Fall Incident
FALL INCIDENT ASSESSMENT
(This tool is only an example. Please adapt it to meet the needs of your facility and residents.)
DATE_______________________
DIRECTIONS
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 ___________________
Last Name
First Name
Attending Physician
Room No.
Res.
(This tool is only an example. Please adapt it to meet the needs of your facility and residents.)
DATE_______________________
DIRECTIONS
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 ___________________
Last Name
First Name
Attending Physician
Room No.
Res.