resident fell), Background (where, how, what they were doing), Assessment (what you found — conscious, pain, bleeding, vitals), Recommendation (nurse needed for assessment).
8. Document objectively. Record the time, location, what the resident was doing before the fall, whether they were wearing nonskid footwear, whether the call light was within reach, what you observed (level of consciousness, complaints, injuries), and what you did. Do NOT chart your opinion — chart the facts.

Trap callout: Many exam questions ask what to do FIRST after a fall. The answer is always: stay with the resident and assess for injury — NOT run to get the nurse, NOT help them up immediately, and NOT document first. The resident's safety is the first priority.

Post-Fall Assessment and Monitoring

After a fall, the resident must be monitored closely for at least 72 hours (per most facility policies, including Indiana LTC). The nurse will do a full neuro check and vital signs. The CNA's role in monitoring:

• Check level of consciousness every time you enter the room — is the resident as alert and oriented as before the fall?
• Watch for new confusion, drowsiness, or difficulty waking. These are signs of a head injury (subdural hematoma) that can develop hours or days after a fall.
• Report any new headache, nausea, vomiting, or vision changes — signs of increased intracranial pressure.
• Report any new pain, especially hip, back, or head pain.
• Report any change in vital signs — the nurse will check them, but if you notice pale skin, rapid pulse, or weakness, tell the nurse.
• Report any bruising or swelling that develops after the fall.
• Keep the resident on fall precautions — bed alarm, lower bed, more frequent checks — until the care plan is updated.

Documentation Requirements (Indiana)

Indiana 410 IAC 16.2 requires that every fall be documented and reported. The incident report includes:

• Time, date, and location of the fall
• What the resident was doing before the fall
• Whether the call light was within reach
• Whether the resident was wearing footwear
• What the CNA observed — level of consciousness, complaints, visible injuries
• What the CNA did — stayed with resident, called for help, did not move resident
• Who was notified and when
• Vital signs after the fall (taken by nurse)
• Resident's condition after the fall

Document objectively — what you saw, heard, and did. Do not chart "I think she tripped" — chart "Resident found on floor beside the bed. Call light was on the overbed table out of reach. Resident stated, 'I was trying to get to the bathroom.'" Objective documentation protects the resident, the facility, and you.

Trap callout: Failure to report and document a fall is neglect under Indiana regulation and can result in a substantiated finding on the Indiana Nurse Aide Registry (INAR), which bars you from working as a CNA in Indiana. Always report, always document, and never alter the record.