FALL INVESTIGATION
For residents experiencing a fall, or a sudden increase or pattern of falls, this checklist may be used as a tool to help determine the cause of the fall(s) and to assist in fall prevention planning. Any item marked “yes” should have immediate follow-up with the appropriate disciplines, adjustments made to service agreements, family and healthcare practitioner notifications. Include new residents with a history of falls prior to move-in to also determine a plan of prevention. This tool can also be used with an incident report for investigational and prevention purposes.
DATE OF CURRENT FALL: DATE OF LAST FALL:
CURRENT DIAGNOSES OR HEALTH CONDITIONS THAT COULD CONTRIBUTE TO FALLS (i.e. cardiac conditions, hypotension, stroke, diabetes, osteoporosis, Parkinson’s, hypothyroidism, dementia, seizures, fractures, etc.)
DIRECTIONS: Check “yes” or “no” and circle appropriate interventions and/or risk factors:
YES / NO / INVESTIGATION AREASIs the resident on any new medications or any recent medication changes? List here:
- OTC meds, possibly reacting with prescription meds
- Monitor and review meds for side effects or contraindicated meds
- Request pharmacy consultation
- Alcohol use with medications
Is the resident on psychotropic medications? List here:
- Monitor postural blood pressure for changes
- Notify health care practitioner of changes
- Request psych evaluation
- Monitor for complaints of muscle stiffness, tremors, sleepiness, fatigue, confusion, balance problems
Does the resident exhibit signs/symptoms of dehydration? Does the resident take diuretic medications? List here:
- Check skin turgor, dry flaky skin or dry mucous membranes
- Request lab order for electrolytes
- Encourage fluid intake unless contraindicated
- Medication review for potential side effects
- Observe dietary intake
YES / NO / INVESTIGATION AREAS
Does the resident complain of dizziness, vertigo, or lightheadedness?
- Auditory impairment?
- Make a medical appointment to check ears
- Medication review for possible side effects
- Check BP for postural hypotension
- Complaints of shortness of breath? Chest pain?
- A change in balance/gait?
- Assist with transfers and/or ambulation?
Is the resident fatigued due to stress or lack of sleep with generalized weakness? Hemiparesis? Stroke? Explain:
- Encourage rest periods
- Review dietary intake
- Monitor weight
- Request PT evaluation
- Place daily items within reach
- Raised toilet seat in BR
- Review medications for possible side effects
- Exercise program to strengthen gait/balance
Is there a possibility of UTI or other infection? Does the resident complain of painful urination? Is the urine dark, odorous, or blood tinged?
- Alert monitor for change in urination, temperature, etc.
- Request UA with C&S
- Encourage fluid intake unless contraindicated
- Toileting assist program
- Urinary incontinence with urgency/frequency changes?
Is the resident impacted or constipated?
- Request treatment and/or medication orders for evacuation
- Alert monitor to assess bowel changes
- Bowel management program until resolved
- Exercise program
- Encourage fluid intake unless contraindicated
- Review dietary intake/menu for fiber
Is the resident suffering from pain or generalized discomfort?
- Request pain management orders
- Assess pain
- Request X-ray report of hip and/or knee, spine
- Stiffness in muscles/joints?
- Osteoporosis?
- Peripheral neuropathy? Numbness/tingling?
YES / NO / INVESTIGATION AREAS
Is the resident’s vision impaired? When was the last eye exam?
- Eye appointment of more than one year ago
- Environmental safety assessment
- Lighting – use a night light
- Clean glasses daily, place within reach
- Place items in sight/reach
Is the resident’s gait impaired? Balance impaired?
- Request PT/OT evaluation – decreased ROM, posture?
- Evaluate the use of body mechanics, appliances, ability to transfer
- Request purchase of new footwear if needed – nonskid, well fitting
- Check bed height and mattress condition
- Involve resident in daily group exercises/walking
- Assess for gait belt use
Did the fall occur outside the community premises or offsite? Where?
- Check outside area for safety, making adjustments as necessary
Did the fall indicate possible abuse, neglect, or resident-to-resident incident?
- Provide safety for the resident
- Follow state reporting guidelines
Is the resident diabetic? IDDM ______NIDDM ______
- Are blood sugars stable?
- Diabetic neuropathy?
- Dietary review
- Does not follow plan of care related to diabetic management
Impaired judgment or cognition?
- The resident does not remember to ask for assistance
- Denial of the aging process
- Fear, anxiety, confusion
- Refuses to use assistive device
- Apathy regarding safety
- Evaluate for mental changes and safety risk
Other:
IN REVIEW:
Review the resident’s falls over the past three months. Is there a pattern? Check the time of day and location(s) of falls.
EXPLAIN ANY PATTERNS/TRENDS:
PROBABLE CAUSE:
PLAN TO MINIMIZE RECURRENCE:
SERVICE PLAN UPDATED: Yes No / DATE:
HEALTHCARE PRACTITIONER NOTIFIED: Yes No / DATE:
RESPONSIBLE PARTY NOTIFIED: Yes No / DATE:
OTHER: / DATE:
STAFF COMPLETING REPORT: / DATE:
RN CONSULTANT (if applicable): / DATE:
RESIDENT: Page 1 of 4