3 Fall Prevention Policy Samples

Policy Title

Fall Prevention and Management Policy

Policy Number

SAF-001

Effective Date

[Insert Date]

Review Date

[Insert Date]

Applicable To

All clinical and non-clinical staff, patients, and visitors within the facility.

1. Purpose

This policy establishes a systematic, evidence-based approach to identifying, reducing, and managing fall risk among patients admitted to or receiving care within this facility. It aims to protect patient safety, support staff in delivering consistent preventive care, and reduce fall-related harm and liability.

2. Scope

This policy applies to all inpatient units, outpatient departments, emergency services, rehabilitation areas, and any other clinical environment within the facility where patient movement or mobility is involved.

3. Definitions

• Fall: An unplanned descent to the floor or a lower surface, with or without injury, regardless of whether a staff member was present.
• Assisted Fall: A fall that occurs while a staff member was in the process of providing physical assistance to a patient.
• Near Miss: An incident where a patient was found in a position that indicated a fall was about to occur but was prevented.
• High Fall Risk: A patient assessed as having a score that meets or exceeds the facility’s defined threshold on the approved fall risk assessment tool.

4. Policy Statement

This facility is committed to providing a safe care environment for all patients. All patients will be assessed for fall risk upon admission, after any significant change in condition, following a fall, and at defined intervals throughout their stay. Preventive measures will be implemented based on individual risk levels and reviewed continuously throughout the patient’s episode of care.

5. Responsibilities

• Nursing Staff: Conduct fall risk assessments using the facility-approved tool. Implement and document individualized fall prevention interventions. Communicate fall risk status during handovers and to other members of the care team.
• Attending Physicians: Review fall risk assessments as part of daily rounds. Adjust medications that may increase fall risk. Collaborate in developing individualized care plans for high-risk patients.
• Allied Health Professionals: Physiotherapists, occupational therapists, and pharmacists will contribute to fall risk assessments and intervention planning within their scope of practice.
• Environmental Services: Maintain clean, dry, and unobstructed floors and patient areas. Promptly respond to spill notifications and report environmental hazards.
• Unit Managers and Charge Nurses: Ensure consistent application of this policy on their unit. Review fall incidents and near misses to identify trends. Support staff education and competency maintenance.
• Safety and Quality Department: Monitor fall data, analyze trends, and report findings to leadership. Coordinate policy reviews and facilitate staff education programs.

6. Fall Risk Assessment

6.1 The facility-approved fall risk assessment tool (e.g., Morse Fall Scale or Johns Hopkins Fall Risk Assessment Tool) will be used for all patients.

6.2 Assessments will be completed:

• Within two hours of admission to any inpatient unit
• Every 12 hours for all inpatients, or more frequently if clinical condition warrants
• Immediately following any fall or near miss
• Upon return from a procedure, surgery, or diagnostic test
• When a patient’s condition, medication, or mobility status changes significantly

6.3 Risk level classifications and corresponding intervention tiers are defined in the associated Fall Risk Intervention Protocol (SAF-001A).

7. Fall Prevention Interventions

Universal Precautions (All Patients):

• Bed in lowest position with brakes locked at all times when not providing direct care
• Call light within patient reach at all times
• Personal items and frequently used belongings within easy reach
• Non-slip footwear provided and recommended for all ambulatory patients
• Adequate lighting in patient room, hallway, and bathroom maintained at all times
• Orientation to room environment, call system, and fall risk status provided to all patients and families upon admission

Targeted Precautions (Moderate to High Risk Patients):

• Fall risk identification band applied to patient’s wrist
• Fall risk alert signage posted at patient room entrance and above bed
• Bed alarm activated and functioning at all times
• Hourly rounding conducted and documented
• Toileting assistance offered every two hours and as needed
• Bedside commode provided where clinically appropriate
• Side rails raised according to patient’s cognitive status and mobility needs
• Patient and family education provided on fall risk and prevention strategies
• Physiotherapy referral initiated for patients with mobility impairment
• Pharmacist review requested for patients on four or more medications or those on high-risk medications including sedatives, hypnotics, diuretics, antihypertensives, and anticonvulsants

Continuous Observation (Very High Risk Patients):

• One-to-one observation or continuous video monitoring as determined by the treating team and unit manager
• Sitter or companion program initiated in accordance with staffing protocol

8. Post-Fall Management

8.1 Following any fall, staff will:

• Remain with the patient and call for assistance
• Assess the patient for injury before moving them
• Notify the attending physician and charge nurse immediately
• Complete a fall incident report within the facility’s reporting system within two hours of the event
• Reassess fall risk and update the care plan accordingly
• Notify the patient’s next of kin or emergency contact

8.2 The unit manager will conduct a post-fall debrief with the involved staff within 24 hours to identify contributing factors and preventive opportunities.

8.3 All falls resulting in injury will be escalated to the Safety and Quality Department for formal review.

9. Documentation

All fall risk assessments, prevention interventions, patient education, fall incidents, and post-fall actions must be documented in the patient’s medical record. Incident reports are separate from the medical record and are to be completed through the facility’s designated reporting system.

10. Education and Training

All staff with direct patient contact will complete fall prevention training upon orientation and annually thereafter. Competency will be assessed through observation and documentation audits. Staff are expected to maintain current knowledge of evidence-based fall prevention practices and to apply them consistently in daily care.

11. Monitoring and Quality Improvement

Fall rates, injurious fall rates, and policy compliance will be monitored monthly by the Safety and Quality Department. Data will be reviewed at the unit level and reported to the Patient Safety Committee quarterly. Trends will inform targeted improvement initiatives, staff education, and policy updates.

12. Policy Review

This policy will be reviewed annually or sooner if significant changes in evidence, regulation, or organizational structure require revision.

Approved By

[Name, Title]   |   [Signature]   |   [Date]

References

• Centers for Disease Control and Prevention. (2023). Falls in older adults.
• The Joint Commission. (2022). National Patient Safety Goals: Fall Reduction.
• Agency for Healthcare Research and Quality. (2023). Fall Prevention in Hospitals Training Program.

Policy Title

Resident Fall Prevention Policy

Policy Number

RES-SAF-002

Effective Date

[Insert Date]

Review Date

[Insert Date]

Applicable To

All staff, residents, volunteers, and contractors operating within the facility.

1. Purpose

This policy establishes a proactive, person-centered framework to minimize the frequency and severity of falls among residents of this facility. It supports staff in delivering safe, dignified care while maintaining each resident’s right to mobility, independence, and quality of life.

2. Scope

This policy applies to all residential wings, common areas, dining rooms, outdoor spaces, and any other area of the facility accessible to residents.

3. Guiding Principles

Fall prevention in a residential care setting must balance safety with dignity. Residents have the right to make informed decisions about their own mobility and daily activities. Restrictive measures will only be used when clearly necessary, when less restrictive alternatives have been considered, and always with the resident’s informed consent or, where applicable, with the consent of their authorized representative.

4. Definitions

• Fall: Any event in which a resident comes to rest on the floor, ground, or lower surface unintentionally, with or without injury.
• Recurrent Fall: Two or more falls within a 90-day period.
• Fall-Related Injury: Any physical harm sustained as a direct result of a fall, including lacerations, bruising, fractures, and head injuries.
• Restraint: Any physical or pharmacological intervention used to restrict a resident’s movement that is not part of their standard medical treatment.

5. Policy Statement

This facility is committed to identifying each resident’s individual fall risk and providing a safe, supportive environment that promotes independence while minimizing preventable falls. Fall prevention is a shared responsibility across all departments. Restraints will not be used as a fall prevention strategy unless all alternative interventions have been exhausted and appropriate consent and clinical authorization have been obtained.

6. Responsibilities

• Registered Nurses and Care Coordinators: Lead fall risk assessments, develop individualized care plans, communicate risk to all relevant staff, and coordinate multidisciplinary reviews following falls.
• Personal Support Workers and Care Aides: Apply daily fall prevention strategies as outlined in each resident’s care plan, report environmental hazards, and document observations of mobility changes.
• Physiotherapists and Occupational Therapists: Conduct mobility and functional assessments, recommend assistive equipment, and develop exercise programs to improve strength and balance.
• Pharmacists: Review medication profiles for fall-risk medications on admission and following any medication changes or fall event.
• Dietitians: Assess nutritional status in relation to fall risk, particularly regarding vitamin D and calcium adequacy.
• Housekeeping and Maintenance: Maintain safe environmental conditions throughout the facility, conduct regular checks of flooring, lighting, and equipment, and respond promptly to reported hazards.
• Facility Manager and Director of Care: Ensure adequate staffing levels for fall prevention, support a culture of safety, and oversee policy compliance and quality improvement activities.

7. Fall Risk Assessment

7.1 All residents will be assessed for fall risk using the facility-approved tool (e.g., STRATIFY, FROP-Com, or equivalent) within 24 hours of admission.

7.2 Reassessments will be conducted:

• Every 90 days as part of the comprehensive care review
• Within 24 hours of any fall or near miss
• Following any change in mobility, cognition, medication, or health status
• Upon return from hospital admission

7.3 Results of all assessments will be documented in the resident’s care record and communicated to the care team during handover.

8. Individualized Care Planning

8.1 An individualized fall prevention care plan will be developed for every resident identified as moderate or high risk. The care plan will be developed in collaboration with the resident and, where appropriate, their family or substitute decision-maker.

8.2 Care plans will include:

• Identified fall risk factors specific to the resident
• Targeted preventive interventions based on those risk factors
• Assistive equipment and mobility aids recommended and in use
• Resident’s preferences, goals, and informed choices regarding mobility and risk tolerance
• Emergency response plan in the event of a fall

8.3 Care plans will be reviewed at each scheduled reassessment and updated following any fall.

9. Fall Prevention Interventions

Environmental Measures:

• All resident rooms, hallways, bathrooms, and common areas to be kept free of clutter and trip hazards
• Non-slip flooring and bath mats used throughout the facility
• Grab bars installed in all bathrooms and showers
• Adequate lighting maintained in all areas, including night lighting in resident rooms and hallways
• Call bells functional and accessible from bed, chair, and toilet in all resident rooms
• Furniture appropriate for residents’ functional needs and positioned to support safe mobility
• Outdoor walkways maintained, free from ice, puddles, and uneven surfaces

Resident-Centered Interventions:

• Non-slip footwear provided and proper use encouraged for all ambulatory residents
• Individualized exercise and balance programs prescribed and delivered by physiotherapy for eligible residents
• Mobility aids assessed for fit and safety, and provided where indicated
• Vision and hearing assessments completed annually and following reported changes
• Medication review completed for all residents on four or more medications or on identified high-risk medications
• Vitamin D supplementation provided in accordance with clinical guidelines
• Resident and family education provided regarding fall risks, preventive strategies, and the resident’s individual care plan

Monitoring and Supervision:

• Scheduled toileting assistance provided based on individual resident patterns and needs
• Regular observations conducted by care staff, with frequency based on assessed risk level
• Bed and chair alarm systems used for residents who are unable to safely call for assistance or who are cognitively impaired, in accordance with the resident’s care plan and consent
• Hip protectors offered to residents at high risk of hip fracture from falls

10. Post-Fall Protocol

10.1 In the event of a fall or suspected fall, staff will:

• Stay with the resident and call for assistance
• Assess the resident for injury prior to moving them, and only move them once it is safe to do so
• Notify the charge nurse and attending physician or on-call clinician immediately
• Complete the facility’s incident report within two hours
• Notify the resident’s family or substitute decision-maker as soon as practicable
• Reassess fall risk and revise the care plan within 24 hours

10.2 Falls resulting in injury, recurrent falls, or falls with unclear contributing factors will be referred for a multidisciplinary post-fall review within 72 hours.

11. Restraint Avoidance

Physical restraints will not be used as a method of fall prevention. Where a resident’s safety cannot be maintained through other means, a formal restraint avoidance review will be conducted by the care team, with involvement of the resident or substitute decision-maker. Any use of restraint requires documented consent, clinical justification, regular reassessment, and a clearly defined discontinuation plan.

12. Documentation

All fall risk assessments, care plan updates, fall incidents, post-fall actions, resident and family education, and multidisciplinary reviews must be documented accurately and promptly in the resident’s care record. Incident reports are to be completed through the facility’s reporting system and are separate from care record documentation.

13. Staff Education

All staff will receive fall prevention training as part of their orientation program. Annual refresher education is mandatory for all staff who provide direct resident care. Education will include fall risk assessment, care planning principles, safe manual handling, post-fall response procedures, and restraint avoidance.

14. Quality Monitoring

Fall rates, injurious fall rates, and care plan compliance will be tracked monthly. Data will be reviewed by the Quality and Safety Committee and reported to the Board on a quarterly basis. Trends and incidents will inform continuous improvement activities and staff education priorities.

15. Policy Review

This policy will be reviewed annually or in response to legislative changes, significant incidents, or updates in evidence-based best practice.

Approved By

[Name, Title]   |   [Signature]   |   [Date]

Policy Title

Workplace Fall Prevention Policy

Policy Number

WHS-003

Effective Date

[Insert Date]

Review Date

[Insert Date]

Applicable To

All employees, contractors, visitors, and other persons present on company premises or conducting work on behalf of the organization at any location.

1. Purpose

This policy establishes the organization’s commitment to preventing falls in the workplace and defines the responsibilities, procedures, and standards required to maintain a safe working environment. It applies to falls at the same level, falls from height, and falls into or onto objects or equipment.

2. Scope

This policy covers all indoor and outdoor work areas, including offices, warehouses, manufacturing floors, construction sites, loading docks, stairways, car parks, and any other location where employees or contractors perform work under the direction of this organization.

3. Legislative Framework

This policy is established in accordance with applicable occupational health and safety legislation, including [insert relevant legislation, e.g., the Occupational Safety and Health Act, Work Health and Safety Act, or OSHA General Industry Standards]. All fall prevention activities must meet or exceed the requirements set out in applicable regulations and codes of practice.

4. Definitions

• Fall at the Same Level: A fall where a person loses balance or footing and lands on the same surface they were standing on, such as slipping on a wet floor or tripping on an obstruction.
• Fall from Height: A fall from one level to a lower level, including falls from ladders, scaffolding, platforms, roofs, vehicles, and elevated work areas.
• Fall Hazard: Any condition or circumstance in the work environment that increases the risk of a person falling.
• Hierarchy of Control: A ranked system for managing hazards, prioritizing elimination, substitution, engineering controls, administrative controls, and personal protective equipment, in that order.

5. Policy Statement

This organization is committed to the health, safety, and wellbeing of all workers. Falls are a preventable hazard. The organization will take all reasonably practicable steps to identify fall hazards, assess associated risks, and implement effective controls using the hierarchy of control. No work task is so urgent that fall safety can be compromised.

6. Responsibilities

Role	Responsibility
Senior Management	Allocate resources for fall prevention, set organizational safety expectations, and support a strong safety culture.
Safety Manager / WHS Officer	Develop and maintain fall prevention procedures, conduct or coordinate risk assessments, oversee incident investigation, and manage compliance reporting.
Supervisors and Team Leaders	Conduct pre-shift inspections, ensure workers follow fall prevention procedures, address hazards immediately, and report incidents promptly.
All Employees	Follow all fall prevention procedures, use provided equipment correctly, report hazards and near misses, and participate in fall safety training.
Contractors and Visitors	Comply with this policy and all site-specific fall prevention requirements while on company premises or conducting work for the organization.

7. Hazard Identification and Risk Assessment

7.1 A formal fall hazard identification and risk assessment will be conducted:

• Prior to the commencement of any new work activity involving fall risk
• When existing work processes, equipment, or environments change in a way that may affect fall risk
• Following any fall incident or near miss
• As part of the annual workplace safety review

7.2 Risk assessments will be documented and reviewed by the WHS Officer. Control measures identified through the assessment will be implemented within a defined timeframe and signed off by the responsible supervisor.

7.3 Employees are encouraged to report fall hazards at any time using the organization’s hazard reporting system. All reports will be acknowledged and investigated within one business day.

8. Fall Prevention Controls

Elimination and Substitution:

• Where practicable, work at height will be eliminated by completing tasks at ground level or by redesigning work processes
• Work platforms or elevated work surfaces will be substituted with lower alternatives where safe and practical

Engineering Controls:

• Permanent guardrails, handrails, and barriers installed at all edges, openings, and elevated surfaces where workers may be present
• Safety mesh, covers, or grating used over floor openings and penetrations
• Elevated work platforms (EWPs) and scaffolding used for sustained work at height, in place of ladders wherever possible
• Anti-slip flooring, tread strips, and mats installed in high-risk areas including stairways, ramps, and wet areas
• Adequate lighting maintained throughout all work areas, including storerooms, loading areas, and external pathways
• Spill containment systems in place in areas where liquid or substance spills are reasonably foreseeable

Administrative Controls:

• Safe work method statements (SWMS) required for all high-risk work at height, as defined by applicable legislation
• Permit-to-work system applied for work involving unprotected edges, confined spaces, or use of scaffolding above the prescribed height threshold
• Housekeeping standards enforced to keep all walkways, aisles, and work areas free from clutter, cords, and materials
• Spill response procedures in place requiring immediate reporting and clean-up of any spilled substance
• Regular workplace inspections conducted by supervisors, with findings documented and actioned
• Pre-task briefings conducted before commencing any task with identified fall risk
• Fatigue management procedures applied for workers in roles with elevated fall risk due to extended hours or shift work
• Signs and floor markings used to identify fall hazards and designate safe pedestrian routes

Personal Protective Equipment (PPE):

• Fall arrest systems (harnesses, lanyards, and anchor points) required for all work at unprotected heights above the regulated threshold
• Safety footwear with slip-resistant soles required in all industrial, warehouse, and outdoor work environments
• Hard hats required in areas where falling objects are a risk
• All PPE must be inspected before each use, maintained according to manufacturer specifications, and replaced when damaged or expired
• Workers must be trained in the correct fitting, use, and limitations of all PPE provided

9. Work at Height Procedures

9.1 No worker will perform work at height without completing the organization’s approved working-at-height training and, where required by legislation, holding a current working-at-height qualification.

9.2 Ladders will only be used for access or short-duration tasks where a more suitable platform is not practicable. Ladders must be:

• Inspected before each use and removed from service if damaged
• Positioned at the correct angle (1:4 ratio) and secured at the top or footed by a second person
• Only used on stable, level surfaces
• Rated for the combined weight of the worker and any tools or materials being carried

9.3 Scaffolding must be erected, altered, and dismantled only by competent persons with the required certification. A scaffold inspection tag must be displayed and current before any worker uses a scaffold.

9.4 Elevated work platforms (EWPs) must only be operated by workers who hold the required operator license. Pre-start checks must be completed and documented before each use.

10. Incident Reporting and Investigation

10.1 All falls, near misses, and identified fall hazards must be reported immediately to the worker’s supervisor and through the organization’s incident reporting system.

10.2 All fall incidents resulting in injury must be investigated within 24 hours. Near misses and high-potential incidents will be investigated within 48 hours.

10.3 Investigations will be conducted using a root cause analysis approach and will result in documented corrective actions with assigned owners and completion dates.

10.4 Falls resulting in serious injury or death must be reported to the relevant regulatory authority in accordance with applicable legislative requirements. The scene must not be disturbed until authorized to do so.

11. Training and Competency

All workers will receive general fall prevention training as part of their induction program. Workers in roles involving specific fall risks, including work at height, operation of elevated work platforms, or work in wet or slippery environments, will receive role-specific training before commencing that work. Training records will be maintained and reviewed annually.

12. Inspection and Monitoring

Supervisors will conduct daily visual inspections of their work areas. A formal monthly safety inspection of the entire facility will be conducted by the WHS Officer, with findings documented and communicated to management. Fall incident data and near miss reports will be reviewed monthly to identify trends and drive targeted prevention activities.

13. Non-Compliance

Failure to comply with this policy may result in disciplinary action up to and including termination of employment or contract. Workers are encouraged to raise safety concerns without fear of reprisal. Victimization of a worker for raising a safety concern will be treated as a serious disciplinary matter.

14. Policy Review

This policy will be reviewed annually, or following any significant fall incident, regulatory change, or major change to the organization’s operations or facilities.

Approved By

[Name, Title]   |   [Signature]   |   [Date]