Appendix B5: Falls Assessment Cue Sheet

The Falls Management Program Manual

Medications

Review the resident's drugs in the MAR and PRN records. Consider all drugs in each of the classes listed below when completing the medications section of the Falls Assessment.

AntipsychoticAntidepressant
Trade namesGeneric namesTrade namesGeneric names
Abilify
Clozaril
Etrafon
Haldol
Loxitane
Mellaril
Moban
Navane
Orap
Permitil
Prolixin
Risperdal
Serentil
Seroquel
Stelazine
Taractan
Thorazine
Tindal
Trilafon
Triavil
Vesprin
Zyprexa
Geodon
aripiprazole
clozapine
perphenazine
haloperidol
loxapine
thioridazine
molindone
thiothixene
pimozide
fluphenazine
fluphenazine
risperidone
mesoridazine
quetiapine
trifluoperazine
chlorprothixene
chlorpromazine
acetophenazine
perphenazine
perhenazine
triflurpromazine
olanzapine
ziprasidone
Anafranil
Asendin
Aventyl, Pamelor
Celexa
Desyrel
Effexor
Elavil
Lexapro
Nardil
Norpramin
Paxil
Parnate
Prozac
Remeron
Serzone
Sinequan
Surmontil
Tofranil
Wellbutrin
Zoloft
clomipramine
amoxapine
nortriptyline
citalopram
trazadone
venlafaxine
amitriptyline
escitalopram
phenelzine
desipramine
fluoxetine
tranylcypromine
paroxetine
mirtazapine
nefazodone
doxepin
trimipramine
imipramine
bupropin
sertraline
BenzodiazepinesDigoxin
Trade namesGeneric namesTrade namesGeneric names
Ativan
Centrax
Dalman
Doral
Halcion
Klonopin
Librium
Paxipam
ProSom
Restoril
Serax
Tranxene
Valium
Xanax
lorazepam
prazepam
flurazepam
quazepam
triazolam
clonazepam
chlordiazepoxide
halazepam
estrazolam
temazepam
oxazepam
chlorazepate
diazepam
alprazolam
Digoxin
Lanoxicaps
Lanoxin
Novo-digoxin
digoxin
Sedatives/hypnotics
Trade namesGeneric names
Ambien
Atarax, vistrail
Buspar
Aquachloral
Equanil, Miltown
Seconal
Sonata
Versed
zolpidem
hydroxyzine
busprione
chloral hydrate
meprobamate
secobarbital
zaleplon
midazolam

Orthostatic Hypotension

Equipment needed: stethoscope, sphygmomanometer, watch with a second hand.

Take the resident's blood pressure in the right arm unless otherwise indicated and take an apical heart rate for 60 seconds. Encourage the resident not to smoke and to remain calm for at least 10 minutes before the test.

For ambulatory residents, take BP readings in the sitting position and then 1 minute after standing. Ensure that the resident has been sitting for at least 5 minutes before taking the first measurement. Use staff assistance when necessary for resident safety.

Subtract the values obtained while resident is standing from the values obtained while the resident was sitting. Determine if there is a reduction of ≥20 mm Hg in systolic pressure for postural hypotension.

Vision

Observe the resident during his/her activities of daily living and while he/she moves about in his/her room, bathroom, hallway, and dining room. Determine if the resident stumbles, trips, has difficulty finding objects or detecting changes in floor surfaces, or shows other signs of poor vision.

Mobility

Complete a Mobility and Transfer Assessment for all residents who ambulate or transfer without human assistance. Include residents who use a cane, walker, or wheelchair and those residents who should be assisted but get up unsafely without assistance.

TestDescription
Get Up and Go Test:Ask the resident to sit in a standard armchair, rise, walk 10 feet, turn, walk back to the chair, and sit down. The resident should wear his/her normal footwear and use his/her customary walking aid. Look for unsteadiness, difficulty rising or lowering, and any gait problems. Determine level of staff assistance required for safety.
Transfer Test:Ask the resident to transfer in and out of the bed, on and off the toilet, and in and out of the lounge chair. Determine if the resident is safe; if the height of the bed, toilet, or lounge chair needs adjustment; if existing handrails need adjustment; and if the resident's assistive device needs further evaluation.
Wheelchair Screen:For all residents who use a wheelchair or sit in a wheelchair for reasons other than transport only, collect the following measurements and assess the resident's position while seated. Based on your evaluation, determine if the resident is unsafe while seated in the wheelchair.

Wheelchair Seating Assessment. Go to [D] Text Description for details.

[D] Select for Text Description.

Unsafe Behavior

Review the chart and MAR, obtain a history from the family, and talk with staff about the resident's behavior. Complete the Unsafe Behavior Worksheet if necessary to determine the following:

  • Location
  • Time of day
  • Frequency
  • Potential triggers
  • Resident's agenda
  • Motivation
  • People involved
  • Unsuccessful staff approaches
  • New interventions
Current as of February 2010
Internet Citation: Appendix B5: Falls Assessment Cue Sheet: 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/fallspxmanapb3.html