The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

Appendix C6: Falls Assessment Report Sample

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

Facility: _______Greystone_Manor____________________
Address: _________1254_Martin Lane________________
City/State: ______Wilkes,_TN_04321_________________
Telephone: ______(423)_403-4881___________________
Fax: ______(423)_403-3312________________________

Date: ____4_____ / _____4____ / ____04____
Resident Name: ___________Mrs._P______________________

Findings: (X) = positive for this resident Suggestions for further assessment and/or interventions
(X) Medications that could increase fall risk:

Ativan 1 mg PRN
Zoloft 50 mg QD
Paxil 40 mg QD

  • Review medications and consider changes if appropriate.
  • Consider psychiatric evaluation if indicated to evaluate psychotropic meds
  • Consider consultant pharmacist recommendations.
( ) Low vision
  • Consider optometry or ophthalmology evaluation.
( ) Postural hypotension
≥20 mm Hg drop in systolic pressure with position change
  • Review cardiovascular and diuretic medications.
  • Consider blood work for BUN/Creatinine ratio.
  • Consider TED hose.
(X) Unsafe gait, transfers, and/or wheelchair seating problems
  • Consider OT/PT evaluation.
Page last reviewed October 2014
Internet Citation: Appendix C6: Falls Assessment Report Sample. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.