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Fall Reduction in a Behavioral Health Setting

Jeffrey Lilly, RN, Beckley Appalachian Regional Hospital, Beckley, WV; Teresa McKenney, BA, RN, CWCN


Inpatient fall rates have been a concern at Beckley Appalachian Regional Hospital (Beckley ARH) for many years. In 2015, a project was launched in order to evaluate and trend the falls that occurred in the Behavioral Science Center (BSC).1 Appalachian Regional Healthcare System found that Beckley falls in the BSC were above the system benchmark of 4.91 falls per 1,000 bed days. Beckley ARH fall rates were 6.15 falls per 1,000 bed days. A Falls Committee was formed and tasked to bring falls under the health system benchmark.


The Falls Committee concluded that the hiring of additional personal care assistants would have the greatest and quickest impact on these totals. This influx of staff helped reduce falls to 4.35 per 1,000 bed days. While this reduction improved falls data dramatically, the Committee was not satisfied. Deeper investigation found an additional resource that promised to improve falls data further. The committee reached out to Beckley ARH’s local bed sales rep, who suggested trialing a fully adjustable, ligature-resistant behavioral health bed frame. The bed’s 7.5” low deck is designed to reduce the number of patient falls, and lessen chances of injury if falls do occur.2, 3


After a successful trial, the BSC purchased 26 of the behavioral health bed frames. The combination of additional staff and the new beds brought the BSC’s numbers to an all-time low of 2.05 falls per 1,000 bed days in Q2 2017.

Chart showing reduction of falls with more support staff and addition of low beds


The new policies at Beckley ARH were proven to be effective in reducing falls and increasing patient safety in the BSC. Focus on patient safety, reduction of falls, and injuries related to falls remains a priority throughout the ARH system, as we push for even lower fall rates.

About the Authors

Jeffrey Lilly, RN
Jeff is Director of Behavioral Sciences and Psychiatry at Beckley Appalachian Regional Hospital in Beckley, WV. He oversees the daily operations of a 60-bed psychiatric facility with 90 staff. Jeff’s prior experience included seven years as a US Army combat medical specialist and deployment during Operation Desert Storm.

Teresa McKenney, BA, RN, CWCN
Teresa is a Clinical Liaison at Agiliti (formerly Sizewise), a certified CWCN, and a member of the NPUAP’s education committee. Prior to joining Sizewise, she worked for a major GPO. Teresa has 10 years’ bedside wound care experience.

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Agiliti stands behind the authenticity of this data.
Poster presented at APNA 2019.


  1. Barker, A, Kamar, J, Tyndall, T, and Hill, K. (2013). Reducing serious fall-related injuries in acute hospitals: are low-low beds a critical success factor? Journal of Advanced Nursing 69(1): 112-121
  2. Tzeng, H, and Yin, C. (2007). Height of Hospital Beds and Inpatient Falls. Journal of Nursing Administration 37(12): 537-538
  3. Wagner, J, and Ingram, T. (2013). A Safe Electric Medical Bed for an Acute Inpatient Behavioral Health Care Setting. Journal of Psychosocial Nursing 51(1): 31-34