Post Fall Investigation

Resident Name: ____________________

1. Was this fall observed?
If yes, by whom?

Yes

Date and Time of Fall: _____________

No

1. _________________________
(name & title of person)

2. ____________________________
(name & title of person)

2. Was the Resident identified as High Risk prior to the fall?

3. Residents Vital Signs
Temp.
Pulse

Resp.

B/P

4. Does the Resident have a history of falls?

O2 Sat.

Yes

Yes

No
BS (diabetics only)

No

5. What was Residents response to Why do you think you fell?

6. What footwear did the Resident have on?

Barefoot / Socks
Slippers
Shoes
Other
7. Resident activity / needs at the time of the fall (Check all that apply):
Yes
No
Getting in or out of bed?
Going to the dining room?
Going to the bathroom?
Transferring?
Getting up from chair?
In pain?
Looking for something?
Other:
Specify:
8. Location of fall:
Residents Room
Dining Room
Activity / Day Room

Bathroom
Shower
Toilet

9. Was a restraint in place at the time of this fall?

Restraint
Yes
No

Yes

No

Outside
Hall
Other:
Was the restraint in good
repair?

Yes

No

None
T-binder
Table Top
Seat Belt
Other

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10.What mechanical devices were in use?

Mechanical Device
Yes

No

Was the mechanical device

in good repair?

Yes

No

None
Personal Alarm
Bed Alert
Bed Rail(s) Circle number
used: 0 1 2 3 4
Hi-Lo bed, at lowest level
11.What assistive devices were in use?
Assistive Device

Yes

No

Was the assistive device in

good repair?

Yes

No

Cane
Straight Quad
Crutches
Walker:
Standard
2-wheeled 4 -wheeled
Wheelchair
Broda Chair
Other:

12. Mental Status of Resident:

(check all that apply)

Prior to the fall

Following the fall

Alert
Able to follow directions
Confused / Disoriented
Change in behaviours
Other:
13.Physical Status of Resident at time of fall:
Incontinence
Weakness / fatigue
Unsteady gait
Recent acute illness
Specify:
Pain
Visual impairment
Hearing impairment
Dizziness
14.Environmental status at time of fall:
Call bell within Residents reach
Bed locked
Wheelchair locked
Throw rugs
Uneven floor surface
Other:

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(check all that apply)

Change in BP
Recent weight loss / gain
Decrease in fluid intake
Recent change in lab values
(Hgb, blood sugar)
Recent cough / cold
Glasses on
Hearing aid on & working
(check all that apply)
Call bell on at time of fall
Room light on
Night light on
Floor wet
Power / phone / TV cords

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15. List all new medications or dosage / time changes or prn medications prescribed / administered to the
resident within the past 48 hours:
Date

Medication

16. Did fall result in transfer to hospital?

Yes
No
If yes, Ministry of Health Unusual Occurrence Form initiated?
Complete WRH Risk Monitor Pro
Yes

Yes

17. Executive Director notified (at ext. 75450) of resident transfer to hospital

Yes No

Date & Time: ___________________

18. Physician notified?

Yes

No

Date & Time: _________________________

19. Family notified

Yes

No

Date & Time: _________________________

20. Is there a need to re-educate the resident, family and staff?

Yes No

Summary: Factors contributing to fall

Action Plan(s)

Post Fall Follow Up

Activity
Fall documented in progress notes
Fall entered in Incident Log
Post Fall Investigation summary documented in progress notes
Fall Risk Assessment Tool completed
Fall Prevention Care Plan reviewed

Date

Assessment completed by:

Name (print) ______________________________
Signature

______________________________

Date

______________________________

Submitted to management on: _____________________

Date and Time
253045105.doc/-ny/-20-Aug-08

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