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

Electronic Reports

Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit

On-Time Quarterly Summary of Falls Risk Factors by Unit

Nursing Unit: ________________________________________________________________

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
Apr-11
# falls	7	9	8	4	6	7	4
% (of monthly total falls)	44	56	50	25	38	44	25
May-11
# falls	5	5	6	4	5	5	4
% (of monthly total falls)	45	45	55	36	45	45	36
Jun-11
# falls	5	7	7	2	0	6	6
% (of monthly total falls)	36	50	50	14	0	43	43
Unit Quarterly TOTALS
# falls	17	21	21	10	11	18	14
% (of quarterly total falls)	41	51	51	24	27	44	34

Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit (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
Apr-11
# falls	1	0	0	4	2	8	2	2	0	1	0	3
% (of monthly total falls)	6	0	0	25	13	50	13	13	0	6	0	19
May-11
# falls	1	0	0	5	2	4	0	2	0	2	0	1
% (of monthly total falls)	9	0	0	45	18	36	0	18	0	18	0	9
Jun-11
# falls	1	0	0	3	0	5	2	2	0	1	0	1
% (of monthly total falls)	7	0	0	21	0	36	14	14	0	7	0	7
Unit Quarterly TOTALS
# falls	3	0	0	12	4	17	4	6	0	4	0	5
% (of quarterly total falls)	7	0	0	29	10	41	10	15	0	10	0	12

Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit (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
Apr-11
# falls	1	3	2	6	0	2	3	2	3	2	1	1	6	8
% (of monthly total falls)	6	19	13	38	0	13	19	13	19	13	6	6	38	50
May-11
# falls	1	3	0	3	0	2	2	3	3	1	1	1	6	4
% (of monthly total falls)	9	27	0	27	0	18	18	27	27	9	9	9	55	36
Jun-11
# falls	1	1	2	3	0	2	4	2	0	0	2	1	6	4
% (of monthly total falls)	7	7	14	21	0	14	29	14	0	0	14	7	43	29
Unit Quarterly TOTALS
# falls	3	7	4	12	0	6	9	7	6	3	4	3	18	16
% (of quarterly total falls)	7	17	10	29	0	15	22	17	15	7	10	7	44	39

Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit (continued)