Fall Risk Assessment Checklist

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FALL RISK ASSESSMENT
PARAMETER
SCORE
RESIDENT STATUS/CONDITION
1
2
3
4
A
0
ALERT – (oriented x 3) or COMATOSE
Level of
2
DISORIENTED x 3 at all times
Consciousness/
4
INTERMITTENT CONFUSION
Mental Status
B
0
NO FALLS in the past 3 months
History of Falls
2
1-2 FALLS in past 3 months
(past 3 months)
4
3 OR MORE FALLS in past 3 months
C
0
AMBULATORY/CONTINENT
Ambulatory &
2
CHAIR BOUND – may require assistance with elimination
Elimination
4
AMBULATORY/INCONTINENT
Status
D
0
ADEQUATE (with or without glasses)
Vision
2
POOR (with or without glasses)
Status
4
LEGALLY BLIND
E
To assess the resident’s Gait/Balance, have him/her stand on both feet without holding onto anything;
walk straight forward; walk through a doorway; make a turn.
Gait/Balance
0
GAIT/BALANCE normal
If total is
1
Balance problem while standing
greater than 1
1
Balance problem while walking
– refer to
1
Decreased muscular coordination
Rehab Dept.
for screening
1
Change in gait pattern while walking through doorway
1
Jerking or unstable when making turns
1
Requires use of assistive devices
(i.e., cane, w/c, walker, furniture)
F
0
NO NOTED DROP between lying and standing
Systolic
2
Drop LESS THAN 20mm Hg between lying and standing
Blood
4
Drop MORE THAN 20 mm Hg between lying and standing
Pressure
G
Respond below based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizures,
Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics.
Medications
0
NONE
of these medications taken currently or within past 7 days
If total is
greater than 2
2
TAKES 1-2 of these meds currently and/or within past 7 days
– refer to
4
TAKES 3-4 of these meds currently and/or within past 7 days
physician or
pharmacy
1
If resident has had a change in medication and/or change in
consultant for
dosage in the past 5 days – score 1 additional point
assessment.
H
Respond below based on the following predisposing conditions: Hypotension, Vertigo, CVA, Parkinson’s,
Loss of Limb(s), Arthritis, Osteoporosis, Fractures.
Predisposing
0
NONE PRESENT
Conditions or
Diseases
2
1-2 PRESENT
4
3 OR MORE PRESENT
TOTAL SCORES
ASSESSMENT
SIGNATURE/TITLE
DATE
ASSESSMENT
SIGNATURE/TITLE
DATE
1.
3.
2.
4.
RESIDENT NAME: ________________________________________________
Room # __________
FALL RISK ASSESSMENT
PARAMETER
SCORE
RESIDENT STATUS/CONDITION
1
2
3
4
A
0
ALERT – (oriented x 3) or COMATOSE
Level of
2
DISORIENTED x 3 at all times
Consciousness/
4
INTERMITTENT CONFUSION
Mental Status
B
0
NO FALLS in the past 3 months
History of Falls
2
1-2 FALLS in past 3 months
(past 3 months)
4
3 OR MORE FALLS in past 3 months
C
0
AMBULATORY/CONTINENT
Ambulatory &
2
CHAIR BOUND – may require assistance with elimination
Elimination
4
AMBULATORY/INCONTINENT
Status
D
0
ADEQUATE (with or without glasses)
Vision
2
POOR (with or without glasses)
Status
4
LEGALLY BLIND
E
To assess the resident’s Gait/Balance, have him/her stand on both feet without holding onto anything;
walk straight forward; walk through a doorway; make a turn.
Gait/Balance
0
GAIT/BALANCE normal
If total is
1
Balance problem while standing
greater than 1
1
Balance problem while walking
– refer to
1
Decreased muscular coordination
Rehab Dept.
for screening
1
Change in gait pattern while walking through doorway
1
Jerking or unstable when making turns
1
Requires use of assistive devices
(i.e., cane, w/c, walker, furniture)
F
0
NO NOTED DROP between lying and standing
Systolic
2
Drop LESS THAN 20mm Hg between lying and standing
Blood
4
Drop MORE THAN 20 mm Hg between lying and standing
Pressure
G
Respond below based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizures,
Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics.
Medications
0
NONE
of these medications taken currently or within past 7 days
If total is
greater than 2
2
TAKES 1-2 of these meds currently and/or within past 7 days
– refer to
4
TAKES 3-4 of these meds currently and/or within past 7 days
physician or
pharmacy
1
If resident has had a change in medication and/or change in
consultant for
dosage in the past 5 days – score 1 additional point
assessment.
H
Respond below based on the following predisposing conditions: Hypotension, Vertigo, CVA, Parkinson’s,
Loss of Limb(s), Arthritis, Osteoporosis, Fractures.
Predisposing
0
NONE PRESENT
Conditions or
Diseases
2
1-2 PRESENT
4
3 OR MORE PRESENT
TOTAL SCORES
ASSESSMENT
SIGNATURE/TITLE
DATE
ASSESSMENT
SIGNATURE/TITLE
DATE
1.
3.
2.
4.
RESIDENT NAME: ________________________________________________
Room # __________

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