PCT Patient Safety, Falls, and Restraints 2 — Questions and Answers
Question 1: A patient identified as a high fall risk should have which intervention in place?
- Bed in the highest position for easier exit
- Bed in the lowest position with call light within reach (Correct answer)
- Room lights turned off to encourage sleep
- Restraints applied at all times
Correct answer: Bed in the lowest position with call light within reach
A low bed position reduces injury from falls, and an accessible call light allows the patient to request assistance before attempting to get up.
Fall prevention bundles include: bed in lowest position, side rails up per policy, call light within reach, non-skid footwear, clear pathway to bathroom, adequate lighting, toileting schedule, and fall risk signage. The PCT should answer call lights promptly and assist with ambulation. Restraints are a last resort, not a routine fall prevention measure.
Question 2: When applying a vest restraint, the PCT should ensure:
- The vest is tied tightly to prevent any movement
- The vest crosses in front and is secured with quick-release knots to the bed frame (Correct answer)
- The vest is applied over the patient's face for maximum security
- The ties are knotted securely to the side rails
Correct answer: The vest crosses in front and is secured with quick-release knots to the bed frame
The vest must cross in front (V opening in front), and quick-release knots allow rapid removal in emergencies while securing to the bed frame, not side rails.
Vest restraints cross in front with the V opening at the chest (crossing in back can cause strangulation). Ties are secured to the movable bed frame using quick-release knots—never to side rails (raising rails could strangle the patient). Check circulation, sensation, and movement every 2 hours, release every 2 hours for exercise, and offer toileting, fluids, and repositioning.
Question 3: How often must a patient in restraints be assessed by the PCT?
- Once per shift
- Every 15 minutes to 2 hours per facility policy (Correct answer)
- Only when the patient calls for help
- Every 4 hours
Correct answer: Every 15 minutes to 2 hours per facility policy
Frequent monitoring (typically every 1-2 hours with checks every 15 minutes) ensures patient safety, circulation, skin integrity, and comfort.
CMS and The Joint Commission require that restrained patients be monitored at regular intervals (commonly every 15 minutes for circulation checks and every 1-2 hours for comprehensive assessment). Assessments include circulation/sensation/movement of restrained extremities, skin integrity, vital signs, hydration/nutrition, toileting needs, continued need for restraint, and documentation of all findings.
Question 4: Which action should the PCT take to prevent patient falls during toileting?
- Leave the patient alone for privacy
- Stay nearby, provide grab bars, and use a non-skid mat (Correct answer)
- Rush the patient to finish quickly
- Have the patient use a bedpan instead of the toilet
Correct answer: Stay nearby, provide grab bars, and use a non-skid mat
Staying nearby while providing assistive devices and non-skid surfaces addresses the high fall risk during toileting without sacrificing dignity.
Toileting is one of the highest-risk activities for patient falls due to positional changes, wet surfaces, and urgency. Prevention measures include non-skid bath mats, grab bars, raised toilet seats, adequate lighting, staying within earshot, using a call bell in the bathroom, and accompanying fall-risk patients. Balance privacy with safety based on the patient's assessed risk level.
Question 5: A patient is found on the floor after a fall. What should the PCT do FIRST?
- Help the patient back to bed immediately
- Assess the patient for injuries before moving them (Correct answer)
- Call the physician
- Complete the incident report
Correct answer: Assess the patient for injuries before moving them
Assessing for injuries before moving the patient prevents worsening of potential fractures or spinal injuries.
After finding a fallen patient: (1) Stay with the patient and call for help. (2) Assess level of consciousness, pain, visible injuries, and ability to move extremities. (3) Check vital signs. (4) Do NOT move the patient if spinal injury or fracture is suspected—wait for the nurse's assessment. (5) Once cleared, assist the patient safely back to bed. (6) Notify the nurse and complete an incident report with objective findings.
Question 6: Which factor does NOT increase a patient's risk of falling?
- Taking multiple medications
- Having adequate lighting in the room (Correct answer)
- Being over 65 years old
- Having a history of previous falls
Correct answer: Having adequate lighting in the room
Adequate lighting is a protective factor that helps prevent falls, unlike the other options which are established fall risk factors.
Fall risk factors include: age over 65, history of falls, polypharmacy (especially sedatives, diuretics, antihypertensives), impaired mobility or balance, cognitive impairment, urinary urgency, poor vision, and environmental hazards. Adequate lighting, clear pathways, non-skid footwear, and accessible call lights are protective factors that reduce fall risk.
PCT Patient Safety, Falls, and Restraints 2
A patient identified as a high fall risk should have which intervention in place?