Unsafe Behavior Worksheet (Text Description)
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:_______________
Step 1 |
Behavior stated clearly using action verbs |
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Step 2 |
Relevant personal and medical history |
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Step 3 |
Circumstances
Time
Frequency
Location
Persons present
Situation
Motivation
Feelings
Agenda |
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Step 4 |
Past staff approaches and resident reactions |
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Step 5 |
New interventions |
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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.
Resident Name |
Date entered into FMP |
Fall Dates |
Notes |
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Return to Document
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:
- Falls Assessment Report and suggestions for further assessment and/or intervention.
- 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: _______________________________________
Findings: (X) = positive for this resident |
Suggestions 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.
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( ) Low vision |
- Consider optometry or ophthalmology evaluation.
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( ) 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.
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( ) Unsafe gait, transfers, and/or wheelchair seating problems |
- Consider OT/PT evaluation.
|
Return to Document
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.
Risk Factor: Medications |
Risk 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 Hypotension |
Risk 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.
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Date: |
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Date: |
Medications |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
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Medications |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
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Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
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Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
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Vision |
Are interventions effective: ___
Yes ___ No
Changes:
Comments:
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Vision |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
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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:
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Signature: _________________________________________ Date: ___________________________
Return to Appendix B Contents
Return to Manual Contents
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