1. health and fitness
2. disease
3. cancer

INDEX
TAB ONE
Fall Prevention and Management program
TAB TWO
Sample forms
- Fall Risk Assessments
- Side Rail Assessments
- Incidents Report and Investigations
- Witness forms
- Post-fall Summary
- Physical Restraint Assessments and
Authorizations
- Event, Fall, and Physical Restraint logs
- QA Audit Tools
TAB THREE
Proposed F-tag 323 and 324 Guidance to Surveyors
and Investigative protocol.
Manual includes:
Program CD –Fall Prevention and Management --includes entire program, protocol, and forms.
Developed by Polaris Group (813) 886-6500
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PROCEDURE
How to use this manual:
All systems and processes have key steps or components that are needed to achieve the desired
outcome. For a clinical program, the desired outcomes include:
1. Compliance with regulations and best practices.
2. Provides for individualized assessment and care planning.
3. Monitors effectiveness of processes in achieving desired resident outcomes.
The QA Committee should review all outlined key components in this manual, then
perform a gap analysis comparing current systems to recommended best practices
recommended.
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Steps:
1. Evaluate current systems to key components outlined in this manual.
2. Define standards and key components for the health center.
3. Review F-tag 323 Accident & Supervision survey guidelines and protocols. Access
clinical resources listed in guidance as resource for developing procedures.
4. Use text from the manual provided on CD to develop center specific procedures.
5. Finalize forms.
6. Provide education and training to staff.
7. Implement systems.
8. Develop ongoing QA to monitor effectiveness.
Fall Prevention Program
1
PRELIMINARY NURSING ASSESSMENT
Admit Date _____________ Admit time ______________ From _______________ Via __________________
Diagnosis __________________________________________ Allergies: ______________________________
T: ___________ P: ___________ R: ___________ BP: __________ HT: __________ WT: ______________
1.
COGNITIVE (CIRCLE)
ALERT / ORIENTED TO: PERSON – PLACE – TIME MEMORY PROBLEMS / ACUTE CONFUSION /
LETHARGIC / SEMI COMATOSE / COMATOSE: DESCRIBE __________________________________________
CARE PLAN Y OR N
2.
MOOD AND BEHAVIOR (CIRCLE)
ELOPEMENT POTENTIAL: Y or N __________________________ If yes, complete full Elopement Assessment tool
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(Circle One) WITHDRAWN / PACING / VERBALLY ABUSIVE / CRYING / WEEPING / ANGRY / RESISTS CARE /
REPETITIVE BEHAVIORS / AGITATION/ OTHER: ____________________________________________________
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CONDITION/DIAGNOSIS:_____________________________________________________CARE PLAN: Y OR N
RECEIVING: HYPNOTIC / ANTIPSYCHOTIC / ANTIANXIETY / ANTIDEPRESSANT:
If applies:
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LIST MEDS: _______________________________________________________________________________________
BEHAVIOR MONITOR INITIATED: _____ REFERRED TO PHARMACY: _____
CONSENT SIGNED:_______SIDE EFFECT MON. STARTED:______ AIMS:__________
3.
COMMUNICATION (CIRCLE)
HOH / DEAF L R B
HEARING AIDE L R B / OTHER:
COMMUNICATES: SPEECH / GESTURES / WRITES / OTHER APHASIC
CAN BE UNDERSTOOD Y OR N UNDERSTANDS Y OR N
CARE PLAN: Y OR N
4.
REFER TO THERAPY: Y OR N
VISION (CIRCLE)
ADEQUATE Y OR N GLASSES Y OR N
BLIND Y OR N – L R B
LENS IMPLANTS L R B
PROSTHESIS L R B GLAUCOMA / CATARACTS / FIELD CUT L R B
5.
CARE PLAN: Y OR N
PAIN (CIRCLE) VERBAL OR NONVERBAL EXPRESSION OF PAIN: PAIN: Yes No CARE PLAN Y OR N
COMPLETE PAIN SCREEN ON ALL RESIDENTS: IF SCORE IS GREATER THAN 3, COMPLETE FULL
ASSESSMENT FORM.: Pain Screen Score: _______ Pain Scale: 1-10:_______
RESIDENT:__________________________________ RM:_______MR#________
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SIDE RAIL USE PLAN AND AUTHORIZATION
RESIDENT FACTORS THAT IMPACT USE OF SIDE RAILS – FALL RISK SCORE: ________
Unsafe independent transfer □ Yes □ No
Comatose, semi, fluctuating
Uses call light effectively
Risk of seizure
Waits for help
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Immobile in bed
□ Yes □ No
Alteration in safety awareness □ Yes □ No
Difficulty with trunk control
Requires spatial awareness reminders □ Yes □ No
Able to use SR for positioning □ Yes □ No
□ Yes □ No
RATIONALE FOR USE - circle all that apply
No side rails needed □ Yes □ No
Resident does not desire side rails
□ Yes □ No
Alert Resident prefers side rails up for feelings of safety
□ Yes □ No
Enhance Bed mobility with use of side rails
□ Yes □ No
Prevent rolling OOB: would not try to rise unassisted
□ Yes □ No
Provide reminder to not rise unassisted; and would try to
rise unassisted (restrictive side rail-restraint)
□ Yes □ No
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POTENTIAL RISKS FROM THE USE OF SIDE RAILS:
1. Increased risk of injury from trying to climb over rails to get out of bed
2. Bruises from bumping into side rails
3. Agitation or increased agitation
4. Decreased vision by creating a visual barrier
5. Decreased physical contact from others
6. Strangulation
7. Entrapment (e.g. getting limbs or head caught in rails)
8. Death
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POTENTIAL BENEFITS FROM THE USE OF SIDE RAILS:
1. Enable/increase independence in bed mobility
2. Enable/increase independence in transfers
3. Enable better positioning and support in bed
4. Provide tactile boundaries for vision or cognitively impaired residents
SAFETY PLAN: X = Side Rail Plan (See restraint assessment if meets definition of a restraint)
… All down
… Full rails both sides up
… One full rail up- R or L
… Both half rails up at head of bed
… One half rail up at head of bed - R or L
… Both bottom rails up
… One bottom rail up - R or L
… All four rails up
… Mini rails up both sides only one side
… Side rail/mattress safety check performed
… Other (e.g. rise alarm, scooped mattress)______________________________________________
I have been fully informed of the above risks and benefits related to the use of side rails in care planning and agree
to the plan above: Resident signature _______________________________________ Date __________ or
Surrogate Decision Maker ____________________________________ Date___________
Initial Review Signature:______________________________________________Date___________
Review Dates and Signature: Date: ______ Signature:____________________________________
Date: _______ Signature: ___________________________________________________________
Date: _______ Signature_____________________________________________________________
RESIDENT’S NAME
PHYSICIAN
RM#
MR#
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EVENT REPORT
(Quality Assurance/Confidential)
Completed By Charge Nurse On Duty.
Nurse/Staff:
Resident:
Date:_____________
Time:
_________a.m. /p.m.
Day of Week
Resident Statement or describe Event Scene:
Describe environment, position of resident, equipment,
floor surface, and site of injury:
Location of occurrence:
Resident room
Bathroom
Hallway #
Shower Room
Nursing Station
Incident:
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Describe Injury and Resident Status overall (size, depth, color, pain, bleeding, limitation in ROM-results of head-to-toe assessment, VS & Neuro checks:
SKIN
Acquired Stage I
Acquired Stage II
Acquired Stage III
Acquired Stage IV
Skin Tear – unknown origin
Skin Tear – known origin
Bruise – unknown origin
Bruise – known origin
Burn/laceration/bite/other
BEHAVIORS
Resident/Resident
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FALL
Unwitnessed-found on ground
During Assisted Transfer
During self transfer – bed
During self transfer – toilet
During self transfer – chair
While self-ambulating
During Assisted Ambulation
MISC
Found in Hazardous Situation
Other
Risk/injury R/T equipment
Front Exit
Other Exit________________
Off Premises
Unknown
Other (specify) _______________
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Dining Room
Activity Room
Therapy Room
Lobby
Grounds/Parking lot
Elopement
Resident/Visitor
Resident/Staff
Unaccompanied Exit
Self inflicted injury
MEDICATION
Repeat Administration
Wrong medication/wrong resident given
Wrong dose/route given
Omission
IV Error
Transcription error only, not administered.
Immediate Intervention initiated to protect resident: (check all that apply):
First Aid
Provide immediate protection__
________________________________
Physician orders/Tx
Initiate Rise Alarm w/c / bed
ER visit/Hospital admission
Initiate frequent checks_______
Med error-Req. Medical care
Lower bed
Med error – no intervention
Mat/mattress by bed
Press. Reduction: Bed / chair
Provide food/diversion
Environmental Adjustment ____
Placed in supervised area
_______________________________
Care plan updated to new interventions
Oriented to call light
Protective clothing-skin
Toileted
Put to bed
Wanderguard initiated
Add Enabler bar/trapeze
______________________
______________________
Review meds
PRN Med_______________
Removed S/R or restraint
Added non-slip device:
w/c chair Geri
Initiated body pillow
_______________________
_______________________
Notification of Physician:
Physician notified
Name:___________________
Notification of Responsible
Party:
Responsible Party notified
No Contact. Date:
Attempt Made No Contact
Date:_________
Time:________
Name:_________________________________________
Date/ Time:
Non Staff Witnesses to event Yes/No Name:__________________________ Phone:__________ Address:__________________
Staff Witness Yes/No
Name
Licensed Nurse
NA
assigned:____________________ Assigned:
First person on scene:
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PHYSICAL RESTRAINT AUTHORIZATION
The following risks/benefits of ____________________________ (restraint type) use have been discussed with
________________________ (resident type), and/or __________________ (surrogate decision maker).
Reason for use:__________________________________________________________________________
Duration of use: _________________________________________________________________________
he rails, tipping over
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POTENTIAL RISKS:
1. Increased injury: from trying to climb over rails, out of bed, getting limbs caught in t
in wheelchair
2. Incontinence or increased incontinence
3. Skin breakdown including pressure sores, skin tears, bruises
4. Agitation or increased agitation
5. Decline of functional mobility (walking)
6. Increased Confusion
7. Becoming withdrawn
8. Strangulation
9. Other
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POTENTIAL BENEFITS:
1. Enable bed mobility
2. Feelings of safety
3. Enable independent wheelchair mobility
4. Enable better sitting balance, positioning or mobility
5. Treat life-threatening problems: Dehydration, electrolyte imbalance, urinary blockage, re-fracture, and severe
violence to self or others.
6. Prevent removal of tube or treatment:
a. Catheter
c. Oxygen mask/cannula
e. Gastrostomy tube
b. IVs
d. Nasogastric tube
f. Dressings
7. Other
I understand that I have the right to refuse the use of a physical restraint, and I have been fully informed of the
above risks and benefits related to restraint usage and the consequences of the non-use of restraint. After careful
consideration of the information provided to me, I hereby: (initial one)
______ Give my consent for the use of the restraint(s).
______ Refuse to give my consent for the use of the restraints.
Date __________________
Resident ________________________________________________________
Date ___________________ Surrogate Decision Maker ___________________________________________
Date___________________ Nurse___________________________________________________________
Rev.Date______________________Rev Date___________________________Rev Date____________________________
Signature______________________Sign______________________________Sign________________________________
RESIDENT’S NAME
PHYSICIAN
ADMISSION NO.
ROOM/BED
HIGH RISK EVENT FLASH REPORT
QUALITY ASSURANCE/CONFIDENTIAL
MOS/YR:____________________________
FALLS
BEHAVIORS
Total Behaviors
Resident/Resident
Resident/Visitor
Resident/Staff
Elopement
Unaccompanied Exit
Self-inflicted injury
MEDICATION ERRORS
Total Reported Medication errors
Repeat administration
Wrong medication/wrong resident
Wrong dose/route
Omission
IV Error
Transcription
DAY OF WEEK - FALL
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
DAY OF WEEK - BEHAVIORS
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
MISC.
LOCATION FALLS
Resident Room
Bathroom
Hallway
Shower Room
Nursing Room
Activity Room
Dining Room
Therapy Room
Lobby
Grounds/parking lot
Front Exit
Other Exit
Off-premises
Unknown
Other
LOCATION BEHAVIORS
Resident Room
Resident/visitor
Hallway
Shower Room
Nursing Station
Activity Room
Dining Room
Therapy Room
Lobby
Grounds/parking lot
Front Exit
Other Exit
Off-Premises
Unknown
Other
FALLS TIME OF DAY
7a.m. - 9a.m.
9a.m. - 11a.m.
11a.m. - 1p.m.
1p.m. - 3p.m.
3p.m. - 5p.m.
5p.m. - 7p.m.
7p.m. - 9p.m.
9p.m. - 11p.m.
11p.m. - 1a.m.
1a.m. - 3a.m.
3a.m. - 5a.m.
5a.m. - 7a.m.
Found in hazardous situation
Other
Risk/injury R/T equipment
Alleged abuse/neglect complaint
# reported to State
# Substantiated
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Total Falls
Unwitnessed-found on ground
During assisted transfer
During self transfer - bed
During self transfer - toilet
During self transfer - chair
While self ambulating
During assisted ambulation
BEHAVIORS TIME OF DAY
7a.m. - 9a.m.
9a.m. - 11a.m.
11a.m. - 1p.m.
1p.m. - 3p.m.
3p.m. - 5p.m.
5p.m. - 7p.m.
7p.m. - 9p.m.
9p.m. - 11p.m.
11p.m. - 1a.m.
1a.m. - 3a.m.
3a.m. - 5a.m.
5a.m. - 7a.m.
PRESSURE ULCERS
______% Acquired ______% Total
Total # residents w/ acquired for month
Acquired Stage I
Acquired Stage II
Acquired Stage III
Acquired Stage IV
Total # residents with Pressure Ulcer
Total Stage I
Total Stage II
Total Stage III
Total Stage IV
Total Skin Tears for month
Skin Tears, unknown origin
Skin Tears, known origin
Bruises total for month
Bruise, unknown origin
Bruise, known origin
Burn/laceration/bite/other
Grievances
Lost Item
Physical Restraints
Restrictive side rails
DEVELOPED BY POLARIS GROUP Page 1 of 2
QA Review of Incident by DON or Designee
Audit at least 10 falls per month
Date of
Incident:
Resident:
Time:
Location:
a.m./ p.m.
RM#:
Type of Incident:
Injury:
Medical Record--Appropriate Forms/ Assessments Complete:
… Assessment/Nurses Notes At time of Event
… Alert Charting
… Dr. Notified
… Family Notified
… On 24 hour report
… Incident Report Complete … Contributors Accurate
… IDT Review
… Care Plan Adjusted per contributors
… Meds/treatment per orders/policy … Other (consent, skin flow etc)
Prior to onset / Incident:
Accurate and Complete Assessment with all Risk Factors Identified (Fall Risk, Skin Risk, RAPs etc per procedures)
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Care Plan was based on Risk Factors?
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Care Plan was implemented?
Any New Contributing Factors identified post-occurrence?
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Care Plan updated to all old/new Risk Factors?
Conclusions / further follow–up:
Avoidable
… Yes
… No
Action Plans/Training needs:
Signature:
Date: