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:_______________

StepDescriptionNotes
Step 1Behavior stated clearly using action verbs 
Step 2Relevant personal and medical history 
Step 3

Circumstances

Time
Frequency
Location
Persons present
Situation
Motivation
Feelings
Agenda

 
Step 4Past staff approaches and resident reactions 
Step 5New interventions 

Signature: _____________________________________________________________________

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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.

Resident NameDate entered into FMPFall DatesNotes
            
            
            
            
            
            
            
            
            
            
            
            
            
            

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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.

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The Falls Management Program

2. Falls Assessment Report (Text Description)

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

Findings: (X) = positive for this residentSuggestions for further assessment and/or interventions
( ) Medications that could increase fall risk:
  • 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.
( ) Unsafe gait, transfers, and/or wheelchair seating problems
  • Consider OT/PT evaluation.

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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.

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Fall Interventions Plan (Text Description)

Resident: ____________________________________________   Room: ___________________

Directions: Check all interventions that apply.

Risk Factor: MedicationsRisk Factor: Mobility

Selected Interventions

For changes in psychotropic meds:

__ Monitor and report changes in anxiety, sleep patterns, behavior, or mood
__ Monitor and report drug side effects
__ Behavior management strategies
   __ Sleep hygiene measures
   __ no caffeine after 4 p.m.
   __ up at night with supervision
   __ comfort measures
    __ pain management
   __ regular exercise, limit napping
   __ relaxing bed routine
   __ individualized toileting at night
   __ safe bathroom routine

For changes in digoxin:

__ Monitor apical heart rate; if <50, notify PCP.

Selected Interventions

__ Increase staff assistance
   __ early morning
   __ to and from toilet
   __ during all transfers
   __ during ambulation
   __ other: ________________________
__ Correct height of bed, toilet, or chair
   __ Keep bed at correct height as marked on footrest or wall
    __ Use raised toilet seat
   __ Use cushion in lounge chair
   __ Lower lounge chair
__ Increase bathroom safety
   __ Use adequate handrail support
   __ Use easy to manage clothing
__ Promote wheelchair safety
   __ Use individualized, labeled wheelchair
   __ Check brakes and instruct pt on use
__ Seating modifications
   __ Use all prescribed seating items
__ Other: _______________________________

Risk Factor: Orthostatic HypotensionRisk Factor: Unsafe Behavior
Selected Interventions
__ Low blood pressure precautions
   __ Instruct pt to change position slowly
   __ Instruct pt to sit on edge of bed and dangle feet before          standing
   __ Instruct pt to use dorsiflexion before standing
   __ Instruct pt not to tilt head backwards
   __ Provide staff assistance in early AM and after meals
__ If medication change:
   __ Take postural VS __ day X 3 days. If systolic drops ≥20 mm          Hg on day 3, notify PCP
__ Promote adequate hydration
__ TED hose
__ Other: _________________________________
Selected Interventions
__ Behavior management strategies
__ Increase assistance and surveillance
   __ Position or pressure change alarm
   __ Movement sensor
   __ Locate patient near station
   __ Intercom
   __ Toilet at regular intervals
   __ Increase activities involvement
   __ Other ___________________________
__ Reduce risk of injury
    __ Low bed
    __ Floor mat
   __ Helmet, wrist guards, hip protectors
   __ Nonslip mat
    __ Nonskid strips or nonskid rug
    __ Nonskid socks
   __ Lower or remove side rails
__ Increase comfort
   __ Pain management
   __ Frequent rest periods
   __ Recliner or chair with deep seat
   __ Rocking chair
   __ Wheelchair seating items
   __ Exercise
   __ Cradle mattress
   __ Sheepskin, air mattress or pillows
__ Other: _________________________________
Risk Factor: Vision
Selected Interventions
__ Low vision precautions
   __ Use maximum wattage allowed by fixture
   __ Increase lighting in room
   __ Use adequate lighting at night
   __ Add high-contrast strips on stairs, curbs, etc.
   __ Use signs with large letters or pictures
   __ Use high contrast to offset visual targets
   __ Reduce glare
__ Corrective lenses
   __ Keep eyewear within easy reach at all times
   __ Encourage patient to wear glasses
__ Other: _________________________________

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.

 Date: Date:
Medications

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Medications

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Vision

Are interventions effective: ___
Yes ___ No
Changes:

Comments:

Vision

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Mobility

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Mobility

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Unsafe Behavior

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Unsafe Behavior

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Signature: _________________________________________   Date: ___________________________

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Page last reviewed February 2010
Internet Citation: Appendix B8: Unsafe Behavior Worksheet (Text Description): 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/fallspxmanapb5txt.html