MAPS Fall Ambassador Manual v.2016

21 Pages·2016·3.19 MB·English

Fall Ambassador Program
Orientation Manual
Fall Ambassador Program
Orientation Manual
Table of Contents
Welcome Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Your Role and Duties as a Fall Ambassador . . . . . . . . . . . . . . 4 - 5

Issues and Tools related to Falls. . . . . . . . . . . . . . . . . . . . . . . 6 - 14
1. The Falling Star sign . . . . . . . . . . . . . . . . . . . . . . . . . 6
What it signifies
Placement on doors
Correcting sign assignments and placement
Replenishing inventory
2. Door/Curtain Closed . . . . . . . . . . . . . . . . . . . . . . . . . .7 - 8
The importance of “Line of Sight”
Procedures when observing no “Line of Sight”
Situations when closed doors/curtains are acceptable
3. Bed Alarms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 - 10
The purpose of Bed Alarms
Correct placement of Bed Alarms
Determing if patient’s alarm is active
Procedures when noticing possible Bed Alarm issues
4. Fall Ambassador Vest. . . . . . . . . . . . . . . . . . . . . . . . . 11
Function of the Fall Ambassador Vest
Where to find and return vests for your shift
5. Inpatient At-High-Risk for Fall Report. . . . . . . . . . . . 12
The function of the Inpatient At-High-Risk for Fall Report
Obtaining the Inpatient At-High-Risk for Fall Report for your shift

6. The Staffing Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Obtaining the Staffing chart for your shift
Heirarchy of whom to contact first, second, etc.
7. The Monitoring Audit Chart. . . . . . . . . . . . . . . . . . . . 14
The importance of your charts in improving patient safety
Categories to monitor
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Table of Contents
How to Carry Out Your Assignment . . . . . . . . . . . . . . . . . . . . . . . .15 - 20
1. Preparation for approaching your assignment. . . . . . . . .15
Backpack items (MAPS Group only)
List of Units to be monitored
Initial Steps
2. Preparation for Rounding. . . . . . . . . . . . . . . . . . . . . . . . . .15
3. Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

4. Concentrating on Accidental Falls . . . . . . . . . . . . . . . . . . .16

5. Handling Possible Situations. . . . . . . . . . . . . . . . . . . . . . . .17
Patient trying to get out of bed unassisted
Patient in an unsafe location in their room
Patient needs/requests assistance
6. Example dialogues for interacting with staff members . . 17
Doors/Curtains not open
Concerns about Bed Alarms

7. Patient Isolation Precautions. . . . . . . . . . . . . . . . . . . . . . . 18
Do not enter patient isolation precaution rooms
Some reasons for patient isolation

8. Ending your Shift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Submitting your Monitoring Audit Form
Returning your backpack
Complying with HIPAA laws (protecting patient privacy)
In Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
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Welcome
Dear Volunteer,
Thank you for your interest in participating in the Fall Ambassador
program. Minimizing hospital fall risk is an important aspect of patient care.
By learning about the issue and assisting in reducing falls you will acquire
knowlege that will be extremely helpful in keeping your patients safe during
your future career in health care.
The goal of this program is to assist the hospital in keeping patients,
during their stay here, as safe and comfortable as possible. Because
patients often come to our facility in weakened conditions, they are
sometimes at risk for inadvertent mishaps.
One of these potential situations is the possibility of patients falling and injuring
themselves. Falls during hospitalization are a serious problem. Two to 15% of
inpatients experience at least one fall during their hospital stay. Preventing
falls is important because about 30% of falls cause injuries, including
bruises, lacerations, fractures, intracranial bleeding and even death.
Two to 15% of Ronald Reagan Medical Center (RRMC) has
inpatients experience implemented methods to improve patient safety and
at least one fall during comfort while reducing falls and fall injuries. In an effort
their hospital stay to further decrease the possibility of patient falls and
fall injuries, the Falls Committee has adopted a method
to reduce falls occurrences further; by using a methodology
to assess individual patient’s fall risk. A score is assigned and special protocols
are followed for patients with scores above a certain threshold.
Some of the practices include:
• Assigning bed alarms to certain patients. Bed alarms are designed to
alert the staff when a patient is no longer in contact with the bed surface.
• Maintaining a clear line of sight to the patient. Often curtains are drawn
or doors closed and any risky actions, such
as getting out of bed unassisted, cannot
...about 30% of falls cause injuries,
be observed by the nursing staff.
including bruises, lacerations,
• Alerting staff of high risk patients by putting fractures, intracranial bleeding and
a falling star sign above the patient’s door. even death
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Your role as a Fall Ambassador
You will be improving patient safety by noticing situations that might put
the patient at risk and alerting the appropriate members of the nursing staff.
Your charge as a Fall Ambassador under the MAPS Group or Nursing
Volunteer Group is to take steps to assist the hospital in further reducing
patient falls by:
• Heightening awareness among nursing staff
Your presence on the floor with a high visibility vest marked with the
program’s logo, or your yellow shirt, will serve to raise the awareness of
nurses, care partners and other members of the patient care team of the
RRMC’s commitment to reducing falls and fall injuries. By being a highly
visible part of the team you will communicate to the staff that situations
relating to falls are being monitored and reaffirm the resources the RRMC
is committing to address the problem of patient falls.
• Put staff on a gentle alert that patient fall-risk reduction is a high priority.
Volunteers will target safety procedures that have been put in place to
minimize falls including helping the staff to:
• Monitor the presence and proper functioning of bed alarms.
• Monitor whether there is a clear line of sight to the patient.
• Monitor whether patients’ doors have been correctly identified
with the Falling Star logo*.
• Assist staff in preventing falls through patient observation.
• Monitor patient efforts to ambulate unassisted.
• Monitor patients in a potentially unsafe position within their room
and engage staff in correcting the situation.
“All patients are everyone’s patients”
*indicates a high fall/fall injury risk
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Your duties as a Fall Ambassador
The Fall Ambassador Program is designed to assist the hospital staff in
reducing the number of patient falls and fall injuries that occur in the
hospital.
Your role as a volunteer will be to raise the awareness in assigned
hospital units for procedural compliance and to bring a heightened
awareness of the patient fall issue to the staff.
The fall-reduction compliance issues you will be auditing are:
1) Whether high-fall/fall injury risk patients are properly identified by
falling star door signs.
2) Whether these patients have doors and curtains open. Did you know that
yellow is the color
4) Whether a patient that has a bed alarm has it nationally-recognized
turned on and correctly in place while in bed. in hospitals for falls?
These results are to assist the Unit Director, ANII, CNS or Unit Educator
so that he/she can better evaluate some of the issues that might need
to be communicated to the staff members.
You will also be there to assist the staff by being an extra resource
that can assess whether any patient can be made safer by making
adjustments to their physical environment. You might be enlisted to
educate and explain the benefits of different strategies for keeping the
patients safe.

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Issues and Tools Related to Falls
An introduction to issues and tools related to falls
1. The Falling Star sign
High-fall/fall injury risk patients are identified so that staff
will know to give them appropriate precautions. One way
of identifying fall risk patients is by placing a sign on their
door.

Based upon a nursing assessment, individual patients
are assigned a fall-risk score. Scores range from 0 to
120. Those patients with an assigned score of 45 or
higher are considered high fall-risk and should be
identified as such with their doors being provided with
a Falling Star sign.
Replenishing inventory
You may need to replenish the inventory of signs over the course of your assignment.
Some assembly may be required.
Tape strips to sign with
clear tape, making note
of proper positioning
1 2 3
Cut strips of magnetic tape
(back of sign)
For supplies, please come to Cait Walsh or Petra Fritz
Nursing Administration, B790
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Issues and Tools Related to Fall Prevention
1. The Falling Star
sign (continued)
Placement
The signs are placed on the door’s upper right corner.
(This allows the signs to be visible from ther entire length
of the hallway.)
They have magnets to adhere them to the door’s metal
frame.
They should not be taped or crammed into crevices.
Proper sign
The Falling Star logo has
placement
been used in hospitals
across the US to highlight
that the patient is at a high
risk for a fall/fall injury.
The Falling Star door sign was
created by our very own
UCLA Hospital Administration
Nurse, Cait Walsh.
* an improperly assigned sign is one that is placed on
the door of a patient that doesn’t need one - or a sign
is missing from the door of one that requires one.
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Issues and Tools Related to Fall Prevention
2. Door Closed/Curtain Closed
Inability to Observe Patient
Because high fall-risk patients may try to get
out of bed unassisted, there should be a clear
line-of-sight from outside the room to the
patient. If they can’t be seen, it is not possible
to intervene when they are putting themselves
in a dangerous situation.
If doors or curtains are closed and the patient
appears to be unattended, please make a note
of it and bring it to the attention of the nursing
staff so that they may correct the situation.
Note: Doors and curtains may be closed in the interest
of privacy such as when the patient is with family or
is being attended to by medical or nursing staff.
Other patients may need to be isolated due to situations
such as having a suppressed immune systems. The
nursing staff will inform you as to whether the door
needs to remain closed.
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Issues and Tools Related to Fall Prevention
3. Bed Alarms
Reasons for bed alarms
Bed alarms are placed on some high
fall /f all injury-risk patients. This alerts the
nursing staff when the patient’s body
loses contact with the bed’s surface. In
times such as when the patient tries to
get out of bed, the alarm will notify the staff to
immediately attend to the patient and intervene.
Bed alarms do not prevent falls. They are used for
timely rescue and/or planning care. Not all high
fall risk patients need a bed alarm.
Determining if alarms are turned on
Sometimes bed alarms can be placed on the
patient yet the alarm is not active. One way to
determine if the alarm is active is to observe
whether the green light on the top corner of the
alarm is on.
Troubleshooting the alarm
Check the batteries in the alarm box.
If they need to be replaced, check floor battery stock in the
Clean Utility Room or order from Materials Management.
Check to see if the alarm is plugged in.
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