How a Falls Risk Assessment Expert Reviews Disputed Protocols in Infection Isolation

When isolation, infection control, and fall risk collide

An elderly patient recovering from pneumonia and C. difficile infection, experienced two inpatient falls in a side room. One resulted in a painful shoulder dislocation. Despite these events, no post-fall protocols were completed, and her falls risk assessment score was erroneously inflated in follow-up entries.

An Apex falls risk assessment expert was asked to review whether the nursing care and documentation met the expected standard and whether any actions could have prevented the second fall.

Falls documentation was incomplete but was it negligent?

The records revealed:

• A first fall occurred after toileting, resulting in a minor head bump and right thigh soreness

• A second fall resulted in a dislocated left shoulder, followed by prompt medical referral

• Neither event was followed by a completed post-falls protocol

• The risk assessments logged after the falls were mathematically inaccurate, overestimating fall risk

  
  

“The absence of post-fall documentation is a breach of policy but in this case, it likely did not affect the outcome. Still, best practice was not followed.”— Apex Falls Risk Assessment Expert

Despite this, the expert felt that the standard of care was generally reasonable, considering the patient's independent mobility and positive rehabilitation trajectory prior to the falls.

What a falls risk assessment expert expects after an incident

Every qualified falls risk assessment expert would expect the following actions to occur after any inpatient fall:

1. Completion of a structured post-fall protocol

2. Accurate re-scoring of the falls risk assessment tool

3. Increased monitoring or bed sensor placement

4. Updated care planning with specific supervision instructions

5. Documentation of family communication, medical escalation, and incident reporting

   
   

In this case, the patient was in a side room at the end of the ward, due to infection control. The expert acknowledged the difficulty in managing isolation patients but noted that the location must not compromise fall prevention practices.

How infection control pressures influence fall prevention practices

Nursing staff placed the patient in an isolated room due to her C. difficile status, limiting observation and access. While practical pressures were understandable, it remains critical to balance:

• Infection control policy

• Falls prevention protocols

• Staffing and visibility of high-risk patients

The falls risk assessment expert concluded that although protocol was not followed to the letter, there was no evidence of gross negligence, and no proof that earlier intervention would have prevented the second fall.