b'Falls Prevention High Risk Standard Protocol (score 12 and above):An unplanned descent to the floor or extension to the floor where the child is at a lower level from where theyIdentify patient with a Humpty Dumpty armband on the started patient (if ambulatory) with a Humpty Dumpty sign at the head of the bed or cribFalls may occur with or without assistance and resultEducate patient/parents of falls protocol precautions or not in injury and classified as non-developmental orCheck patient minimum every 1 hour developmental falls. Accompany patient with ambulationNon-developmental falls are anticipated physiologic orDevelopmentally place patient in appropriate bedunanticipated physiologic. Consider moving patient closer to nurses station Developmental falls are caused by environmental factorsAssess need for 11:1 supervisionor errors in judgement. They occur as a direct result of theEvaluate medication administration timeschilds developmental stage or walking capability. UsuallyRemove all unused equipment out of the room associated with age except of the chronological age of the child is reflective of the developmental stage and walkingKeep the bed in the lowest positioncapability of a younger age child. Document in the patient education of HER & on the Assessment and Protocols: High Risk for fall IPOCAll patients, inpatient and outpatient receiving nursing or rehabilitation services will be assessed for risk of falls using Humpty Dumpty risk assessment scale.Assessment is performed upon admission or service and once per shift or whenever there is a change in the level of care or major change in patients status/condition.Low Risk Standard Protocol (score 7-11):Orientation to the roomBed in low position, assessing gaps, & secured Use of non-skid footwear for ambulating patients, use If a fall occurs:of appropriate size clothing to prevent risk of trippingAssess eliminations needs In the event that the patient falls, a Power Form is to be completed describing the fall event (e.g. how did the Call light within reach fall occur, when did the fall occur, where did the patient Environment clear of unused equipment, furnitures infall, was the fall witnessed, who was present and who place, clear of hazards was notified, condition of the patient, and any nursing Assess for adequate lighting leave night light on or medical interventions rendered).Patient and family education available to parents andAn incident report is completed and sent to risk patient management per any fall occurrence.Document fall prevention education and include inA post fall huddle is to be completed during the shift plan of care post the fall event.44 Nicklaus Childrens Health System'