Fall Incident Assessment Form Page 2
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3FALL INCIDENT ASSESSMENT
(Continued)
*What was the resident’s state of mind when the incident occurred:
___Oriented/No Problem ___Judgment Impaired ___Non-communicative ___Confused/Disoriented ___Cooperative
___Unable to understand others
___Behavior Problems ___Unknown
Has there been a change in mental status in the last week before fall? ___Yes ___No
*What time was it when the incident occurred:
Day of Week______________ Time of Day__________am/pm
Phase of moon__________Last meal time__________
Last toileting time_______________
Last incontinence episode______________________________
CURRENT MEDICATIONS
___Antianxiety
___Antiparkinson
___Hypoglycemic
___Antihistamine
___Hypnotic
___Antipsychotic
___Analgesic
___Anticoagulant*
___Antihypertensives
___Anticonvulsant
___Laxatives
___Non steroidal
___Antidepressant
___Diuretics
___Narcotics
___Anti-inflammatory
*Not a medication that leads to falls, but increases risk for injury when fall occurs.
**Within 24 hours of fall, notify pharmacy consultant by fax for medication review due to fall.
After faxing fax sheet to pharmacy consultant, attach fax sheet to this form.
ENVIRONMENTAL FACTORS
Has there been a recent change in the environment? ___No ___Yes, please list change__________________________
_______________________________________________
Floor Surface
___Unknown
___No problem
___Loose rug, tiles
___Clutter
___Slippery/Glare
___Threshold > ½”
___Uneven surfaces
___Other_________________
___Patterned carpet
___Thick pile carpet
Lighting
___Unknown
___No problem
___Inadequate
___Glare
___Too much
___Other_________________
Handrail
___Unknown
___No problem
___Not accessible to resident
___Difficult to grip
___Loose
___Other_________________
Bathroom
___Unknown
___No problem
___No grab bar
___Grab bar loose
___Floor slippery
___Other_________________
Chair
___Unknown
___No problem
___No armrest
___Unlocked wheels
___Poor construction
___Lack of 3 right angles when seated
___Other________________
Last Name
First Name
Attending Physician
Room No.
Res. #
KDOA Workgroup05
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