"Fall Risk Screening Tool" - Delaware

This "Fall Risk Screening Tool" is a document issued by the Delaware Health and Social Services specifically for Delaware residents with its latest version released on June 5, 2015.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Delaware Health and Social Services.

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Download "Fall Risk Screening Tool" - Delaware

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Exhibit B
Division of Developmental Disabilities Services
Community Services
Fall Risk Screening Tool
Name: _____________________________
Site:______________________________
Date of birth: _______________________
MCI: ______________________________
Prepared by: ________________________
Date of screening:____________________
Directions: This assessment is to be completed on all residents upon admission into Residential Services
Points
or Day Services/Employment Provider. Reassessment shall be completed any time there is a change in
health status that would affect his/her risk for falls. Check applicable items that best apply and indicate
points to the right. Add points and note total score below.
Mental Status:
□ (0 pt) Oriented/alert at all times/ or comatose
□ (1 pt) lethargic/forgetful/inconsistent orientation or response to stimuli
□ (2 pts) confused-non-agitated/ highly distractible/ depressed/ uncooperative/ impaired judgment
□ (3 pts) confused/agitated/aggressive/non-purposeful behavior/impulsive
Physical Status:
□ (0 pt) Normal/well/healthy/no remarkable medical and physical problems
□ (1 pt) dyspnea/respiratory conditions
□ (2 pts) syncope/orthostatic hypotension/joint difficulties (arthritis, contractures)
□ (3 pts) seizure disorder/ cachexia/wasting/LE amputation/vestibular imbalance
Elimination: □ (0 pts) Independent and continent
□ (1 pt) Catheter and/or ostomy/ dependent (uses protective undergarments)
□ (2 pts) Elimination with assistance/occasional incontinence
□ (3 pts) Independent but incontinent (urgency/frequency)
Sensory: □ (0 pt) No hearing or vision problems
□ (1 pt) hearing loss/impairment only
□ (2 pts) vision loss/impairment only
□ (3 pts) has both hearing and vision loss/impairments
Neuromotor: □ (0 pt) Normal muscle tone/ no weakness/ no paralysis/ no spasticity
□ (1 pt) Upper extremities only (weakness/paralysis/spasticity/athetosis)
□ (2 pts) Lower extremities only (weakness/paralysis/spasticity/athetosis)
□ (3 pts) both upper and lower extremities (weakness/paralysis/spasticity/athetosis)
□ (0 pt) independent ambulator/ non-ambulatory/ immobile
Gait:
□ (1 pt) non-ambulatory/has bed mobility/has wheelchair mobility
□ (2 pts) independent ambulator with assistive device (i.e. walker/cane)
□ (3 pts) ambulatory with physical assistance and assistive device/unsteady gait
History of Falling Within Past 3 Months: □ (0 pt) None
□ (1 pt) near falls or fear of falling
□ (2 pts) 1-2 falls
□ (3 pts) multiple falls (more than 2)
Medications
□ Antihistamine
□ Antihypertensives
□ Antiseizure/Antiepileptic
□ Benzodiazepines
□ Cathartics
□ Diuretics
□ Hypoglycemic agents
□ Psychotropics
□ Sedatives/Hypnotics
□ Narcotics
□ Other
On the above medication groups, indicate how many the resident is currently taking:
□ (0 pts) No medications □ (1 pt) 1 medication □ (2 pts) 2 medications □ (3 pts) 3 or more
Total Score:
0- 9 points: Low risk
10- 17 Moderate risk
18 or more: High risk
If the person scores 10 or more: safety support should be implemented and reflected in the ELP.
6/5/2015
Exhibit B
Division of Developmental Disabilities Services
Community Services
Fall Risk Screening Tool
Name: _____________________________
Site:______________________________
Date of birth: _______________________
MCI: ______________________________
Prepared by: ________________________
Date of screening:____________________
Directions: This assessment is to be completed on all residents upon admission into Residential Services
Points
or Day Services/Employment Provider. Reassessment shall be completed any time there is a change in
health status that would affect his/her risk for falls. Check applicable items that best apply and indicate
points to the right. Add points and note total score below.
Mental Status:
□ (0 pt) Oriented/alert at all times/ or comatose
□ (1 pt) lethargic/forgetful/inconsistent orientation or response to stimuli
□ (2 pts) confused-non-agitated/ highly distractible/ depressed/ uncooperative/ impaired judgment
□ (3 pts) confused/agitated/aggressive/non-purposeful behavior/impulsive
Physical Status:
□ (0 pt) Normal/well/healthy/no remarkable medical and physical problems
□ (1 pt) dyspnea/respiratory conditions
□ (2 pts) syncope/orthostatic hypotension/joint difficulties (arthritis, contractures)
□ (3 pts) seizure disorder/ cachexia/wasting/LE amputation/vestibular imbalance
Elimination: □ (0 pts) Independent and continent
□ (1 pt) Catheter and/or ostomy/ dependent (uses protective undergarments)
□ (2 pts) Elimination with assistance/occasional incontinence
□ (3 pts) Independent but incontinent (urgency/frequency)
Sensory: □ (0 pt) No hearing or vision problems
□ (1 pt) hearing loss/impairment only
□ (2 pts) vision loss/impairment only
□ (3 pts) has both hearing and vision loss/impairments
Neuromotor: □ (0 pt) Normal muscle tone/ no weakness/ no paralysis/ no spasticity
□ (1 pt) Upper extremities only (weakness/paralysis/spasticity/athetosis)
□ (2 pts) Lower extremities only (weakness/paralysis/spasticity/athetosis)
□ (3 pts) both upper and lower extremities (weakness/paralysis/spasticity/athetosis)
□ (0 pt) independent ambulator/ non-ambulatory/ immobile
Gait:
□ (1 pt) non-ambulatory/has bed mobility/has wheelchair mobility
□ (2 pts) independent ambulator with assistive device (i.e. walker/cane)
□ (3 pts) ambulatory with physical assistance and assistive device/unsteady gait
History of Falling Within Past 3 Months: □ (0 pt) None
□ (1 pt) near falls or fear of falling
□ (2 pts) 1-2 falls
□ (3 pts) multiple falls (more than 2)
Medications
□ Antihistamine
□ Antihypertensives
□ Antiseizure/Antiepileptic
□ Benzodiazepines
□ Cathartics
□ Diuretics
□ Hypoglycemic agents
□ Psychotropics
□ Sedatives/Hypnotics
□ Narcotics
□ Other
On the above medication groups, indicate how many the resident is currently taking:
□ (0 pts) No medications □ (1 pt) 1 medication □ (2 pts) 2 medications □ (3 pts) 3 or more
Total Score:
0- 9 points: Low risk
10- 17 Moderate risk
18 or more: High risk
If the person scores 10 or more: safety support should be implemented and reflected in the ELP.
6/5/2015
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