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

Appendix C8: Fall Interventions Plan 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: Check all interventions that apply.

Risk Factor: Medications Risk Factor: Mobility

Selected Interventions

For changes in psychotropic meds:

_X_ Monitor and report changes in anxiety, sleep patterns, behavior, or mood
___ Monitor and report drug side effects
_X_ Behavior management strategies
   _X_ Sleep hygiene measures
   _X_ no caffeine after 4 p.m.
   _X_ up at night with supervision
   _X_ comfort measures
    _X_ pain management
   ___ regular exercise, limit napping
   ___ relaxing bed routine
   _X_ individualized toileting at night
   _X_ safe bathroom routine

For changes in digoxin:

__ Monitor apical heart rate; if <50, notify PCP.

Selected Interventions

_X_ Increase staff assistance
   ___ early morning
   _X_ to and from toilet
   _X_ during all transfers
   ___ during ambulation
   ___ other: ________________________
___ Correct height of bed, toilet, or chair
   ___ Keep bed at correct height as marked on footrest or wall
    ___ Use raised toilet seat
   ___ Use cushion in lounge chair
   ___ Lower lounge chair
_X_ Increase bathroom safety
   _X_ Use adequate handrail support
   _X_ Use easy to manage clothing
___ Promote wheelchair safety
   ___ Use individualized, labeled wheelchair
   ___ Check brakes and instruct pt on use
___ Seating modifications
   ___ Use all prescribed seating items
___ Other: _______________________________

Risk Factor: Orthostatic Hypotension Risk Factor: Unsafe Behavior
Selected Interventions
___ Low blood pressure precautions
   ___ Instruct pt to change position slowly
   ___ Instruct pt to sit on edge of bed and dangle feet before standing
   ___ Instruct pt to use dorsiflexion before standing
   ___ Instruct pt not to tilt head backwards
   ___ Provide staff assistance in early AM and after meals
___ If medication change:
   ___ Take postural VS __ day X 3 days. If systolic drops ≥20 mm Hg on day 3, notify PCP
___ Promote adequate hydration
___ TED hose
___ Other: _________________________________
Selected Interventions
_X_ Behavior management strategies
_X_ Increase assistance and surveillance
   _X_ Position or pressure change alarm
   ___ Movement sensor
   _X_ Locate patient near station
   ___ Intercom
   _X_ Toilet at regular intervals
   _X_ Increase activities involvement
   ___ Other ___________________________
_X_ Reduce risk of injury
    _X_ Low bed
    _X_ Floor mat
   _X_ Helmet, wrist guards, hip protectors
   ___ Nonslip mat
    ___ Nonskid strips or nonskid rug
    _X_ Nonskid socks
   _X_ Lower or remove side rails
_X_ Increase comfort
   _X_ Pain management
   ___ Frequent rest periods
   ___ Recliner or chair with deep seat
   ___ Rocking chair
   ___ Wheelchair seating items
   ___ Exercise
   ___ Cradle mattress
   _X_ Sheepskin, air mattress or pillows
___ Other: _________________________________
Risk Factor: Vision
Selected Interventions
___ Low vision precautions
   ___ Use maximum wattage allowed by fixture
   ___ Increase lighting in room
   ___ Use adequate lighting at night
   ___ Add high-contrast strips on stairs, curbs, etc.
   ___ Use signs with large letters or pictures
   ___ Use high contrast to offset visual targets
   ___ Reduce glare
___ Corrective lenses
   ___ Keep eyewear within easy reach at all times
   ___ Encourage patient to wear glasses
___ Other: _________________________________

Signature: ___________Susan_Brown_LPN_______________   Date: _______4/19/04_____________

Page last reviewed October 2014
Page originally created February 2010
Internet Citation: Appendix C8: Fall Interventions Plan Sample. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.