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🛡️ Safety & Infection Prevention · Lesson 4 of 6 · 5 min

Falls: Bed Low, Wheels Locked, Call Light in Reach

🚶 Most falls on a unit happen the same way: a client who did not want to bother anyone gets up alone for the bathroom at night. The exam gives you a room and asks what is wrong with it.

💡 Key idea

Low locked bed, call light in reach, non-skid footwear, scheduled toileting and hourly rounding. After a fall, assess before you move the client.

🧠 Why it matters

Assess fall risk on admission and after any change, using a tool such as the Morse Fall Scale: history of falls, secondary diagnoses, ambulatory aids, IV lines, gait and mental status. Risk factors include age, sedatives and antihypertensives, orthostatic hypotension, urinary urgency, confusion and poor vision. Interventions: bed in the LOWEST position with wheels LOCKED, CALL LIGHT and personal items within reach, NON-SKID footwear, adequate lighting and a clear path, hourly rounding, scheduled toileting, bed or chair alarms for high-risk clients, and assistance with ambulation. Use the client's glasses and hearing aids. Side rails can increase injury when a confused client climbs over them, and all four rails up counts as a restraint. After a fall, assess the client before moving them, take vital signs and check for injury, notify the provider, and complete an incident report.

🏥 In the real world

🌙 A client on a new diuretic is told to call for help to the bathroom. At 0200 she needs to go, sees the nurse is busy, and tries alone. The nurse who scheduled toileting before the diuretic peaked and left the urinal within reach does not get that call. Anticipation prevents more falls than warnings do.

📌 Takeaways

  • Reassess risk after sedatives, diuretics and changes in mental status
  • Bed low and locked, call light in reach, non-skid socks, clear path
  • All four side rails up is a restraint, not a safety measure

📖 Terms in this lesson

Morse Fall Scale: A fall-risk score built from fall history, diagnoses, mobility aids, IV lines, gait and mental status.

✅ Test yourself

Which client has the highest fall risk?
  1. A 30-year-old post-appendectomy on day 2
  2. A 55-year-old with controlled hypertension
  3. An 82-year-old who was given a sedative, is confused, and has a new IV
  4. A 40-year-old with a fractured arm who is alert and ambulating independently

Answer: C · An 82-year-old who was given a sedative, is confused, and has a new IV

Age, sedation, confusion and an IV line are all fall risk factors; the confusion and the IV line also score on the Morse Fall Scale.

A nurse finds a client on the floor. What is the first action?
  1. Help the client back to bed immediately with a second staff member
  2. Call the family
  3. Complete the incident report
  4. Assess for injury before moving the client

Answer: D · Assess for injury before moving the client

Moving a client with an unrecognized fracture or head injury can worsen it. Assess first, then move with help, then notify and report.

Which intervention is most effective for a confused client at risk of falling?
  1. Raise all four side rails
  2. Leave the bed in the high position so the client cannot get out
  3. Apply a bed alarm and move the client closer to the nurses' station
  4. Keep the room dark to encourage sleep

Answer: C · Apply a bed alarm and move the client closer to the nurses' station

Alarms and proximity allow quick response. Four rails up is a restraint and increases injury severity when clients climb over.

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