Policy Manual sample

MDT Home Health Care Agency, Inc. PATIENT RISK OF FALLS ASSESSMENT POLICY: The Agency staff take appropriate actions to reduce the risk of patient ham due to falls. PROCEDURE: At the time of the initial skilled assessment visit: • A basic home safety assessment is completed and documented in the patients medical record; • And following items are assessed and documented in the record:  The patient’s functional limitations;  The patient’s current medications, both prescribed and over-the-counter, including herbal remedies, based on current knowledge for: — Actions — Drug-to-drug and drug-to-food interactions — Dosage appropriateness — Appropriateness of administration routes — Medication effectiveness  Patient’s nutritional status  Patient’s pain level and pain management modalities • The above mentioned areas should be evaluated and documented in the patient record as to the degree of impact on the patient’s risk of harm from falls.  Recommended: The patient’s risk of harm from falls will be evaluated objectively on a scale of 1 to 10, similar to an objective pain scale, the Agency will use any professional Fall Assessment scale, but preferable Timed Get Up scale . • The patient’s physician is to be notified of the patient’s potential for harm resulting from falls and collaborative plan of action developed. • The patient/caregiver/significant other should be instructed about the potential risks and a plan documented in the record of the actions to be taken to reduce the risks. • A copy of the written plan is to remain in the patient’s home. • The patient’s/caregiver’s/significant other’s level of understanding and agreement to comply with the plan is documented in the medical record.. • A copy of the identified risks and risk reduction plan is distributed to all healthcare team members providing care, treatment and/or services to the patient, including the physician. • The patient’s compliance with the initial risk reduction plan and potential for harm from falls, are to be assessed and documented in the record at the time of each visit and appropriate interventions implemented to decrease the potential for falls. • All patients at risk for falls and the number of reported falls are tracked and trended as part of the organization’s performance improvement program and the aggregated results are reported to the Board of Directors and Safety Committee on a quarterly basis. • Any falls that result in permanent harm or death to a patient are sentinel events and are reported to the Safety Committee as per the organization’s Sentinel Event policy. • Root cause analysis is conducted on any identified variances and a plan of correction is developed, implemented and evaluated. Home Health Agency Nursing Manual J-51