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Accréditation Sans Frontières · ASF Health Standards 9.0

Standard 19 · Falls Prevention

15 criteria · base standard

Base standard. 15 criteria, of which 5 non-negotiable. Each criterion is numbered 19.Y, with its classification and verification questions.

Criteria

19.1 Falls Risk in the Environment Is Assessed on a Schedule

NON-NEGOTIABLE

The environment in which patients move is assessed for falls risk on a defined schedule, with each finding recorded and acted on, not checked once at opening and assumed safe thereafter.

VERIFICATION QUESTIONS

  1. Is every patient area walked through for falls risk on a defined schedule, with the walk-through recorded?
    A walk-through that happens only when a fall has already occurred is a reaction, not an assessment.
  2. Does the assessment cover floors, lighting, handrails, grab bars, call systems, clutter and furniture, not only the main corridors?
    Toilets, stairs, bedsides and storage rooms are common locations for falls.
  3. Is every finding given an owner and a deadline, and is the closure checked?
    An identified hazard that stays open for months is a known risk that was not managed.

19.2 Universal Falls Precautions Apply to Every Patient Area

NON-NEGOTIABLE

A standard set of falls precautions applies to every area where patients move, so that protection does not depend on which unit a patient is in or which staff member is on duty.

VERIFICATION QUESTIONS

  1. Are the universal falls precautions written down and applied in every patient area, including day-care and waiting areas?
    Precautions that exist only on the inpatient unit leave every other area unprotected.
  2. Do staff know the precautions and apply them without needing to be reminded?
    Knowledge that depends on a poster in the office is not reliable at night.
  3. Are the precautions reviewed at least yearly, and after any fall that shows a gap?
    Precautions unchanged for years do not reflect the patients being cared for now.

19.3 Handrails Are Fitted Where Patients Walk

CORE

Sturdy, continuous handrails are fitted on both sides of corridors, stairs and ramps where patients walk, so that a patient can hold on for the whole route.

VERIFICATION QUESTIONS

  1. Are handrails fitted on both sides of corridors, stairs and ramps where patients walk?
    One-sided handrails leave a patient without support on the other side.
  2. Are the handrails continuous, without gaps where a patient would need to let go?
    A gap at a door or landing is where a fall happens.
  3. Are handrails checked for firmness and security on a defined schedule?
    A loose handrail gives false support and is worse than none.

19.4 Toilets and Washrooms Have Correct Grab Bars

CORE

Grab bars in toilets and washrooms are placed for toilet transfer, both horizontal and vertical where the design allows, and are fixed so that they do not turn in their fittings.

VERIFICATION QUESTIONS

  1. Are grab bars fitted beside the toilet and in the shower or bathing area, in positions that support sitting down and standing up?
    A bar in the wrong place gives support only to someone who does not need it.
  2. Are bars horizontal where they support a transfer, and do they hold firm when tested?
    A bar that rotates or pulls out of the wall does not prevent a fall.
  3. Where space allows, are fold-down bars fitted beside the toilet, so that a patient can use one on either side?
    Fixed wall bars on one side only leave the other side unsupported.

19.5 An Accessible Toilet Is Available Where Patients Need One

CORE

At least one toilet in the facility is accessible to a patient who uses a wheelchair, with enough clear floor space for a transfer and bars placed for that transfer, to recognised international design guidance for health facilities.

VERIFICATION QUESTIONS

  1. Is at least one toilet accessible to a wheelchair user, with clear floor space for a transfer, designed to recognised international guidance for health facilities, and is the basis of the design recorded?
    Local custom alone does not establish accessibility.
  2. Is the accessible toilet clearly signed and placed on the route patients take from the main entrance?
    An accessible toilet that patients cannot find is not available to them.
  3. Is the accessible toilet kept free of storage, so that it can be used at any time?
    A toilet used as a store room is closed to the patient who needs it.

19.6 An Emergency Call Is Reachable From the Toilet and the Bed

NON-NEGOTIABLE

A call button or pull cord is within reach of a patient in the toilet and in the bed, connected to a staff alert that is answered, and tested on a defined schedule, so that help can be summoned without standing or moving.

VERIFICATION QUESTIONS

  1. Is an emergency call button or pull cord reachable from the floor and from the toilet, as well as from the bed?
    A call point that a patient on the floor cannot reach does not summon help.
  2. Does the call activate a staff alert in a location where it is answered, and is the response time recorded?
    A call that rings in an empty room is not an alert.
  3. Is the call tested on a defined schedule, with the test recorded?
    A call system that has failed unnoticed can leave a fallen patient undiscovered for a long time.

19.7 Toilet and Washroom Doors Allow Rescue

NON-NEGOTIABLE

Toilet and washroom doors open outward, or can be released from outside in an emergency, so that a patient who has fallen or is unable to open the door can be reached and removed promptly.

VERIFICATION QUESTIONS

  1. Do toilet and washroom doors open outward, or can they be released from outside without a key?
    A door that opens inward and is locked from inside can trap a patient who falls against it.
  2. Is the emergency release tested on a defined schedule, and does it work?
    A release that has not been tested may fail when it is needed.
  3. Are staff trained to use the release, and is the release location known to all staff?
    A release that only one person knows how to use delays rescue.

19.8 Lighting Supports Safe Movement

CORE

Corridors, stairs, toilets, washrooms and patient rooms are lit at a level that allows safe movement at all hours, with night lighting or motion-activated lighting where patients walk at night.

VERIFICATION QUESTIONS

  1. Are corridors, stairs and washrooms lit to a level that allows safe movement at night?
    Patients often get up at night, when light is low and staff presence may be thinnest.
  2. Is night lighting provided where patients walk between bed and toilet?
    Lighting that only works when the main lights are on does not serve the patient at night.
  3. Are lights checked on a schedule, and are failed lights replaced promptly?
    A corridor that is dark because a bulb has failed for weeks is a known hazard.

19.9 Floors Are Non-Slip, Dry and Maintained

NON-NEGOTIABLE

Floor surfaces in patient areas are non-slip and maintained, spills are cleared within a stated time, and wet floors are marked, so that a slip on a floor surface does not cause a fall.

VERIFICATION QUESTIONS

  1. Are floor surfaces in patient areas, toilets and washrooms non-slip when wet, and is their condition checked?
    Polished or worn surfaces that are slippery when wet are a common cause of falls.
  2. Is each spill cleared within a stated time, and is a wet floor marked while it is being cleaned?
    A spill left for an hour is a fall waiting to happen.
  3. Is there a defined responsibility for floor maintenance and a record of checks?
    A floor that everyone assumes someone else has cleaned is not maintained.

19.10 Beds and Chairs Are Set to Reduce Fall Risk

CORE

Patient beds are set to a low height when the patient is in them, brakes are locked, and the call system and personal items are within reach, so that a patient can get in and out safely.

VERIFICATION QUESTIONS

  1. Are patient beds kept at a low height when the patient is in bed, and raised only for care and transfer?
    A bed raised for convenience of care is a risk when the patient gets up alone.
  2. Are bed and chair brakes locked when the patient is in them, and is this checked?
    A bed that moves when a patient sits on its edge is a common cause of falls.
  3. Are the call button, water, glasses and personal items within reach from the bed and the chair?
    Items out of reach lead patients to stretch, climb or stand unsupported.

19.11 Walking Aids and Mobility Equipment Are Available and Checked

CORE

Walking aids, wheelchairs and other mobility equipment are available in the sizes needed, are in working order, and are checked on a defined schedule, so that a patient's own aid or a facility aid is safe to use.

VERIFICATION QUESTIONS

  1. Are walking aids and wheelchairs available in the sizes and types the patients need?
    An aid that is too tall or too short for the patient is an additional fall risk.
  2. Are walking aids and wheelchairs checked on a defined schedule, with the check recorded?
    A worn wheel or loose clamp is a fall waiting to happen.
  3. Are defective aids removed from use immediately, and is their repair or replacement tracked?
    A defective aid left in use is worse than none.

19.12 Routes Are Clear of Clutter and Trip Hazards

CORE

Routes that patients walk are kept clear of equipment, cables, boxes, mats and other objects that could cause a trip, and any hazard that cannot be removed is marked and managed.

VERIFICATION QUESTIONS

  1. Are patient routes kept clear of equipment, cables, trolleys, boxes and loose mats?
    A trolley left in a corridor for an hour is a trip hazard for every patient who passes.
  2. Are cables and leads routed so they do not cross walkways?
    A cable across a walkway is a trip hazard that patients cannot see.
  3. Where a trip hazard cannot be removed, is it marked and managed until it is removed?
    A hazard that is known and unmarked is not managed.

19.13 Staff Are Trained in Falls Prevention and Awareness

STANDARD

Staff are trained in falls prevention and the precautions that apply to their work, and patients and families receive information about falls prevention appropriate to their care.

VERIFICATION QUESTIONS

  1. Do all staff who care for patients complete falls prevention training when they join and at a defined interval?
    Falls prevention is part of the job for every member of staff who moves patients.
  2. Do patients and families receive information about falls prevention, including what to do after a fall?
    A patient who knows how to use the call button and how to get up safely is safer.
  3. Is the effect of the training checked, such as through observation or review of falls?
    Training that is attended but not applied does not reduce falls.

19.14 Staff Falls and Workplace Slips Are Prevented and Reported

CORE

Manual handling and slip risks at work are assessed, staff falls and slips are reported, and the causes are reviewed, so that staff are protected from the falls and injuries that arise from their own work.

VERIFICATION QUESTIONS

  1. Are manual handling and slip risks in staff work assessed, and are controls in place?
    A nurse lifting a patient without equipment is exposed to injury and is a risk to the patient.
  2. Are staff falls and slips reported and reviewed, with the causes acted on?
    A staff fall that goes unreported cannot prevent the next one.
  3. Is footwear and protective equipment for slip risk provided and used?
    Protective equipment that is available but not worn does not protect.

19.15 Every Patient Fall Is Reviewed and the Environment Is Changed

CORE

Every patient fall is reviewed, the environmental causes are identified, and changes are made and checked, so that each fall improves the environment for all patients, not only the one who fell.

VERIFICATION QUESTIONS

  1. Is every fall reviewed, with its environmental causes recorded?
    A fall recorded only as a clinical event hides the environmental cause.
  2. Are environmental changes made after a fall, and is their effect checked?
    A change that is made and never checked may not have worked.
  3. Are falls and their causes shared across the facility, and linked to incident reporting and learning?
    A lesson learned from a fall on one unit should prevent the same fall on other units. ————————————————————

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