AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Electronic Reports
On-Time Falls High-Risk Report
Table 1. Sample Falls High-Risk Report
Unit: ________________________________________________________________
Date: ___/___/___
Resident | Within 90 Days | |||||||
---|---|---|---|---|---|---|---|---|
Name | Room | High-Risk Existing Conditions | ||||||
Mental: Unsafe Behaviors | Mental: Cognitive Impairment | Gait and Balance Instability | Fall: 8-30 Days | Fall: 31-180 Days | Psychoactive Medications | Other High-Risk Medications | ||
Resident A | 122 | X | X | X | ||||
Resident B | 114 | X | X | |||||
Resident C | 103 | X | X | |||||
Resident D | 142 | X | ||||||
Resident E | 112 | X | ||||||
Resident F | 133 | X | X | |||||
Total | 3 | 1 | 2 | 2 | 1 | 1 | 1 |
Table 1 (continued)
Resident | Within 7 Days | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Name | Room | High-Risk Change in Condition | |||||||||||||||
Acute Mental Status Change |
Behavior: New Unsafe |
New Gait/ Balance or Device Order |
New Fall | Med: New Med or Dose Change |
Orthostatic Hypo- tension/ Dehydra- tion |
Vertigo/ Dizzi-ness |
Syncope/ Faint- ing |
Hypogly-cemia | Possible Infection | New Seizure Activity |
New Admission | ||||||
Resident A | 122 | X | X | X | |||||||||||||
Resident B | 114 | X | X | ||||||||||||||
Resident C | 103 | X | X | ||||||||||||||
Resident D | 142 | X | |||||||||||||||
Resident E | 112 | X | |||||||||||||||
Resident F | 133 | ||||||||||||||||
Total | 1 | 1 | 1 | 1 | 2 | 3 |
Table 1 (continued)
Resident | Within 7 Days | ||||
---|---|---|---|---|---|
Name | Room | New Contributing Risk Factors | |||
Pain: New or Uncontrolled Chronic | Urinary Incont: New or Increased | Mobility: More Independent | Room Change | ||
Resident A | 122 | ||||
Resident B | 114 | X | |||
Resident C | 103 | X | |||
Resident D | 142 | ||||
Resident E | 112 | ||||
Resident F | 133 | X | |||
Total | 1 | 1 | 1 |
Table 1 (continued)
Resident | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Name | Room | ADL Decline and Other Clinical Information | |||||||||
Bed Mobility | Transfer | Toileting | Depression Score Increase |
Monthly BMI <18.5 kg/m2 |
Significant Weight Change |
Vitamin D Order |
Osteop- orosis |
Diabetes | Visual Impair- ment |
||
Resident A | 122 | 25* | X | ||||||||
Resident B | 114 | X | |||||||||
Resident C | 103 | 21 | |||||||||
Resident D | 142 | X | X | ||||||||
Resident E | 112 | ||||||||||
Resident F | 133 | X | X | ||||||||
Total | 2 | 1 | 2 | 1 | 2 |
ADL = Activities of Daily Living.