DIET & NUTRITION 
PATIENT EDUCATION 
OBESITY/WEIGHT MANAGEMENT 
EXERCISE/TRAINING 
LEGAL MATTERS 
GUIDELINES/RECOMMENDATIONS ⚠️ Small Study Evidence
Fall T.I.P.S. toolkit pilot on an Alabama geropsychiatric unit cut falls by more than 40% (from 7 to 4) over six weeks. Both licensed and unlicensed staff showed increased self-efficacy, with unlicensed staff (CNAs/PCTs) gaining the most.
Key Clinical Considerations
- Geropsychiatric patients fall at 11.7 per 1,000 bed-days vs. 8.9 on non-psychiatric units, driven by psychotropic effects and cognitive impairment
- Each added medication raises fall risk by 14% regardless of drug class, making polypharmacy review a bedside priority
- Bedside posters made fall risks visible to every team member entering the room, including float and night staff unfamiliar with the patient
- Small sample (n=11 matched) and short timeframe limit statistical significance, but clinical signal aligns with prior Fall T.I.P.S. evidence
Practice Applications
- Update the bedside fall poster at every shift change and after any status change
- Communicate fall risk face-to-face during nurse-to-CNA handoff, not just in the chart
- Engage patient and family in the three-part plan at admission, not after the first near-miss
- Flag new psychotropic orders as fall-risk triggers requiring plan revision
