FALLS MANAGEMENT INVESTIGATION – POST FALL TOOL

Resident ______Age ______Room # ______

Date of Fall ______Day of Week ______Time ______AM PM

1. Was the fall observed? r Yes r No If yes, by whom:

(name and title of individual)

2. Location of fall (be as exact as possible)

3. Was the resident alone at the time of the fall? r Yes r No

4. What was the reason for the resident to be in that location?

5. Was this the resident’s first fall? r Yes r No

6. Were protective of safety devices in use at the time of the fall? r Yes r No

7. Investigate the surroundings where the incident occurred for any evidence of the following:

·  The witness, if any, is to complete this section. If no witness, then person completing investigation.

Clue / Yes / No / Clue / Yes / No
Water spills? / Resident in a hurry? If yes, explain why:
Clutter on the floor? / Resident using cane/walker?
Phone cords/TV cords, etc. exposed? / Improper footwear?
Poor lighting? / Clothing in the way?
Improper bed height? / Resident using incontinent supplies at time of
fall?
Other furniture involved? / Resident tired?
Wheelchair unlocked? / Resident reaching for something?
Wheelchair footrests in the way? / Other:

8. Has the resident’s health status changed? Answer the following questions:

Clue / Yes / No / Clue / Yes / No
New/increase/decrease in meds? / Decrease in fluid intake?
Weakness/fatigue? / Recent fever/cough/cold?
Dizziness? / Changes in diagnosis status?
Changes in blood pressure? / Changes in mental status?
Recent return from the hospital? / Changes in behaviors?
Recent weight loss? / Changes in mobility status?
Pain? / Recent changes in lab values?
(blood sugar, O2, Hct/Hg)

POTENTIAL TOPICS TO COVER IN PROGRESS NOTE:

1. Do the “clues” reflect any environmental factors that could be involved in this fall? r Yes r No

2. Do the “clues” reflect any health care factors that could be involved in this fall? r Yes r No

3. If the resident has had more than one fall, are there any similarities? r Yes r No

4. How do the “clues” that you have found relate to each other?

5. Previous falls: (a) how many have there been in the past 3 months? (b) Where did they occur? (c) What time did they occur? (d) What actions were set in place after the previous fall(s)?

6. Is there a need to re-educate the resident, family, and/or staff? r Yes r No

7. Has the resident’s care/service plan been updated? r Yes r No

Signature of person completing form Date