FALL INCIDENT ASSESSMENT
(This tool is only an example. Please adapt it to meet the needs of your facility and residents.)
According to facility policy, the fall assessment shall be completed following any resident fall. This fall assessment shall not be made part of the resident’s medical record. The assessment is completed as part of the facility’s continuing quality assurance program. Information in this assessment should be used to revise the resident’s plan of care. Items noted below with a star* should be appropriately documented in the resident’s clinical record. All other items should be reviewed and acted upon solely at the discretion of the nursing facility.
IMMEDIATE ACTION *The following items should be documented in the resident’s clinical record: ___Physician contacted ___Family contacted ___Administration contacted, according to facility policy ___Resident first-aid and treatment ___Neuro-checks ___Vital signs: BP (sitting, then standing), temperature, pulse and respiration ___Signs/symptoms of injuries such as pain, bleeding, abrasions, contusions, bruises, swelling reddened areas, etc. ___Medical conditions such as: Cardiac arrhythmia’s Syncope Hemiplegia Arthritis Osteoporosis Hypotension Parkinson’s Seizure disorder Pain CHF
Bladder dysfunction (worsening or new onset) ___Acute conditions or signs/symptoms of unknown origin. ___Urine tested by dipstick within 4 hours of fall ___The position of the resident upon discovery ___Resident and witness statements
INVESTIGATION *What was the resident doing when incident occurred: ___Standing ___Sitting ___Transferring (___Assistive Devices Used) ___In Bed ___Reaching ___Other___________
*Where was the resident when the incident occurred: ___Own bedroom ___Another bedroom ___Own bathroom ___Another bathroom ___Hall ___Dining Room ___Lounge ___Other – Specify ___________________
FALL INCIDENT ASSESSMENT (Continued)
*What was the resident’s state of mind when the incident occurred: ___Oriented/No Problem ___Judgment Impaired ___Non-communicative ___Confused/Disoriented ___Cooperative ___Unable to understand others ___Behavior Problems ___Unknown
Has there been a change in mental status in the last week before fall? ___Yes ___No
*What time was it when the incident occurred: Day of Week______________ Time of Day__________am/pm Last toileting time_______________ Phase of moon__________Last meal time__________
Last incontinence episode______________________________
CURRENT MEDICATIONS ___Antianxiety ___Hypnotic ___Antihypertensives ___Antidepressant ___Antiparkinson ___Antipsychotic ___Anticonvulsant ___Diuretics ___Hypoglycemic ___Analgesic ___Laxatives ___Narcotics ___Antihistamine ___Anticoagulant* ___Non steroidal ___Anti-inflammatory
*Not a medication that leads to falls, but increases risk for injury when fall occurs.
**Within 24 hours of fall, notify pharmacy consultant by fax for medication review due to fall. After faxing fax sheet to pharmacy consultant, attach fax sheet to this form.
ENVIRONMENTAL FACTORS Has there been a recent change in the environment? ___No ___Yes, please list change__________________________ _______________________________________________ Floor Surface ___Unknown ___Slippery/Glare ___Patterned carpet Lighting ___Unknown ___Too much ___No problem ___Inadequate ___Glare ___No problem ___Threshold > ½” ___Thick pile carpet ___Loose rug, tiles ___Uneven surfaces ___Clutter ___Other_________________
Handrail ___Unknown ___Loose ___No problem ___Not accessible to resident ___Difficult to grip
Bathroom ___Unknown ___Floor slippery ___No problem ___No grab bar ___Grab bar loose
Chair ___Unknown ___Poor construction ___No problem ___No armrest ___Unlocked wheels...
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