Safety/Falls Risk Assessment
Q. If a patient is in restraints where will this now be documented and what elements need to be
captured?
A. The restraints documentation is now under the Safety Care Implemented section of the Safety/Falls
Risk Assessment. The nurse should document every 2 hours the status of restraints as “on” or “off”
along with the Restraint and Safety Comfort Care. When hovering over the Restraint and Safety
Comfort Care field, required elements that the nurse is documented against are listed so that when the
nurse documents “done” it is acknowledged that all of these elements have been performed. If for some
reason one of more required action could not be done, check the box but add an annotation stating why
an action was not done.
Q. Should I now always have a safety priority problem present?
A. A Safety Priority Problem should always be intitated/maintained when a patient is restrained. For
patients not restrained, Regardless of acuity, prioritizing problems and determining the focus for care on
a given shift often requires complex decision making. Some general principles that may help:
 If the patient is NOT tracking as expected against the pathway, what is causing the variation?
That is probably a priority problem. For example, if a patient on an Abdominal Aneurism Repair
pathway is meeting all goals on the pathway at the expected time EXCEPT by Post Op Day 2,
they have still not successfully ambulated, then Activity Tolerance (or perhaps Pain or some
other reason that is preventing them from meeting the Activity Goal) would be a Priority
Problem.
 If the patient has co-morbidities not covered by the Pathway, there may be Priority Problems
that are not being addressed related to those co-morbidities. For example, if a patient with
ADRS related to Sepsis is also a Diabetic and they are experiencing unstable glucose control, that
might be a Priority Problem.
 What is going on with the patient that may prolong the LOS in the ICU or the overall ? Any kind
of complication (eg. a Fall, a Pressure Ulcer, etc.) would warrant consideration as a Priority
Problem.
 Finally, focus on “nursing-centric” problems. For example, a patient with Meningitis would likely
have several significant problems but nursing care is more likely to drive desired outcomes for
some problems than others. For example, a skin breakdown issue or preventing injury with in a
confused, restrained patient are things nurses can more directly impact and may therefore
make more sense as priority problems than the Infection.
Remember, you are only making decisions for your 12 hour shift and if the patient condition changes
during your shift, you can always alter your focus. There’s not usually a right or wrong answer but we
hope you’ll see value in the decision making process required to determine the specific problems and
outcomes that will drive your care for your shift. In general, there should usually be no more than 3-4
active priority problems – the exception being when placement of Restraints might add a 5th PP.
Q. Can we make Morse Falls Risk Score viewable within the OPC ?
We are working on this right now and expect to have this available at some point during this
pilot.