Fall Incident Assessment Form Page 3
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3FALL INCIDENT ASSESSMENT
(Continued)
Bed
___Unknown
___No problem
___Too narrow
___Overlay
___Too low
___Unlocked wheels
___Side rails
___Other________________
Clothing and Shoes
___Unknown
___No problem
___Tripped person
___Loose/ill-fitting shoes
___Walking in stocking feet
___Other_________________
Other factors contributing to incident
___None
___Restraint
___Lift
___Staff
___Other device, List_____________________________________________________________________________
__
RESIDENT SPECIFIC CARE PLAN IN PLACE, FOLLOWED AND DOCUMENTED
Appropriate safety precautions and devices
___Yes
___No
___NA
Positioning devices
___Yes
___No
___NA
Toileting programs
___Yes
___No
___NA
Rehab/restorative program
___Yes
___No
___NA
Behavioral program
___Yes
___No
___NA
Other, list________________________________________________________________________________________
Did you educate resident about safety concerns? ___Yes
___No – why not_________________________
Did you educate resident on ways to fall?
___Yes
___No – why not_________________________
Individual Completing Investigation_________________________________________Date______________________
QA USE ONLY
ACTION PLAN
___Review incident report
___Review nurse’s notes
___Review and revise care plan
___Communicate changes to staff
___Observation of implementation of care plan at least every shift
CONCLUSION/SUMMARY
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Last Name
First Name
Attending Physician
Room No.
Res. #
KDOA Workgroup05
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