Preventing Falls During Home Health: An OT's Guide

Your parent is home and home health is coming. The nurse has been. Maybe the physical or occupational therapist has too. The house is as ready as you could make it. If you haven't done that part yet, our guide to getting the house ready for home health walks through it room by room.

This article is about something else. Falls rarely happen because of the house alone. They happen in moments, like standing up too fast at 3 a.m. or carrying a coffee cup with a walker. I'm an occupational therapist, and most of my work in people's homes is about those moments.

So this goes room by room through the times of day and the movements where I've seen people fall, and what you can do about each one. Then what to do if a fall happens, and why the agency needs to hear about it.

Most of what follows is my practice as an OT, and I say so. Where it comes from the CDC or from Medicare's rules, I quote them.

Why This Matters Now

CDC's page on older adult falls says "more than one out of four older people falls each year, but less than half tell their doctor." The same page says "Falling once doubles your chances of falling again."

The first weeks home after a hospital stay are often when people are weakest and most sure they can manage on their own. That mix is where falls come from.

The Bedroom: Getting Up

The riskiest moment in the bedroom is the first one: getting out of bed.

Some people's blood pressure drops when they sit up or stand. CDC calls this postural hypotension and says it can make a person "more likely to fall." Its brochure lists times when symptoms might happen, including "In the morning when blood pressure is naturally lower" and "When straining on the toilet".

CDC's advice for getting up is simple: "Get out of bed slowly. First sit up, sit on the side of the bed, then stand up." It also says "Make sure you have something to hold on to when you stand up" and "Do not walk if you feel dizzy."

What I teach families:

Sit on the edge and count. Feet flat on the floor. Give it a slow count before standing. If the room spins, lie back down and tell the nurse. If the dizziness comes with slurred speech, a drooping face or weakness on one side, call 911.
Stand, then pause. Once up, stand still with the walker or a hand on something solid before taking the first step.
Plan the night trip. Most night falls I've heard about happen on the way to the bathroom, half asleep and in a hurry. Lights on first. Walker or cane next to the bed, not in the hallway. If your parent gets up many times a night, the bedside commode in our house guide is worth asking the therapist about.
Don't rush to answer the phone or the door. It can wait. A fall can't be undone.

The Bathroom: The Transfers

In the bathroom, the danger is the transfer: sitting down and standing up from the toilet, and getting in and out of the shower or tub. Wet floors and tight turns make it worse.

CDC's postural hypotension brochure says "Try to sit down when washing, showering, dressing, or working in the kitchen." I agree. Sitting to dry off and sitting to put on pants takes away a lot of the risk.

Use what the therapist set up, the way they taught it. If the OT or PT showed your parent a way to step into the tub or use the bench, that's the way. Shortcuts are where people slip.

Don't rush. If your parent often can't make it to the toilet in time, tell the nurse. There may be something to do about it. And ask them to leave the door unlocked, so you can get in if they fall.

The Kitchen and Living Room: Carrying, Reaching, Turning

These are the rooms where people forget they are recovering.

Carrying with a walker. Both hands belong on the walker. A cup in one hand means one hand on the walker, and that's how walkers tip. A walker bag or tray helps. Ask the therapist which fits.
Reaching. Reaching up into a cabinet or down to the oven tips the body forward past its balance. Step close to what you want. Don't reach from a distance with one hand still on the walker.
Turning. Most people turn by twisting on one foot. Teach your parent to take small steps around and bring the walker with them.
Pets. A dog or cat underfoot is a real risk. Know where the pet is before your parent stands, and think about a gate or a closed door during the first weeks.
Getting up from the recliner. Scoot forward first, feet back under the knees, then push up from the armrests, not from the walker.

Stairs, the Front Door and the Car

Even on home health, your parent still goes out to see the doctor.

On stairs, one step at a time, with the handrail, the way the therapist taught. If the therapist hasn't worked on stairs yet and your parent has to use them, ask them to.

Outside, watch for wet steps, curbs and uneven driveways. Let them hold your arm, and walk on the side of their weaker leg if they have one.

For the car, here's what I teach, and it's practice, not a rule. Push the car seat all the way back. Your parent backs up until they feel the seat behind their legs, sits down first, then swings their legs in. Out is the reverse: legs out, feet flat, then stand. Never let them grab the car door to pull up. It swings.

What Goes With Them Every Time

These sound small. They matter as much as anything in this article.

The walker or cane, every time. Not parked across the room for a quick trip to the kitchen. Most falls I've seen around a walker happened when the walker wasn't being used.
Shoes. CDC's footwear sheet says "Avoid walking in only socks inside and outside your home." It recommends "sturdy shoes with low heels, traction, and strong arch and heel support." Loose slippers and backless shoes are what I see most often on someone who has fallen.
Glasses. On, and clean, before getting up. CDC's caregiver brochure says to "Replace eyeglasses as needed."
The exercises. CDC says "Exercises that improve balance and make your legs stronger, lower your chances of falling." If the therapist gave your parent exercises, do them as they were taught, how often they were taught. Don't add new ones without asking.

New Medicines and Dizziness

CDC's brochure for older adults says "Some medicines, or combinations of medicines, can make you sleepy or dizzy and can cause you to fall." A new prescription after the hospital, a changed dose, or a sleep aid from the drugstore can all change how steady your parent is.

CDC's caregiver brochure says to show a healthcare provider or pharmacist all of their medications and to "Discuss any side effects, like feeling dizzy or sleepy." The postural hypotension brochure says to "Ask if any of your medicines should be reduced or stopped."

Note the word "ask." My advice, and it's a firm one: don't stop or cut back a medicine on your own. Tell the home health nurse or the pharmacist what you're seeing, and let them sort it out with the doctor.

If Your Parent Falls

This is general safety, not medical advice.

Don't rush to lift them. Your instinct will be to pull them up. Stop. Ask where it hurts. Look at their arms, legs and head before anyone moves.

Call 911 if they are hurt, can't move an arm or leg, hit their head, passed out before the fall, seem confused, have new weakness or slurred speech, or you aren't sure. CDC says head injuries from falls "can be very serious, especially if the person is taking certain medicines (like blood thinners)," and that "An older person who falls and hits their head should see their doctor right away to make sure they don't have a brain injury." In the hours and days after a head bump, watch for headache, vomiting, sleepiness or confusion. If any of those show up, call 911, especially if your parent takes a blood thinner.

If they are not hurt, let them rest a minute. If your parent recently had hip or knee surgery, use only the method their therapist taught, and if they weren't taught one, call 911 for help getting up. Otherwise, what I teach, as practice: roll onto the side, come up onto hands and knees, and crawl to a sturdy chair. With both hands on the seat, bring the stronger leg forward with the foot flat, push up, and turn to sit. You can steady them and guide them. Don't lift them by the arms. If they can't do it, or you'd have to lift them, don't. Keep them warm with a blanket and a pillow and call 911. Asking for help getting someone up off the floor is a fair reason to call, even when nobody is hurt.

Then call the agency. Same day.

Tell the Agency About Every Fall, and Every Near-Fall

This is the part families skip most. Your parent will often ask you not to mention it. They're embarrassed, or afraid it means a nursing home. Tell the agency anyway.

CDC's caregiver brochure says "Tell a healthcare provider right away if your loved one has fallen, or if they are worried about falling, or seem unsteady."

Here's why it matters for home health. Medicare's rules put a duty on the agency. The plan of care must be reviewed and revised "as frequently as the patient's condition or needs require," and the agency must "promptly alert" the doctor to "changes in the patient's condition or needs that suggest that outcomes are not being achieved" or that the plan should change (42 CFR §484.60(c)(1)). That rule is on the agency, not on you. But the agency can't act on a fall nobody told it about. Your part is the phone call.

Near-falls count too. The manual agencies use for Medicare's patient assessment (OASIS) says, in its definition of a fall: "An intercepted fall is considered a fall." It defines that as a fall that would have happened if the patient hadn't caught themselves or been caught by another person. So if you grabbed your parent on the way down, the agency will want to know.

What can change after a fall is up to the doctor and the agency. In my experience it's often more therapy visits, a different walker or a bathroom bench, or a medicine review. The rule says that when the plan changes because your parent's health changed, the change "must be communicated to the patient" and to their representative and caregiver (§484.60(c)(3)(i)).

Also, CDC notes that "Many people who fall, even if they're not injured, become afraid of falling." That fear makes people move less, and moving less makes them weaker. If your parent is scared to walk now, tell the therapist. That's something they can work on.

If You Want the Agency's Side

This article is for families. If you want to see how agencies document a fall, including a caught one, our clinician article on intercepted falls on OASIS-E2 goes through it.

Frequently Asked Questions

What should we do if our parent falls at home?

Don't rush to lift them. Ask where it hurts and look before anyone moves. If they are hurt, can't move an arm or leg, hit their head, or you aren't sure, call 911. If they are not hurt but can't get up without being lifted, keep them warm and call 911 for help getting up. Then call the home health agency the same day.

Should we tell home health about a fall if our parent wasn't hurt?

Yes. Tell the agency about every fall and every near-fall, even when nobody was hurt and even when you caught them. The agency must promptly alert the doctor to changes in your parent's condition that suggest the plan isn't working, and it can only do that if it knows.

Can a new medicine make my parent more likely to fall?

It can. CDC says some medicines, or combinations of medicines, can make you sleepy or dizzy and can cause you to fall. Tell the home health nurse or the pharmacist about any dizziness after a new medicine or a dose change. Don't stop a medicine on your own.

Can the home health plan change after a fall?

Yes. The plan of care must be reviewed and revised as often as your parent's condition or needs require, and any change due to a change in health status must be communicated to the patient and caregiver. In my experience, a fall often leads to more therapy visits or a new piece of equipment.

Sources

Look up an exercise the therapist gave your parent

Illustrated home exercises a PT or OT may prescribe, with plain instructions and a figure for most. Do only the ones your parent's therapist taught.

Open the exercise library

Preventing Falls During Home Health: Room by Room, From an OT