Appendix B8: Unsafe Behavior Worksheet (Text Description)

The Falls Management Program Manual

All behavior is meaningful; however, it may be difficult to understand the unsafe behaviors of some residents. Your perception of the behavior may be very different from the actual situation. To discover the meaning, you will need to explore the circumstances of the behavior, review the resident's personal and medical history and analyze staff/resident interactions.

Example: A resident gets out of bed unsafely at night and becomes very agitated when staff try to keep him in his room. To staff, he may be anxious, combative, uncooperative and difficult. From the resident's perspective, staff are preventing him from catching the bus to go to work.

Understanding the unsafe behavior of residents requires data collection, investigation and analysis. As you and the team better understand the behavior, you can problem-solve to develop additional individualized approaches. The Unsafe Behavior Worksheet is a 5-step process that directs you to define the behavior, review the resident's personal and medical history, investigate the circumstances, analyze staff approaches and develop new interventions.

Step 1: Define the behavior clearly.

Example: Resident gets out of bed between 2-4 a.m. He comes out into the hallway. His hands are shaking. He pushes staff away when they attempt to return him to the room. He talks loudly and becomes angry when staff ask him to lower his voice.

Step 2: Get as much information as possible about the resident's personal and medical history.

Include health status, family history, occupation, interests, cultural background and spirituality. Determine mental status including orientation, concentration, memory, judgment and psychological history. Incorporate information about mobility status, wheelchair use, postural hypotension, vision, and medications that was obtained during the Falls Assessment and from the evaluations by other health care professionals.

Step 3: Analyze the circumstances of the behavior.

Use a behavior log to track the behavior for at least one week. Gather information from staff and family. Look for patterns and meaning in the behavior by determining the following:

• Time of day.
• Persons present.
• Frequency.
• Situation.
• Location.
• Resident motivation, feelings and agenda.

Step 4: Analyze past staff approaches as well as the resident's reaction to them.

Ask staff about their previous approaches to the behavior and interaction with the resident. Determine with staff what has worked well and what has not been effective. Find out which staff member the resident responds to best.

Step 5: Develop new individualized interventions.

Address underlying medical conditions and medication use first. Ensure that all staff simplify the resident's care environment and use the positive communication skills and management strategies necessary for the care of residents with dementia. Problem solve with staff about the specific behavior, brainstorm about solutions and be creative. Develop a strategy and try it for a set period of time. Monitor the behavior each shift to determine the effect of the intervention. Revise the intervention based on your observations and staff feedback.

Unsafe Behavior Worksheet

Resident:__________________________ Rm #:___________ Date:_______________

Signature: _____________________________________________________________________

Return to Document

FMP Entry Log

Instructions: Write in the names of residents who have been entered into the Falls Management Program. Record the date of any fall that occurs after entry.

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The Falls Management Program

Primary Care Provider Fax Report and Orders

1. Fax Cover Sheet (Text Description)

Facility: ________________________________________
Address: _______________________________________
City/State: ______________________________________
Telephone: _____________________________________
Fax: ___________________________________________

Date: __________ / __________ / __________

Primary Care Provider: ___________________________________ Fax #: __________________

Resident Name: ___________________________________ Unit/Room: ____________________

This resident was identified in our Falls Management Program as having a high risk of falls, and underwent a Falls Assessment per our protocol. Attached are the following:

1. Falls Assessment Report and suggestions for further assessment and/or intervention.
2. A form for you to Fax Back Orders on which you can indicate those that you select for this resident.

Please review the Falls Assessment Report and return the Fax Back Orders form the next business day. Thank you.

Falls Coordinator: ______________________________________ Phone number: __________________

Confidentiality Statement: The documents accompanying this fax transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this fax in error, please notify the sender immediately and shred/destroy all documents.

Return to Document

The Falls Management Program

2. Falls Assessment Report (Text Description)

Facility: _______________________________________
Address: _______________________________________
City/State: _______________________________________
Telephone: _______________________________________
Fax: _______________________________________
Date: __________ / __________ / __________
Resident Name: _______________________________________

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The Falls Management Program

3. Fax Back Orders (Text Description)

Facility: _______________________________________
Address: _______________________________________
City/State: _______________________________________
Telephone: _______________________________________
Fax: _______________________________________

Date: __________ / __________ / __________

Return by Fax to: ______________________________________ Fax #: ______________________

Resident Name: ______________________________________ Unit/Room: ___________________

Please mark the orders that are appropriate for this resident with an (X) and sign at the bottom.
( ) Medication changes (please specify)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

( ) Psychiatric evaluation to evaluate psychotropic medications
( ) Optometry evaluation
( ) Ophthalmology consult
( ) Blood for BUN and Creatinine
( ) TED hose during the day
( ) Physical or occupational therapy screen/evaluation of gait/balance/transfer/seating
( ) Other orders:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Signature: ______________________________________________ Date: _________________  
                          (primary care provider)

Confidentiality Statement: The documents accompanying this fax transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this fax in error, please notify the sender immediately and shred/destroy all documents.

Return to Document

Fall Interventions Plan (Text Description)

Resident: ____________________________________________   Room: ___________________

Directions: Check all interventions that apply.

Signature: __________________________________________________     Date: ______________

Fall Interventions Monitor

Resident: _____________________________________________   Room: ____________________

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.

Signature: _________________________________________   Date: ___________________________

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