Fall Incident

 Fall Event Essay


(This tool is only an example. You should adapt this to meet the needs of your facility and residents. )



According to facility coverage, the show up assessment will probably be completed pursuing any homeowner fall. This kind of fall evaluation shall not become part of the resident's medical record. The assessment is completed as part of the facility's continuous quality assurance software. Information from this assessment needs to be used to revise the resident's plan of care. Items noted under with a star* should be appropriately documented in the resident's specialized medical record. All the other items must be reviewed and acted upon solely at the acumen of the breastfeeding facility.

QUICK ACTION *The following products should be written about in the resident's clinical record: ___Physician approached ___Family contacted ___Administration approached, according to facility insurance plan ___Resident first-aid and treatment ___Neuro-checks ___Vital signs: BP (sitting, after that standing), temperature, pulse and respiration ___Signs/symptoms of accidents such as soreness, bleeding, corrosion, contusions, bruises, swelling reddened areas, and so forth ___Medical conditions such as: Heart failure arrhythmia's Syncope Hemiplegia Joint disease Osteoporosis Hypotension Parkinson's Seizure disorder Discomfort CHF

Urinary dysfunction (worsening or fresh onset) ___Acute conditions or signs/symptoms of unknown source. ___Urine examined by dipstick within numerous hours of land ___The location of the resident upon breakthrough ___Resident and witness claims

INVESTIGATION *What was the homeowner doing the moment incident occurred: ___Standing ___Sitting ___Transferring (___Assistive Devices Used) ___In Bed ___Reaching ___Other___________

*Where was the resident if the incident happened: ___Own room ___Another room ___Own bath room ___Another bathroom ___Hall ___Dining Room ___Lounge ___Other – Specify ___________________

Last Name

First Name

Participating in Physician

Space No .

Cabeza de ganado. #

KDOA Workgroup05


*What was the resident's state of mind if the incident took place: ___Oriented/No Difficulty ___Judgment Impaired ___ noncommunicative ___Confused/Disoriented ___Cooperative ___Unable to comprehend others ___Behavior Problems ___Unknown

Has there been a big change in mental status in the last week before fall? ___Yes ___No

*What time was that when the occurrence occurred: Working day of Week______________ Time of Day__________am/pm Last toileting time_______________ Stage 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 leading to falls, but increases risk for harm when fall occurs.

**Within 24 hours of fall, alert pharmacy advisor by send for medication review due to fall. After faxing send sheet to pharmacy specialist, attach send sheet to the form.

ENVIRONMENTAL FACTORS Provides there been a recent difference in the environment? ___No ___Yes, make sure you list change__________________________ _______________________________________________ Flooring Surface ___Unknown ___Slippery/Glare ___Patterned carpet Lamps ___Unknown ___Too much ___No problem ___Inadequate ___Glare ___No problem ___Threshold > ½” ___Thick pile carpet ___Loose rug, ceramic tiles ___Uneven surfaces ___Clutter ___Other_________________


Handrail ___Unknown ___Loose ___No issue ___Not attainable to resident ___Difficult to grip


Bathroom ___Unknown ___Floor smooth ___No trouble ___No pick up bar ___Grab bar loose


Chair ___Unknown ___Poor construction ___No problem ___No armrest ___Unlocked wheels...

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