Leadership Considerations: F689-Free from Accidents and Hazards

This CMS regulation is number four on the most frequently cited deficiencies in 2021. In an effort to avoid a citation, we may take a routine approach to assess and plan for fall reduction. Can we really prevent residents from falling? The accurate answer is “No.” However, we have many tools in our toolbox to minimize the number of falls and injuries from falls.

Perspective: Fall risk screening or assessment only predicts the likelihood of a fall; it does not prevent falls.

As clinical leaders, we are familiar with the myriad of fall risk screening and assessment tools available to the nursing and therapy profession to assess fall risks in the elderly, the Berg Balance Scale, the Hendrich IITimed Up and GoTinneti Balance Scale, Morse Fall Risk Scale and more. Each has its strengths and weaknesses. Each has a slightly different focus. There is no single fall risk assessment tool that includes all fall risk factors. Therefore, we need to apply critical thinking to the data we collect about each person’s fall risks in order to prioritize them and understand the risks in the context of the individual person. The use of a fall-risk score alone will not help with the development of an effective care plan.

Often an individual resident will have multiple risk factors. Analyze risk data to determine which factors are reversible or modifiable. Address the easily modified factors and develop a plan to address the more complex or challenging factors as soon as possible. For example, you can lower the bed and leave a night light on in the bathroom without assistance from others, but a medication review will need to include the pharmacist and access to the medical record.

Include the individual’s preferences, self-assessment of their abilities, knowledge of their conditions and willingness to accept assistance in your overall assessment of fall risks. These factors can be underlying causes of the failure of our best fall prevention care plan. By acknowledging these personal characteristics, we can approach fall prevention with a realistic and personalized plan. Educate the resident and engage them in a plan to regain those abilities most important to them.

Finally, try to avoid focusing the entire fall prevention plan on restrictions. Include interventions that bolster the person’s strengths. People who are inactive and those who are very active are at the highest risks for accidents. A review of research on fall prevention conducted by Gillespie et al. identified a 17% reduction in falls for those involved in a multiple-component group exercise program. This approach facilitates the resident’s abilities by building strength, stamina, and balance to minimize fall risks. Ask your team, “What can we do to make it safe for the resident to do what they are trying to do?”

In addition to the usual approaches, such as eliminating trip hazards and improving lighting, an Hourly Staff Rounding Policy has a major positive impact on fall reduction in hospitals and nursing homes. Use an interdisciplinary approach to ensure the schedule is met. Hourly rounding includes a staff member checking in with the resident every hour. The schedule can be modified, depending on the resident’s needs. The staff member goes into the resident’s room, asks if they need anything and meets that need. Some organizations focus rounding on the “Four P’s” (pain, potty, positioning and personal items (in reach)). By maintaining a consistent schedule, the resident is reassured that someone will be in to visit them and make sure they get assistance as needed. A positive effect of hourly rounding is the decrease in the call lights.

Key Take-Aways

  1. By using a person-centered approach to fall risk assessment and care planning, clinicians can develop a more effective plan of care to minimize the risk of falling.
  2. When we focus on the resident’s strengths, we improve their function and minimize fall risks rather than restricting their movement, which may increase the risk for falls.
  3. Providing reassurance that the resident’s needs will be met helps decrease anxiety and minimize spontaneous high-risk behaviors.

Pathway Health’s team of experts is available to support your organization. Contact us to learn more.


Analyzing the problem of falls among older people. Yannis Dionyssiotis. Int J Gen Med. 2012; 5: 805–813. Published online 2012 Sep 28. doi: 10.2147/IJGM.S32651.PMCID: PMC3468115

Development and evaluation of evidence-based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies, D. Oliver, M. Britton, P. Seed, F. C. Martin, A. H. Hopper. BMJ. 1997 Oct 25; 315(7115): 1049–1053. doi: 10.1136/bmj.315.7115.1049. PMCID: PMC2127684

Interventions for preventing falls in older people living in the community. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007146. doi: 10.1002/14651858.CD007146.pub2. Update in: Cochrane Database Syst Rev. 2012;9:CD007146. PMID: 19370674.

Karolee Withers, RN, RACT-CT
Director of Reimbursement and Clinical Consulting