The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix C3: Unsafe Behavior Worksheet Sample
Table of Contents
Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Resident:_____Mrs._P_______________ Rm #:_401-A_____ Date:___4/12/04_____
|Step 1||Behavior stated clearly using action verbs||Gets up frequently, climbs out of bed and tries to ambulate unsafely. Appears anxious and fearful.|
|Step 2||Relevant personal and medical history||Married for 45 years, mother of 3 children and 10 grandchildren. Catholic, homemaker, gardener. Husband lives at home with daughter and is unable to visit.|
Time: 11 PM - 4 AM
|Step 4||Past staff approaches and resident reactions||Low bed with mat—helpful.
Position alarm—partially effective. Staff gets there 50% of time before the fall
Paint medications—responded well to prescribed analgesic
|Step 5||New interventions||Shorten time interval for toileting schedule.
Provide snack and activity at night.
Find at least 3 activities that interest patient.
Continue to assess for pain using pain scale for dementia patients.
Page originally created February 2010