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

Appendix C3: Unsafe Behavior Worksheet Sample

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 Description Notes
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.
Step 3


Time: 11 PM - 4 AM
Frequency: 3-4 time per week
Location: Room
Persons present: Often alone
Situation: Dementia, new environment
Motivation: Sometimes to use bathroom. ? Pain
Feelings: Fear, anxiety
Agenda: Physical need to urinate, misses usual environment

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.

Signature: _____Susan_Brown_LPN_________________________________________________

Page last reviewed December 2017
Page originally created February 2010
Internet Citation: Appendix C3: Unsafe Behavior Worksheet Sample. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.