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

Electronic Reports

On-Time Falls High-Risk Report

Table 1. Sample Falls High-Risk Report

Unit: ________________________________________________________________

Date: ___/___/___

Resident Within 90 Days
Name Room 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
Resident A 122 X     X   X  
Resident B 114       X X    
Resident C 103 X X          
Resident D 142     X        
Resident E 112             X
Resident F 133 X   X        
Total   3 1 2 2 1 1 1

Table 1 (continued)

Resident Within 7 Days
Name Room 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 Hypo-
tension/
Dehydra-
tion		 Vertigo/
Dizzi-ness		 Syncope/
Faint-
ing		 Hypogly-cemia Possible Infection New
Seizure Activity		 New Admission
Resident A 122           X       X   X
Resident B 114             X     X    
Resident C 103   X     X              
Resident D 142                       X
Resident E 112                       X
Resident F 133                        
Total     1     1 1 1     2   3

Table 1 (continued)

Resident Within 7 Days
Name Room New Contributing Risk Factors
    Pain: New or Uncontrolled Chronic Urinary Incont: New or Increased Mobility: More Independent Room Change
Resident A 122        
Resident B 114     X  
Resident C 103   X    
Resident D 142        
Resident E 112        
Resident F 133       X
Total     1 1 1

Table 1 (continued)

Resident  
Name Room ADL Decline and Other Clinical Information
    Bed Mobility Transfer Toileting Depression
Score
Increase		 Monthly
BMI
<18.5 kg/m2		 Significant
Weight
Change		 Vitamin D
Order		 Osteop-
orosis		 Diabetes Visual
Impair-
ment
Resident A 122       25*     X      
Resident B 114                 X  
Resident C 103       21            
Resident D 142             X     X
Resident E 112                    
Resident F 133           X       X
Total         2   1 2   1 2

ADL = Activities of Daily Living.

Page last reviewed October 2017
Page originally created October 2017

Internet Citation: AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention. Content last reviewed October 2017. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/highrisk.html

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