The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

Appendix C1: Falls Assessment Sample

Note: This form has been filled out with information for the sample case study patient, Mrs. P.

Resident: _____________Mrs._P_________________________   Room: ____401-A__________

Directions: Use the instructions on the Falls Assessment Cue Sheet to assess the resident in the five areas listed in the first column. Put a check beside each risk factor present for this resident. If the resident does not have a risk factor, put a check beside N/A. In the second column, check when the primary care provider report is faxed and orders are received and when the resident is discussed in the interdisciplinary team meeting. Check all appropriate evaluations and referrals. Once the assessment is complete, proceed to the Fall Interventions Plan and select specific individualized interventions for each risk category identified for this resident.

Risk Factors Interdisciplinary Assessments
_X_ Primary Care Provider Report faxed
_X_ Primary Care Provider Orders received
___ Discussed in falls team meeting


___ Antipyschotics
_X_ Antidepressants [Handwritten note added: Paxil, Zoloft, Ativan]
___ Benzodiazepines
_X_ Sedatives/hypnotics
___ Digoxin
___ N/A

_X_ Medication review by consultant pharmacist
___ Psychiatric evaluation

Orthostatic Hypotension

___ Reduction of ≥20 mm Hg in systolic pressure 1 minute after change in position from sitting to standing

Sitting BP: ___/___    Standing BP: ___/___     _X_ N/A

___ Review cardiovascular medications


___ Stumbles and trips
___ Difficulty finding objects or detecting changes in floor surfaces
_X_ N/A

___ Optometrist evaluation
___ Ophthalmologist referral


_X_ Unsafe during the Get Up and Go Test
___ Unable to transfer on and off toilet, bed, or chair safely
___ Unsafe wheelchair seating
___ N/A

___ OT consultation
_X_ PT consultation

Unsafe Behaviors

_X_ Tries to stand, transfer, or walk alone unsafely
_X_ Tries to climb over bed rails or get out of bed alone unsafely
___ Walks or paces alone in unsafe areas
___ N/A

_X_ Behavioral assessment
___ Evaluation of restraint use

Signature: ____Susan_Brown_LPN___________________________ Date Completed: ____4/3/04________

Page last reviewed December 2017
Page originally created February 2010
Internet Citation: Appendix C1: Falls Assessment Sample. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.