Appendix C3: Unsafe Behavior Worksheet Sample

The Falls Management Program Manual

Note: This form has been filled out with information for the sample case study patient, Mrs. P.

Resident:_____Mrs._P_______________ Rm #:_401-A_____ Date:___4/12/04_____

Step 1Behavior stated clearly using action verbsGets up frequently, climbs out of bed and tries to ambulate unsafely. Appears anxious and fearful.
Step 2Relevant personal and medical historyMarried for 45 years, mother of 3 children and 10 grandchildren. Catholic, homemaker, gardener. Husband lives at home with daughter and is unable to visit.
Step 3


Time: 11 PM - 4 AM
Frequency: 3-4 time per week
Location: Room
Persons present: Often alone
Situation: Dementia, new environment
Motivation: Sometimes to use bathroom. ? Pain
Feelings: Fear, anxiety
Agenda: Physical need to urinate, misses usual environment

Step 4Past staff approaches and resident reactionsLow bed with mat—helpful.
Position alarm—partially effective. Staff gets there 50% of time before the fall
Paint medications—responded well to prescribed analgesic
Step 5New interventionsShorten time interval for toileting schedule.
Provide snack and activity at night.
Find at least 3 activities that interest patient.
Continue to assess for pain using pain scale for dementia patients.
Signature: _____Susan_Brown_LPN_________________________________________________
Page last reviewed October 2014
Internet Citation: Appendix C3: Unsafe Behavior Worksheet Sample: The Falls Management Program Manual. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.