Facility's Fall Assessment Policy Raises the Bar

Matt Phillion, for HealthLeaders Media , May 8, 2009

In the summer of 2006, Bellin Home Health Care in Green Bay, WI, created a tool to assess patients' likelihood and risk of falling by utilizing resources from hospital-affiliated home care.

However, the policy did not capture what was needed to assess home care patients, and Melissa Smits, RN, team leader, administrator for home health/home infusion and Emily Nelson, RN, BSN, quality/regulatory coordinator, sat down to draw up a new fall assessment policy for home care patients.

Using the original policy and building on that, Nelson and Smits worked with physical and occupational therapists, as well as nurses to help draw up the new policy.

The original care plan had staff members specifically initiating the process themselves, along with going in and having to document the assessment on three different plans.

After sending out the first draft and receiving feedback from the facility that it was too lengthy, it was decided Bellin needed something more cut and dried.

"In January 2007, the Joint Commission came in and felt as if we needed to have the program beefed up, as it appeared our staff was not consistently following the policy," says Smits.

"We needed to live it and breathe it and follow it completely," says Nelson. "We had it going, but it wasn't where it should have been."

Using the original assessment policy, key pieces were pulled over that needed to be documented. Also, the update tried to make it easier for staff members by reducing the number of steps, says Smits.

The updated fall assessment policy was introduced in February 2007, and was Bellin's first formal policy that staff members had to sign off on and begin implementing.

The policy specifically outlines what is expected of each staff member. It covers the purpose, policy itself, what staff members perform the fall risk assessment, the procedure for doing a fall risk assessment, and finally how to document the fall risk assessment correctly.

Upon reading the new policy, staff members would be required to sign a form saying the policy had been read and understood. Once the employee had signed the policy, it was noted on his or her file, and thus holding the staff member accountable for anything that happened to the patient.

In August 2007, not long after the policy was introduced, Nelson and Smits decided to revisit the policy.

Nelson says the verbiage change focused on assessing on admission, when the patient leaves a healthcare facility, and any significant change in condition.

"We were assessing patients in home care and taking a step back," says Nelson.

In addition to changing the verbiage, a post test for all staff members was created to ensure that the new policy was read and understood. Once the staff member had read the policy, he or she was required to take the test and receive a perfect score.

"By creating a post test, we could validate their accountability to the policy and process," says Nelson.

Now, each new staff member is required to read the policy at orientation, take the test, and sign a document that he or she has read the policy.

Nelson and Smits also believe that the Joint Commission's visit to Bellin Home Health gave staff members another reason to be compliant with the new fall assessment policy.

"The timing of the Joint Commission's visit, and all the hype that surrounded the development of a better fall risk assessment policy helped to get the staff on the right track," says Nelson. "Coming only from us, there may not have been quite an impact [on the staff], but with the Joint Commission coming in, we were able to reiterate the importance of the new policy."

Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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