When a Fall Occurs If a fall does occur, the most important consideration is prompt evaluation and treatment of the patient. All events related to a patient trip, slip, or fall should be documented in the medical record, using objective, factual information of the events, evaluation, treatments, and patient response to interventions. It is prudent to carefully assess the circumstances related to the incident to determine where preventative measures can be implemented using a post-fall report form. The National Institute for Occupational Safety and Health (NIOSH) has an event reporting tool that was adapted from the Bureau of Labor Statistics Occupational Injury and Illness Classification manual (BLS 2007). Completion of a similar reporting document may help identify ways to improve performance and processes. The event reporting form should not be included in the patient’s medical record. Fall Prevention and the Physician Quality Reporting System Underscoring the significance of fall prevention, measures are included in the Physician Quality Reporting System (PQRS). PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services. The measures pertaining to falls is a two-part measure. Measure #154 (NQF: 0101) Falls: Risk Assessment, is a measurement of the percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months. Measure #155, is the percentage of patients aged 65 years and older with a history of falls, and who had a plan of care for falls documented within a 12 months period of time. According to one study, although one out of three older adults (those aged 65 or older) falls each year, less than half talk to their healthcare providers about it. Providers are encouraged to perform proactive risk assessments on patients aged 65 years and older with a history of falls and develop an individualized fall prevention intervention care plan.
According to the guidance from the Center for Medicare and Medicaid Services (CMS), a falls risk assessment is a clinical evaluation that should include the following, but are not limited to: A history of fall circumstances Review of all medications and doses Evaluation of gait and balance, mobility levels and lower extremity joint function Examination of vision Examination of neurological function, muscle strength, proprioception, reflexes, and tests of cortical, extrapyramidal, and cerebellar function Cognitive evaluation Screening for depression Assessment of postural blood pressure Assessment of heart rate and rhythm Assessment of heart rate and rhythm, and blood pressure responses to carotid sinus stimulation, if appropriate Assessment of home environment The falls risks assessment should be followed by direct intervention on the identified risk. The plan of care must include: Consideration of appropriate assistance device The medical record must include: documentation that an assistive device was provided or considered OR referral for evaluation for an appropriate assistance device); and Balance, strength, and gait training The medical record must include: documentation that balance, strength, and gait training/instructions were provided OR referral to an exercise program, which includes at least one of the three components: balance, strength or gait.