AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention

Electronic Reports

Table 5. Sample Quarterly Summary of Falls Risk Factors by Facility

On-Time Facility-Level Quarterly Summary of Falls Risk Factors

Date: ___/___/___

	High-Risk Existing Conditions
	Mental: Unsafe Behaviors	Mental: Cognitive Impairment	Gait and Balance Instability	Fall: 8-30 Days	Fall: 31-180 Days	Psychoactive Medications	Other High-Risk Medications
Unit A
# falls	17	21	21	10	11	18	14
% (of Q total falls)	41	51	51	24	27	44	34
Unit B
# falls	9	9	6	3	12	12	5
% (of Q total falls)	24	24	16	8	32	32	14
Unit C
# falls	5	7	7	2	0	6	6
% (of Q total falls)	19	26	26	7	0	22	22
# falls	31	37	34	15	23	36	25
% (of Q total falls)	30	35	32	14	22	34	24

Table 5. Sample Quarterly Summary of Falls Risk Factors by Facility (continued)

	High-Risk Change in Condition
	Acute Mental Status Change	Behavior: New Unsafe	New Gait/Balance or Device Order	New Fall	Med: New Med or Dose Change	Orthostatic Hypotension/ Dehydration	Vertigo/ Dizziness	Syncope/ Fainting	Hypogly- cemia	Possible Infection	New Seizure Activity	New Admission
Unit A
# falls	3	0	0	15	4	17	4	6	0	4	0	5
% (of Q total falls)	7	0	0	37	10	41	10	15	0	10	0	12
Unit B
# falls	1	4	6	20	2	11	0	2	9	2	1	1
% (of Q total falls)	3	11	16	54	5	30	0	5	24	5	3	3
Unit C
# falls	1	0	0	14	0	14	2	2	9	1	0	1
% (of Q total falls)	4	0	0	52	0	52	7	7	33	4	0	4
# falls	5	4	6	49	6	42	6	10	18	7	1	7
% (of Q total falls)	5	4	6	47	6	40	6	10	17	7	1	7

Table 5. Sample Quarterly Summary of Falls Risk Factors by Facility (continued)

	New Contributing Risk Factor				Additional Info Within 30 Days
	Pain: New or Uncontrolled chronic	Urinary Incontinence: New or Increase	Mobility: More Independent	Room Change	Bed Mobility	Transfer	Toileting	Depression Score	Monthly BMI <18.5 kg/m²	Significant Wt Change	Vitamin D Order	Osteoporosis	Diabetes	Visual Impairment
Unit A
# falls	3	7	4	12	0	3	0	7	10	1	4	3	18	16
% (of Q total falls)	7	17	10	29	0	7	0	17	24	2	10	7	44	39
Unit B
# falls	1	3	0	3	0	7	7	3	3	1	3	1	13	4
% (of Q total falls)	3	8	0	8	0	19	19	8	8	3	8	3	35	11
Unit C
# falls	1	1	2	3	0	2	4	2	0	0	11	1	6	4
% (of Q total falls)	4	4	7	11	0	7	15	7	0	0	41	4	22	15
# falls	5	11	6	18	0	12	11	12	13	2	18	5	37	24
% (of Q total falls)	5	10	6	17	0	11	10	11	12	2	17	5	35	23

Table 5. Sample Quarterly Summary of Falls Risk Factors by Facility (continued)