What is the appropriate assessment and management for a patient status post fall in a skilled nursing facility (SNF)?

Post-Fall Assessment in Skilled Nursing Facilities

Immediately perform a systematic ABCDE (Airway, Breathing, Circulation, Disability, Exposure) assessment to identify life-threatening injuries, followed by a comprehensive evaluation for occult trauma and fall risk factors. 1, 2, 3

Immediate Assessment (First 15 Minutes)

Primary Survey - ABCDE Approach

• Airway: Assess patency, look for obstruction, bleeding, or foreign bodies 2, 3
• Breathing: Check respiratory rate, oxygen saturation (SpO2), lung sounds bilaterally, work of breathing 2, 3
• Circulation: Measure blood pressure, heart rate, assess for bleeding, check peripheral perfusion 2, 3
• Disability: Evaluate level of consciousness, pupillary response, focal neurological deficits 2, 3
• Exposure: Complete head-to-toe examination for ALL patients, even with seemingly isolated injuries, looking for occult trauma 1

High-Risk Injury Screening

Falls in elderly SNF residents warrant heightened suspicion for specific injuries that may present without classic signs 1:

• Head trauma: Check for scalp hematomas, altered mental status, loss of consciousness, new confusion 1
• Spinal fractures: Assess for midline tenderness, neurological changes, mechanism suggesting axial loading 1
• Hip fractures: Evaluate for groin pain, leg shortening/rotation, inability to bear weight 1

Comprehensive Fall Evaluation

Critical Historical Elements

Obtain the following key information to determine if this was a "mechanical" fall or indicates underlying pathology 1:

1. Circumstances: Location, activity during fall, witnessed vs. unwitnessed 1
2. Time on floor/ground: Prolonged immobility increases risk of rhabdomyolysis, pressure injuries 1
3. Loss of consciousness or altered mental status 1
4. Presyncope, syncope, or orthostatic symptoms 1
5. Melena or other bleeding symptoms 1
6. Previous falls in recent months 1
7. Gait or balance difficulties 1

Medication Review

Perform immediate medication reconciliation, specifically identifying 1:

• Vasodilators
• Diuretics
• Antipsychotics
• Sedative/hypnotics
• Other high-risk medications (anticholinergics, benzodiazepines)

Physical Examination Components

Orthostatic vital signs: Measure blood pressure and heart rate supine, then after 1 and 3 minutes of standing (or sitting if unable to stand) 1

Neurological assessment 1:

• Peripheral neuropathies (light touch, vibration sense in feet)
• Proximal motor strength (hip flexors, quadriceps)
• Cerebellar function (coordination, balance)
• Visual acuity and fields

Cardiovascular assessment: Auscultate for arrhythmias, murmurs suggesting valvular disease 1

Musculoskeletal examination: Palpate all long bones, spine, pelvis for tenderness; assess joint range of motion 1

Diagnostic Testing

While no standardized test panel exists, maintain a low threshold for 1:

• ECG: For syncope, palpitations, chest pain, or unexplained falls
• Complete blood count: To assess for anemia (melena, fatigue)
• Basic metabolic panel: Electrolyte abnormalities, renal function, glucose
• Medication levels: Digoxin, anticonvulsants if applicable
• Imaging: Head CT for any head trauma with loss of consciousness, anticoagulation, or altered mental status; spine imaging for midline tenderness; hip/pelvis imaging for inability to bear weight

Functional Assessment Before Discharge

"Get Up and Go" test: Patient must demonstrate ability to 1:

1. Rise from bed independently or with usual assistive device
2. Turn safely
3. Ambulate steadily

Patients unable to complete this assessment require reassessment of discharge safety and may need admission. 1

Disposition and Follow-Up

Criteria for Hospital Transfer

Transfer to acute care if 1:

• Unstable vital signs or ongoing resuscitation needs
• High-risk injuries requiring surgical evaluation (hip fracture, subdural hematoma)
• Inability to determine cause of fall requiring advanced diagnostics
• Patient safety cannot be ensured in SNF setting

For Patients Remaining in SNF

Immediate interventions 1:

• Physical therapy and occupational therapy consultation for all admitted fall patients
• Home safety assessment (even within SNF room): remove trip hazards, ensure adequate lighting, install grab bars if needed
• Expedited physician follow-up within 30 days 1

Ongoing monitoring 1:

• Surveillance for infections (respiratory, urinary), electrolyte imbalances, mental status changes—common causes of falls and rehospitalization
• Daily assessment of mobility, activities of daily living, cognitive status 1

Fall Prevention Measures

Implement environmental modifications 1:

• Rubber/nonskid floor surfaces
• Handrails in hallways
• Bedside commodes with grab bars
• Properly positioned bedrails
• Adequate lighting, especially at night
• Appropriate footwear and clothing (avoid long, baggy garments)

Common Pitfalls

• Assuming isolated injury: Always perform complete head-to-toe examination; elderly patients frequently have occult injuries at distant sites 1
• Attributing falls to "old age": Ask "would a healthy 20-year-old have fallen in this situation?" If no, investigate underlying causes 1
• Discharging without functional assessment: Never discharge a patient who cannot safely ambulate from the examination area 1
• Missing medication-related causes: Polypharmacy and high-risk medications are modifiable fall risk factors requiring immediate attention 1