Policy and procedure outlines specific steps for risk assessment, risk prevention, post-fall assessment, interventions, and evaluation

Yes/No

Policy and procedure indicates specific forms for implementation of program

Resident is considered high risk until admission fall assessment is done

Fall risk assessment is done at admission

Admission assessment includes evaluation of balance, strength, gait, transfer, and safety

Restorative Nursing and Therapy departments are involved in assessments and fall interventions

Fall interventions include programs to prevent functional declines, such as exercise and restorative programs for transfer, gait, and balance

Facility policy states clear guidelines for high fall risk identification

High fall risk identification is initiated as soon as residents are assessed at risk

Staff is educated about fall risk identification program

Facility has a restraint reduction program

Staff education on falls includes instructions on restraint regulations, risks, and alternatives

Falls care plan is initiated immediately when resident is identified as fall risk

Falls care-planning includes all members of health care team

Resident and family are instructed in fall prevention

Risk reduction interventions include maximizing the resident’s mobility and transfer abilities

Environment is modified to reduce fall hazards

Post-fall protocols are clearly outlined for follow-up, documentation, and monitoring

Post- fall assessment is comprehensive

New interventions are implemented after each fall

Guidelines indicate protocols for filling out and following through with incident reports

Medication review is done after fall

Falls Committee membership consists of key department heads

Each resident fall is recorded in the Falls Log

Falls are tracked monthly by day, hour, location, and unit

Falls statistics are analyzed to discern patterns

When improvement or decline in facility rate of falls is noted, causes are   investigated

P  Plans of correction are written to decrease the facility’s frequency of falls

Staff is kept informed about level and frequency of falls month to month