Since falls impact patient safety, require notification for CMS quality reporting, and may result in patient injury or worse, it is good to consider how we assess our patients, educate our staff, and improve our processes to ensure we are doing everything possible.

One question I get asked frequently, is: do I need to perform a fall risk assessment on all patients as part of admission? I tell them: No. Probably not the answer you expected.

My recommended approach is that we treat ALL patients as a fall risk. If you think about it, they are. Patients may be at an increased risk that we create:

  • Cognitive impairment (medications)
  • Impaired balance (medications)
  • Impaired mobility (surgery to extremities)

If we treat all patients as fall risks, we can structure our fall policies and processes to support that thinking: that all patients will be instructed on obtaining ambulation assistance when needed, especially when needing to stand when seated or during bathroom use.

Other things to consider for policy/process/education activities related to fall prevention:

  • Ensuring that traffic areas will remain clear to prevent trip hazards (add to your safety round checklist and check regularly if not doing so already).
  • Using non slip socks on all patients for ambulation safety.
  • Providing ambulation assistance as needed throughout the patient stay.
  • Utilizing wheelchairs consistently after procedures and when needed.

Check your policy and review your process with the staff and anesthesia team so that should a patient fall occur, it is understood that patients will be assessed and treated if needed by the physician or anesthesia provider, and the fall and any treatment necessary be documented in the medical record. Should the patient need further care or treatment due to fall injury, follow your transfer protocol and follow up with the patient outcome to close the loop on your risk management activities.

Take a minute to do a fall risk facility check-up:

  • Does your policy reflect your facility activities for fall prevention? If you want to change or update the policy and/or processes, make sure to check with your Governing Body for approval and document.
  • Do all your staff and credentialed providers know and understand the policy, including prevention, response, and documentation? This would make for a great staff in-service, and any process changes would provide a robust quality study.
  • Do you offer fall prevention as part of your facility education program? (If not-we offer it here ASC Solutions Academy – Fall Prevention).

If you need a template for facility safety assessments or a template fall prevention policy, e mail me at, and I’ll be happy to share.

To check out all my tools and resources, go to

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