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

Appendix B1: The FMP Self-Assessment Tool (Text Description)

The purpose of the FMP Self-Assessment Tool is to identify what processes of care your facility has in place and what areas need improvement. It is divided into 7 areas of focus. Use your facility's policies, procedures, and general practices to answer the questions listed under the first 4 areas (A, B, C, D). To answer the questions listed under the last 3 areas (E, F, G) in the Chart Audit, select a minimum of 5 residents who have fallen during the last 6 months. Answer the questions based on the documentation you find in each resident's chart and care plan. Further instructions are provided in the Chart Audit section. Complete the Plan for Improvement when finished.

A. Culture, Organizational Commitment, and Team Skills (Chapter 1) Yes No Comments
1. Updated policies and procedures for a comprehensive Falls Management Program?      
2. Appointed falls team leader and resource person for staff?      
3. Selection of staff members (including one or more CNAs) for interdisciplinary falls team?      
4. Weekly falls team meeting using ground rules, a leader, timekeeper, and recorder?      
5. Effective team problem solving to develop and monitor interventions for recurrent fallers?      
6. Administrator and DON attend team meetings periodically and monitor falls data at least monthly?      
7. No blame/no shame environment with honest investigation and reporting by staff?      
8. Celebration of success stories and rewards for caregivers who reduce falls?      
9. Adequate staffing for leader to spend 8 hours/week and team to meet for 30 minutes/week?      
10. Funds for adaptive equipment, environmental modifications, and wheelchair improvements?      
11. Activity programs for frequent structured supervision of residents?      
12. Employee orientation materials emphasize importance of and facility commitment to resident safety?      
B. Data Collection and Analysis (Chapter 3) Yes No Comments
1. Accurate completion of fall incident report form by all licensed staff?      
2. Monthly falls analysis by: location and time of fall
shift and day of week
type of injury
3. Monthly falls analysis by # of falls, fallers, patients ≥2 falls, and falls with serious injury?      
4. Falls data reported to medical director and primary care providers every quarter?      
5. Feedback about falls data given to direct care staff each month?      
6. Falls data trended over 6 months or more?      
C. Staff Training and Information for Primary Care Providers, Families, and Residents (Chapter 5) Yes No Comments
1. Education on falls management during new employee orientation and CAN training?      
2. Annual inservice training on falls management for all staff?      
3. Staff education materials, including:

facility policy and procedures
internal and external fall risk factors and consequences of falls
high-risk medications, sleep hygiene measures for management of anxiety
low blood pressure precautions
low vision precautions
safety during transfer, ambulation, and wheelchair use
unsafe behaviors, monitoring devices, and management strategies
environment and equipment safety hazards and methods for improvement
foot care and footwear

4. All nurses trained in a fall response system that includes:

immediate evaluation and increased monitoring of resident
investigation of fall circumstances
documentation of fall
immediate intervention within first 24 hours
falls assessment
care plan development

5. Information for families and residents on falls risk reduction?      
6. All primary care providers given information about the program and their role?      
D. Environment and Equipment Safety (Chapter 6)      
1. Regular inspection of all resident rooms and bathrooms for safety problems, including:

poor or insufficient lighting
unstable furniture
hard-to-reach personal items
unsafe flooring
footwear and foot care

2. All staff trained to inspect and report environmental and equipment safety problems?      
3. Repair of reported safety problems in a timely manner by maintenance staff?      
4. Inspection and repair of all wheelchairs, canes, and walkers every 6 months?      
5. Communications and inspections documented for ongoing monitoring and accountability?      

Chart Audit Instructions: Select the charts of 5 residents who have fallen within the past 6 months. For each selected resident, read through the chart and care plan to answer all 24 questions. Check yes (Y) or no (N) in the column under each chart across from each question. If the question does not apply to a resident, write NA in either box. For accuracy, use only the information that is written in the chart and care plan. Common locations of the information as well as rationales are described below.

Section E: Screening and Assessment

Location. MDS for risk and history; physician notes, nurse notes, assessment form, and any other that may include different components of the assessment, such as notes by the physical or occupational therapist.

Rationale: All of the listed areas of risk are components of an interdisciplinary, comprehensive assessment process. All areas warrant assessment and should be accessible in the medical record. Appropriate referrals during the assessment process should be evident and easily tracked through documentation.

Section F: Care Plan Development

Location: Care plan, nurse notes, progress notes.

Rationale: All areas of concern identified during assessment should be addressed with specific individualized interventions. Dates of implementation for new interventions should be included to show completeness and follow through.

Section G: Monitoring Implementation and Resident Response

Location: Nurse notes, interdisciplinary progress notes, consultant notes and care plan; after a fall, all items under #21 should be investigated with a written summary in the nurse or progress notes.

Rationale: The medical record must show the success or failure of new interventions that are being tried. In the event a new intervention has been unsuccessful, revisions of the care plan and subsequent progress notes should be evident. After a resident falls, documentation should reflect a new intervention added within 24 hours, increased monitoring during the next 72 hours, and physician involvement.


Chart Audit Chart 1 Chart 2 Chart 3 Chart 4 Chart 5
E. Screening and Assessment (Chapter 4) Y N Y N Y N Y N Y N
1. Residents screened for fall risk on admission, readmission, or last MDS?                    
2. History of falls documented in the medical record?                    
3. Comprehensive falls assessment completed for those identified at high risk during screening or after resident's initial fall?                    
4. Falls assessment reflects a multidisciplinary approach addressing the following risk factors:

underlying medical condition(s)
high-risk medication use (antipsychotics, antidepressants, benzodiazepines, sedative/hypnotics, digoxin)
orthostatic hypotension
poor vision
mobility/gait/transfer problems
wheelchair eating problems
unsafe behavior(s)
environmental hazards
unsafe footwear/foot care

5. Assessment of all risk factors complete and documented with the appropriate health professionals contacted for additional followup?                    
Chart Audit Chart 1 Chart 2 Chart 3 Chart 4 Chart 5
F. Care Plan Development (Chapter 4) Y N Y N Y N Y N Y N
6. Orders from primary care provider, therapist, and other professionals added to care plan?                    
7. Treatment of underlying medical conditions in care plan?                    
8. For residents with changes in an antipsychotic, antidepressant, benzodiazepine, or sedative/hypnotic, does care plan include sleep hygiene measures and behavioral management interventions to reduce anxiety, agitation, and other behavioral symptoms?                    
9. For residents with changes in digoxin, do the nurse notes or care plan include adequate monitoring of apical heart rate?                    
10. For residents with any of the following unsafe behaviors, does care plan include general behavior management strategies and specific interventions to reduce risk of injury, increase comfort, provide assistance, and increase surveillance?

trying to get out of bed alone unsafely
trying to stand, transfer, or walk alone unsafely
walking or pacing when too tired to be safe
propelling or walking alone in unsafe areas

11. For residents with orthostatic hypotension, does care plan address changes in medications and low BP precautions?                    
12. Does care plan include interventions to minimize falls risk during:


13. For residents in wheelchairs, does care plan include interventions to improve positioning and comfort and to ensure correct fit?                    
14. For residents with poor vision, does care plan include low vision precautions?                    
15. Have environmental and equipment hazards been corrected?                    
16. Interim plan of care implemented while falls assessment and care plan are completed?                    
17. New intervention added within 24 hours of each fall?                    
Chart Audit Chart 1 Chart 2 Chart 3 Chart 4 Chart 5
G. Monitoring Implementation and Resident Response (Chapters 2 and 4) Y N Y N Y N Y N Y N
19. Monitoring of success or failure of interventions documented in the nurse, progress, or consultant notes?                    
20. Review of interventions and revision of care plan by falls team?                    
If the resident has fallen within the past 6 months,                    
21. Data collected after each fall? (If fall is unwitnessed, give credit for investigation.)

time, location, day of week, shift
activity at time of fall
equipment used
staff present
assistive device
restraint use
side rail use
results of fall (BP, BS, mental status, VS, tests ordered, ER or hospital visit)
description of injury
process and results of notification of family and MD

22. Does the primary care provider refer to resident's fall and/or risk factors in first progress note after fall?                    
23. Care plan revision with new interventions added based on data collection at time of fall?                    
24. Nurse notes reference fall and show increased monitoring for 72 hours after fall?                    

Signature: ______________________________________________________________________          Date: __________________

Plan for Improvement

  1. Once you have completed the self-assessment for all 7 areas of focus in the Falls Management Program, determine which of the areas need improvement and develop a plan. Improvement in some of the areas requires changes in the facility's management strategies and improvement in other areas requires changes in care practices.

Using the checks under Yes or No on the previous pages, determine which areas have one or more questions answered "No." For those areas with a No, put a check by it in the list below. Your falls team should review those areas and identify priorities for improvement.

Areas that need improvement

___  Culture, organizational commitment, and team skills
___  Data collection and analysis
___  Staff training and information for primary care providers, family, and residents
___  Screening and assessment
___  Care plan development
___  Monitoring implementation and resident response

List of priorities for improvement:


Page last reviewed December 2017
Page originally created February 2010
Internet Citation: Appendix B1: The FMP Self-Assessment Tool (Text Description). Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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