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Fall Scene Report
Transcriptions
Description of Fall
Date of Fall *
Time of Fall *
AM/PM *
AM
PM
Was the resident in pain? *
Yes
No
Was the resident incontinent? *
Yes
No
Was the resident hungry? *
Yes
No
Was the resident thirsty? *
Yes
No
Did the resident appear to be restless? *
Yes
No
How did you fall? *
What were you doing just prior to the fall? *
Whether pain management review/PAINAD is required
Yes
No
Did the resident have to go to the bathroom? *
Yes
No
Detailed description of resident's activity prior to fall *
Resident's mental and psychological status prior to fall *
Fall Details
Type of Fall *
Unwitnessed
Witnessed
Intercepted fall
Self reported fall
Location *
Bed
Own room
Bathroom
Hallway
Dining room
During an activity
During therapy
How did the resident fall? *
Ambulating
Self-transferring from bed
Self-transferring from w/c
Self-transferring to toilet
During staff assisted transfer
Rolled out of bed
While reaching for something
Lowered to floor by staff
Additional details about how the fall occurred
Contributing Factors
Time of last toileting *
Results *
Voided urine
BM
Did not void
If resident wears a brief, Results *
Wet
BM
Dry
Other footwear details
Factors contributing to fall *
Resident lost their balance
Resident slipped
Lost strength or became weak
Wheelchair/bed brakes unlocked
Bed height not appropriate
Equipment related
Resident positioning
Environmental factors
Low air loss mattress in use? If yes, functioning properly?
Yes
No
Footwear at time of fall *
Shoes
Bare feet
Gripper socks
Slippers
Socks
Off load boots
Amputee
Medical Assessment
Does recent Hgb show evidence of anemia? *
Yes
No
Time of last pain medication
Pulse rate (bpm) *
Respiratory rate (breaths/min) *
Temperature reading (°F) *
Blood oxygen saturation (%) *
B/P Lying (mmHg) *
B/P Sitting (mmHg) *
B/P Standing (mmHg) *
Not able to stand for B/P
Yes
No
Was the resident's blood sugar significant? *
Not applicable
Within normal range for resident
Out of normal range for resident
Medications given in the 8 hours prior to fall *
Anti-anxiety
Antidepressant
Antipsychotic
Hypnotic
Cardiovascular
Diuretic
Laxative
Narcotic
Anticonvulsant
Medication side effects if applicable
Medical Conditions/History *
Current Infections
Status Assessment
Vision Status *
OK
Blind/severely impaired
Glasses
Transfer Status *
Independent
Requires assist
Total assist
Bed Mobility Status *
Independent
Requires assist
Total assist
Ambulation Status *
Independent
Requires assist
Total assist
Uses assistive device
Cognition History *
Alert
Comatose
Oriented to self
Oriented to place
Oriented to time
Recognizes family/visitors
Recognized staff
Knows location of room
Locomotion Status *
Independent
Standard W/C
Motorized W/C
Requires assist
Total assist
Type of assistive device used if applicable
ADL Status
ADL Status - change from baseline *
Transfer
Bed mobility
Locomotion
Ambulation
Interventions
Medication change related to pain
Yes
No
Medication change related to B/P
Yes
No
Equipment
Fall mat - put in place
Fall mat - remove
Self-releasing seat belt
Body pillow
Scoop mattress
Transfer pole
Position the bed to low position
Position the bed at resident's knee height
Wheelchair or walker within reach
Reacher device within reach
Call light within reach
Supervision or staff assistance *
Check resident's position Q_____
Check for incontinence Q_____
Assist resident with voiding during the day
Voiding trials at night
Increase in-room activity
Increase out of room activity
[The resident is receiving] physical therapy for:
[The resident is receiving] occupational therapy for:
[The resident is receiving] speech therapy for:
Other medication changes
Required laboratory tests
Other medical interventions
Conclusion
Analysis of the root cause of the fall *
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