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Fall Risk

 

 

    Resident______________________________                               Date____________________ 

 

 

 

Value

Resident Status

Resident

Score

 

History of falls

for past 3 months

0

2

4

 

No falls

1-2 falls

3 or more falls

 

 

 

Ambulation

0

2

4

 

Independent

Non-ambulatory

Assist required

 

 

 

Toilet use

0

2

4

 

Independent

Does not use

Assist required

 

 

 

Gait

0

1

1

 

Normal

Unstable

Requires assistive device

 

 

 

Balance

0

1

1

 

Normal

Balance problem while standing

Balance problem while walking

 

 

 

Vision

0

2

4

 

Adequate with or without glasses

Poor

Blind

 

 

 

Mental status

0

2

4

 

Oriented times three

Intermittent confusion

Disoriented times three

 

 

 

Medications

2

3

4

 

Takes one or more medications daily

Takes 2-9 medications daily

Takes more than 9 medications daily

 

 

 

Systolic blood pressure

0

2

4

 

No change between lying and standing

Drop less than 20 mm Hg

Drop more than 20 mmHg

 

 

 

Restraint

0

4

 

No restraint

Restraint used

 

 

IV Pole, O2, Tubing,

Catheter

(if ambulatory)

0

4

 

None used

Attached equipment used

 

 

 

                                       Total Score

          

 

 

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