Appendix C9: Fall Interventions Monitor 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________________________   Room: ______401-A________

Directions: Monitor staff implementation and effectiveness of the Fall Intervention Plan each week. Revise interventions as needed and record below. Use one sheet for every 2 weeks.

 Date: 4/19/04 Date: 4/19/04
Medications

Are interventions effective: _X_ Yes ___ No

Changes:

Comments: Pt [Patient] adjusting to new environment. Agitation decreased

Medications

Are interventions effective: ___ Yes _X_ No

Changes:

Comments: Pt with occasional periods of agitation.

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments: NA

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments: NA

Vision

Are interventions effective: ___
Yes ___ No
Changes:

Comments: NA

Vision

Are interventions effective: ___ Yes ___ No

Changes:

Comments: NA

Mobility

Are interventions effective: _X_ Yes ___ No

Changes:

Comments: Staff Assisting with all transfers

Mobility

Are interventions effective: _X_ Yes ___ No

Changes:

Comments:

Unsafe Behavior

Are interventions effective: ___ Yes _X_ No

Changes:

Comments: Pt needs toileting 1-1½ hrs instead of 2 hrs.

Unsafe Behavior

Are interventions effective: _X_ Yes ___ No

Changes: Medicate with analgesic as ordered.

Comments: Monitor agitation in conjunction with analgesic effectiveness.

Signature: ___________Susan_Brown_LPN_______________   Date: _______4/19/04_____________
Page last reviewed February 2010
Internet Citation: Appendix C9: Fall Interventions Monitor Sample: The Falls Management Program Manual. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/apcfigtxt9.html