On-Time Falls Prevention
Overview Materials Packet
Samples of four types of reports are provided here:
- On-Time Falls High-Risk Report.
- Quarterly Summary of Falls Risk Factors by Unit or Facility.
- Monthly Contextual Factors Report.
- Postfall Assessment Summary Report.
On-Time Falls High-Risk Report
Sample Falls High-Risk Report
Unit: ________________________________________________________________
Date: ___/___/___
Select for accessible version of report.
ADL = Activities of Daily Living.
Quarterly Summary of Falls Risk Factors by Unit or Facility
Sample Quarterly Summary of Falls Risk Factors by Unit
On-Time Quarterly Summary of Falls Risk Factors by Unit
Nursing Unit: _________________________________________________________
Date: ___/___/___
Select for accessible version of report.
Sample Quarterly Summary of Falls Risk Factors by Facility
On-Time Facility-Level Quarterly Summary of Falls Risk Factors
Date: ___/___/___
Select for accessible version of report.
Monthly Contextual Factors Report
Sample Monthly Contextual Factors Report by Facility
Monthly Contextual Factors Report
Date: ___/___/___
Select for accessible version of report.
Note: Percentages may not add to 100 due to rounding.
Postfall Assessment Summary Report
Sample Postfall Assessment Summary Report
Resident Name: _________________________________________
| Date of Fall | |||||||
|---|---|---|---|---|---|---|---|
| Fall Date | Date | 10/4/13 | 1/16/14 | 2/11/14 | 2/27/14 | 3/6/14 | 4/17/14 |
| Fall Day | Day of week | Saturday | Thursday | Tuesday | Thursday | Thursday | Thursday |
| Fall Time | Time or “not known” | 6:35 a.m. | 5:35 a.m. | 7:15 a.m. | 6:50 a.m. | 6:10 a.m. | 5:15 a.m. |
| Shift | Shift | N | N | D | E | N | N |
| Fall Witnessed? | Yes/no | N | N | Y | Y | N | N |
| If yes, who witnessed? | Staff, family, visitor, volunteer, other | Staff | Staff | Family | Staff | Staff | Family |
| Name of person who witnessed the fall | text | text | text | text | text | text | |
| If no, who found the resident? | Staff, family, visitor, volunteer, other | Staff | Staff | Family | Staff | Staff | Family |
| Name of person who found the resident | text | text | text | text | text | text | |
| Fall Location | Fall location: room; bathroom; hallway; dining room; activities; therapy; beauty parlor; shower/tub; nursing stations; out of facility; other | Bathroom | Bathroom | Room | Room | Bathroom | Bathroom |
| Resident Position When Found | Position when found: supine, lying left, lying right, sitting, other | Supine | Sitting | Lying right | Supine | Sitting | Sitting |
| Resident Activity at Time of Fall | Activity prior to fall: walking; transferring; toileting; in bed; in chair; other | Toileting | Toileting | Walking | Walking | Toileting | Toileting |
| Potential Causes of Fall | Unknown | ||||||
| Behavior – agitation/other | |||||||
| Loss of balance (reaching, turning, sudden movement, other) | |||||||
| Gait/balance instability | X | X | |||||
| Bowel/bladder: trying to get to bathroom on own | X | X | X | X | X | X | |
| Personal device or equipment or attached appliance (cane, walker, crutch, O2) – improper use | X | X | |||||
| Equipment failure, bed, chair, floor mat alarms | |||||||
| Potential medication issue: new med/dose change/suspected reaction | |||||||
| Resident chooses not to follow recommendations: alert and oriented | |||||||
| Resident unable to follow recommendations: cognitively impaired | |||||||
| Other, please describe | |||||||
| Fall Comments | Free text | ||||||
| Fall Injury? | Yes/no | N | N | Y | Y | Y | N |
| If yes, what type of injury? | |||||||
| Injury Type: Major | Fracture: hip | X | |||||
| Fracture: other | |||||||
| Joint dislocation | |||||||
| Closed head injury with altered consciousness | |||||||
| Subdural hematoma | |||||||
| Injury Type: Minor | Skin tear | X | |||||
| Abrasion | X | ||||||
| Laceration | X | ||||||
| Superficial bruises, hematomas | X | X | |||||
| Sprain | |||||||
| Other injury that causes pain | |||||||
| Injury Site | Head Upper extremity (UE) Lower extremity (LE) |
LE | LE | LE | LE | LE | UE |
| Injury Assessment | ROM upper: full/decreased | Full | Full | Full | Full | Full | Decr |
| ROM lower: full/decreased | Decr | Decr | Decr | Decr | Decr | Full | |
| Loss of consciousness: yes or no | No | No | No | No | No | Yes | |
| Neuro status: usual or not usual (changes noted) | Usual | Usual | Usual | Usual | Usual | Not usual | |
| Bleeding: none, minor, significant | None | None | None | None | None | None | |
| Other | |||||||
| Free text | |||||||
| Where Resident Was Treated | Facility, ER, hospital admit | Facility | Facility | ER | ER | Facility | Facility |
| PCP Notified? | Yes/no | Y | Y | Y | Y | Y | Y |
| MD Notified | Physician name | Brewer | Brewer | Cannon | Jackson | Brewer | Brewer |
| PCP Notification Date | Date | 10/4/13 | 1/16/14 | 2/11/14 | 2/27/14 | 3/6/14 | 4/17/14 |
| PCP Notification Time | Time | 7:00 a.m. | 7:00 a.m. | 8:00 a.m. | 7:00 a.m. | 7:00 a.m. | 6:30 a.m. |
| Family Notified? | Yes/no | Y | Y | Y | Y | Y | Y |
| Family Notified | Family name/relationship | Daughter | Daughter | Son | Son | Son | Son |
| Family Notification Date | Date | 10/4/13 | 1/16/14 | 2/11/14 | 2/27/14 | 3/6/14 | 4/17/14 |
| Family Notification Time | Time | 8:00 a.m. | 8:00 a.m. | 8:30 a.m. | 7:30 a.m. | 8:00 a.m. | 8:00 a.m. |
| PCP Exam Performed? | Yes/no | Y | Y | Y | N | Y | Y |
| PCP Exam Date | Date | 10/6/14 | 1/17/14 | 2/12/14 | 3/6/14 | 4/17/14 | |
| PCP Exam Time | Time | 8::00 a.m. | 8:00 a.m. | 8:30 a.m. | 8:00 a.m. | 8:00 a.m. | |
| PT Notified? | Yes/no | Y | Y | Y | N | Y | Y |
| PT Consult | Date | 10/4/13 | 1/16/14 | 2/11/14 | 3/6/14 | 4/17/14 | |
