Fall Risk Assessmentform
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1
2FALL RISK ASSESSMENT
Adapted from the Ohio Falls Work Group, 1999
(This tool is only an example. Please adapt it to meet the needs of your facility and residents.)
Complete fall risk assessment upon admission, readmission and according to facility policy.
Check appropriate responses. Care Plan the appropriate areas.
Resident Name _____________________________________________________Room ______
□ Admission
□ Readmission
□ Other
Falls History
□ None/no history of falls
□ Fall(s) in last 90 days/# of fall(s) ___
□ Fall(s) in last 30 days/# of fall(s) ___
□ Fall(s) in last 180 days/# of fall(s) ___
Circumstances surrounding fall(s) __________________________________________________
Life Style Factors
What does the resident like to …
Hear ______________________________
Resident can identify edge of bed □ Yes □ No
Smell _____________________________
Behavioral patterns that make resident unsafe,
Touch _____________________________
e.g. need to be independent, pacing, and other?
Taste ______________________________
_______________________________________
See _______________________________
_______________________________________
What is the resident’s favorite chair?
Where has the resident been sleeping?
__________________________________
If bed, include size _______________________
Night time sleep and behavior patterns _______________________________________________
______________________________________________________________________________
Elimination Patterns (Most descriptive of past seven days.)
□ Independent and continent
□ Requires assistance and incontinent
□ Independent and incontinent
□ Catheter or ostomy
□ Requires assistance and continent
Internal Risk Factors
Cardiovascular
□ None
□ Orthostatic hypotension (systolic BP change > 20mm Hg drop lying and standing)
Lying ____________
Sitting ___________
Standing ___________
□ Cardiac dysrythmia
□ Pacemaker – last date checked ___________________
Diagnoses, e.g. PVD, other _______________________________________________________
Orthopedic
□ Joint pain
□ Hip fracture
□ Other fracture
□ Missing limb(s)
Diagnoses, e.g. osteoporosis, arthritis, other __________________________________________
Perceptual Deficits
□ None
□ Impaired hearing
□ Impaired vision
□ Dizziness/vertigo/syncope/BPPV
KDOA Workgroup05
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