Nurses documentation of falls prevention in a patient centred care plan in a medical ward

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Caglayan Yasan
Trish Burton
Mark Tracey


patient falls, assessment, implementation of strategies, patient engagement, health education


Objective: To evaluate the consistency of nurses’ documentation in the falls prevention assessment tool, and to ascertain whether patients identified as high risk of falling had falls preventative strategies implemented.

Background: Falls are one of the leading causes of adverse events for patients in the hospital setting. The current practice of implementing falls prevention strategies for patients has not been able to be sustained, which remains a challenge for healthcare providers. Among the falls prevention strategies, falls risk assessment tools have been identified as a crucial element in falls prevention so as the number of falls are minimised.

Study design and methods: A retrospective chart audit, with the auditing of falls assessment documentation on the Patient Centred Care Plan.

Results: The Patient Centred Care Plan audit revealed that 60.8% of patients (n=508) were identified as high risk of falls by the principal investigator. For the cohort of patients identified by the nurses as having a high risk of falling (53.4%), 53.7% of patients had falls prevention strategies implemented, and only 17.5% of patients were engaged with their falls prevention plan. The strategies that were documented by the nurses on the care plan for the high-risk cohort were not implemented for 16.8% of the patients, and 29.5% of high risk of falls patients did not have documentation on the plan indicating their falls status.

Discussion: The findings show that there is a significant gap in the identification of high falls risk patients and the documentation and implementation of falls prevention strategies, between nursing staff records on the Patient Centred Care Plan and the audit conducted by the principal investigator for patients who are identified as high falls risk. As part of the audit patient engagement in their falls prevention plan revealed that patients were not informed of their falls risk status by the nursing staff.

Conclusion: The outcome from this audit signifies that not all high falls risk patients were identified as a high falls risk, and most of the high falls risk patients were not engaged in their falls prevention plan.

Implications for research, policy and practice: Understanding the current practices of falls prevention and raising nursing staff awareness of the identified variance in the implementation of falls prevention strategies will improve the quality, efficiency of healthcare and the patient safety

What is already known about the topic?

  • Nurses’ do not always document patient assessment and associated nursing care.

  • There are multiple factors which impact on nurses’ documenting assessment findings and implementation of nursing care.

What this paper adds:

  • At times nurses rely on a falls risk assessment made on the previous day when not able to conduct a current falls assessment.

  • Patients are not engaged in their falls prevention plan, even though they are identified as being of risk of falls.

  • Patients are not aware of the implemented falls prevention strategies which are part of their care.

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