Standards › Standard S4 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LTC-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S4 (Long-term care), criterion S4.1
At a glance
- Screen every resident on admission for falls, pressure injury and nutrition risk.
- Repeat the screen on the schedule set for each risk level and after any fall, skin change or weight loss.
- Put a written measure in place for every resident at risk.
- Review the measures at each screen.
- Stop and get help straight away if: a resident at risk has no screen on record, or no measure in place for a known risk.
1. Purpose
To find residents at risk of falls, pressure injury and malnutrition early, and to act before harm happens (S4.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Older people and people with limited mobility can fall, develop pressure injuries, or lose weight quickly, often without anyone noticing until harm is done. A risk check on arrival and on a schedule, with measures put in place, prevents most of these.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Care home nurse in charge | Completes the screen and sets the measures | Registered nurse |
| Care staff | Watch for change and report it the same shift | Trained in the screen |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Screen on admission.
- Complete the falls, pressure injury and nutrition screen within 24 hours of arrival.
- Record the result on LTC-FRM-001.
Key point: Admission is the first and most important screen.
Step 2. Set measures.
- For each resident at risk, write the measure: mobility aids, pressure relieving equipment, or food and fluid plan.
- Tell the care team where it is recorded.
Key point: A risk with no measure is not managed.
Step 3. Repeat and react.
- Repeat the screen on the schedule for the risk level.
- After any fall, new skin change or weight loss, screen again the same day.
Key point: Change is the trigger.
Step 4. Record in the register.
- Enter each at-risk resident on LTC-REG-001 with the date of the next screen.
Key point: The register shows who is due.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Residents screened on admission within 24 hours | 100% | Monthly | Nurse in charge | Escalate to clinical lead |
| At-risk residents with a measure in place | 100% | Monthly | Nurse in charge | Escalate to clinical lead |
| Screens repeated on schedule | At least 70% | Quarterly | Clinical lead | Escalate to clinical lead |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| LTC-FRM-001 | Risk screen and measures record | Screen form |
| LTC-REG-001 | Falls, pressure injury and weight register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Scale choice to follow the national care home guidance. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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