FALL RISK ASSESSMENT – West Region



Individual:      

Baseline Date:   /  /   Assessed By:       , RN Date:   /  /  

|Section 1: |Section 2: |

| | |

|Is individual ambulatory? |Plan: |

|YES NO | |

| |Proper footwear |

|Potential risk factors present? |Environmental changes |

|1. Diagnosed dementia |Well lit room |

|2. Gait abnormality |Encourage to change positions slowly |

|3. Seizure disorder |Assistive device, i.e., cane, walker |

|4. Behavior (e.g., rushing) |Assist with positioning |

|5. Sensory impairment |Assist with ambulation in unfamiliar areas |

|6. Medication effects |Assist with ambulation on stairs |

|(e.g., behavior–modifying or blood pressure medication, anticonvulsants) |Assist with ambulation on uneven surfaces |

|7. Orthostatic hypotension |Assist with all ambulation |

|B/P Lying    /    |Monitor follow-up PRN |

|B/P Standing    /    |Other:       |

|8. Other (e.g., environmental factors, medical diagnoses with risk potential) | |

|Specify:       | |

| |Referral: |

|Significant Injury Risk: | |

|Osteoporosis/Osteopenia |PT |

|Anticoagulant use |OT |

|Fracture History |Psych/Behavioral |

|Other |MD |

|Specify:       |Other |

|Recorded fall in last three months? | |

|NO | |

|YES High Risk | |

| | |

|Plan in place to address above risks? | |

|YES Assessment is complete | |

|NO Complete Section #2 | |

Fall Risk Assessment Algorithm for Consultation

|Impaired Mobility | |Demo unsafe behavior or choices | |ADL deficits | |Elimination deficit |

|History of falls | | | |Sensory deficits | |Medication issues |

|Weakness | | | |Decreased cognition | |Predisposing DX |

|Non-compliance with activity restrictions | | | |Living environment concerns | |Uncontrolled pain |

| | | | |Physical limitations | |Medical decline |

|P.T. | |Psych/Behavioral | |O.T. | |Medical |

Individual:       Review Date(s):   /  /   Plan remains appropriate? YES*NO** *Team Signatures Only** Plan Revision Indicated Revision: Identify factors that can be staff intervention and Identify any further evaluation needed Plan Revision/Review Date:   /  /  

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|Signatures: |

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Plan Revision/Review Date:   /  /   Plan remains appropriate? YES*NO**

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| Signatures: |

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Plan Revision/Review Date:   /  /   Plan remains appropriate? YES NO**

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| Signatures: |

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