Tuesday, August 24, 2021

How Fall Incidences Among Residents Are Minimised At St. Andrew’s Nursing Home (Buangkok)


Fall prevention is important among seniors who are prone to falls. This preventive measure is useful not only at home, but also in a residential setting.

Serious injuries can result from falls. In certain instances, they may lead to a loss of independence that may affect a senior’s quality of life. At times, there is also the potential loss of morbidity.

A study showed that falls in healthcare institutions that provide care for persons with mental health conditions were significantly more common as compared to other healthcare settings.  (Meng, Sim, Pee, Kwok & Ng, 2010). St. Andrew’s Nursing Home (Buangkok), which serves residents who have dementia and stable psychiatric conditions, houses a majority of residents aged above 60. This study motivated the team to embark on the   “Keeping Falls At Bay, The Care Bundle Way!” project in 2019.

With the residents’ well-being at the core, the project aimed to improve clinical quality and patient safety within the nursing home. Putting the plan in motion, the project team initiated a care process that assessed the fall risk of the residents. The intent was to introduce appropriate care plans and preventive measures to prevent falls.  

Customising The Fall Intervention Plan

Determined to bring about improvements in fall prevention and management, the project team analysed the data collected from incidents occurring between January and June 2018. What stood out as the common risks factors for falls were:

  1. Poor safety awareness
  2. Altered mental state
  3. Underlying medical conditions
  4. Frailness in the residents

With the findings foremost in the minds of the project team, they formulated a care bundle that mapped out an intervention plan to better manage the residents’ fall risks and commenced a trial in a ward within the Nursing Home.

The care bundle was nuanced, which led to the development of three sections of care interventions

  1. “Must Do Care Bundle”
  2. “Good To Do Care Bundle”
  3. “To Do Situational Care Bundle”

"Must Do Care Bundle"

The “Must Do Care Bundle” is a mandatory care protocol that must be performed for all residents in the ward. This bundle includes a Fall Risk Assessment Tool (FRAT), which is a form that screens a senior’s history of falls in the past year, medication, peripheral sensation, strength and balance.

For new admissions to SANH (Buangkok), FRAT and other visual assessments are conducted on new residents within 24 hours of admission. Under this care bundle, there are specific roles for occupational therapists, nurse managers, physiotherapists and pharmacists.

Care Staff

Care Protocols

Occupational Therapists

  • Conduct mini mental state examinations to determine the cognition of the resident.


  • Refer newly admitted residents to the Physiotherapist for assessment of gait, balance, and endurance strength, and make recommendations for walking aids if necessary

  • Raise incident report using situation-background-action format

Occupational Therapists,


  • On-the-job training in the first week in the ward for new staff

  • Standard operating procedures on fall prevention and mobility for new and all existing staff

  • Separate training for non-local staff for better communication and understanding

  • At every handover, highlight to all ward staff the list of residents who have had new medications or changes in drug dosage, and place them on the list of residents to be observed closely

  • Ensure the head of the bed is adjusted at an angle of between 20 and 30 degrees to prevent orthostatic hypotension

  • Assign at least one care staff to supervise residents who are not engaged in activity

Nurse Manager

  • Perform post-fall root cause analysis with the ward team

  • Make recommendations to address the cause of fall


  • Conduct transfer technique training for all care staff


  • Reconcile all the residents' medication every six months

"Good To Do Care Bundle"

The “Good to Do Care Bundle” outlines a care protocol whereby the care team takes note of residents' physical needs and update the Project Team on any falls within the wards. A fall committee was also set up by the Project Team, comprising nurse leaders and care staff, to monitor the progress in this care bundle.

Care Staff 


Care Protocols

Fall Committee,,


  • Increase staff awareness of specific residents’ fall risks during daily handover of duties

  • Attend to residents' physical needs such as cold, hunger, pain, or sleeplessness

  • Update ward staff with the number of falls and their causes on the first day of each month

  • Update the team on achievements and reiterate improvement measures (if any)


Fall Committee

  • Review fall incidence every three months to brainstorm measures to take to prevent falls

  • Review the effectiveness of the implemented recommendations

Fall Committee

  • Inform all staff of the nursing home at the third monthly town hall meeting on fall statistics to increase staff awareness and responsibility to reduce fall incidences

Care Staff

  • Conduct fall prevention education for the residents every Sunday

"To Do Situational Care Bundle"

The “To Do Situational Care Bundle” is a care protocol that is performed on a case-by-case basis. The care team monitors residents' vital signs and supervise the residents’ reactions to any change in medication. Specific tasks are assigned to nursing aides, healthcare staff and nurses in this care bundle.

Care Staff 

Care Protocols

Nursing Aide,

Health Care Assistant

(supervised by nurses)

  • Monitor orthostatic hypotension for three days; recommended once in the morning for newly admitted residents and those prescribed with new medications

  • Instruct residents to sit and rise slowly when changing position

Healthcare Staff

  • Observe behaviour of residents who had a change in medication 

Staff Nurse,

Enrolled Nurse

  • Inform the night duty staff to observe sleeping patterns of residents who skipped dinner

  • Recommend early psychiatric review for residents with sleep anomaly and change in behaviour

  • Make an appointment for pharmacist’s weekly review of residents on new medication

SANH (Buangkok) residents in the midst of a health education session on fall prevention guided by the ward nurse – photo was taken prior to the COVID-19 pandemic.

Expanding The Project Within SANH

The project was first implemented in ward 3A in January 2019. By September 2019, the care bundle was implemented in all the other 9 wards in SANH (Buangkok). The project has benefited both the residents and staff. Besides enhanced safety for residents, the training provided for staff has equipped them with the skills on using the fall assessment tool and improved their competency in transfer techniques.

A collage of a person's face

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SANH (Buangkok) nurses, both on- and off-duty, gathered together online for a virtual fall case presentation. 

To further ensure the consistency of the care bundle at SANH (Buangkok), all staff in the wards were also audited every six months on staff knowledge, environment and compliance to Fall Prevention Standard Operating Procedures. Additionally, regular meetings were held to address the challenges encountered by the team.

Making this project a success was the positive attitude of the care team members at St. Andrew’s Nursing Home (Buangkok). They complemented the Project Team which through its strong leadership piloted the care bundle smoothly by overcoming any prevalent challenges. The unity between the staff and the firm support from the Management were instrumental in helping SANH (Buangkok) achieved the desired outcomes.

“It was indeed a challenge to achieve our goals, considering the profile of our residents. With strong leadership to ensure enforcement of the care bundle, alongside the positive attitude of our staff, the word ‘impossible’ became ‘possible’ for the team.”
Madam Theresa Lein, Assistant Director of Nursing at SANH (Buangkok)

About St. Andrew’s Nursing Home (Buangkok)

Established in November 2013, SANH (Buangkok) is a nursing home that provides long-term residential care for 300 residents with mental health conditions and dementia. Being a non-profitable, voluntary welfare organisation, they pride themselves on the provision of holistic and person centered nursing care to all their residents. With a team of more than 160 staff, SANH (Buangkok) engages residents in rehabilitative and vocational training. Find out more about SANH (Buangkok) here.

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