Fall Incident Assessment Form printable pdf download

FALL INCIDENT ASSESSMENT

(This tool is only an example. Please adapt it to meet the needs of your facility and residents.)

DATE_______________________

DIRECTIONS

According to facility policy, the fall assessment shall be completed following any resident fall. This fall assessment shall not be

made part of the resident’s medical record. The assessment is completed as part of the facility’s continuing quality assurance

program. Information in this assessment should be used to revise the resident’s plan of care. Items noted below with a star*

should be appropriately documented in the resident’s clinical record. All other items should be reviewed and acted upon

solely at the discretion of the nursing facility.

IMMEDIATE ACTION

*The following items should be documented in the resident’s clinical record:

___Physician contacted ___Family contacted

___Administration contacted, according to facility policy

___Resident first-aid and treatment

___Neuro-checks

___Vital signs: BP (sitting, then standing), temperature, pulse and respiration

___Signs/symptoms of injuries such as pain, bleeding, abrasions, contusions, bruises, swelling

reddened areas, etc.

___Medical conditions such as:

Cardiac arrhythmia’s

Hypotension

Syncope

Parkinson’s

Hemiplegia

Seizure disorder

Arthritis

Pain

Osteoporosis

CHF

Bladder dysfunction (worsening or new onset)

___Acute conditions or signs/symptoms of unknown origin.

___Urine tested by dipstick within 4 hours of fall

___The position of the resident upon discovery

___Resident and witness statements

INVESTIGATION

*What was the resident doing when incident occurred:

___Standing ___Sitting ___Transferring (___Assistive Devices Used) ___In Bed ___Reaching ___Other___________

*Where was the resident when the incident occurred:

___Own bedroom ___Another bedroom ___Own bathroom ___Another bathroom ___Hall ___Dining Room ___Lounge ___Other –

Specify ___________________

Last Name

First Name

Attending Physician

Room No.

Res. #

KDOA Workgroup05

Fall Incident Assessment Form

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