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The Falls Management Program

Nursing Inspection List (Text Description)

Write the unit name, date, and room numbers across the top line. Put the bed number or letter across the second line and sign it. Put a √ under the room number and bed beside all the tasks that need to be done. Write notes about special problems or add details in the Notes column.

Unit Date: Room Number:               Notes:
Signature: Bed:                              
1. Paths Remove unused equipment (canes/walkers).                              
Instruct SW to ask family to remove unused items.                              
If bedside commode is unused, ask staff to remove it.                              
With resident's permission, rearrange room to clear paths.                              
Instruct staff to keep paths clear.                              
Instruct staff to keep overbed table across bed.                              
Remove unused items from bathroom and store elsewhere.                              
2. Furniture Instruct nursing staff and housekeepers to keep bed in locked position except during care or cleaning.                              
Replace unstable bed with a stable one.                              
Push bed to wall (check local and state fire codes).                              
Remove all cardboard, lightweight, or unstable furniture.                              
Instruct SW to ask family to remove or replace unstable items.                              
3. Easy Access Arrange room so that items are within resident's reach.                              
Instruct staff to keep items within arm's length of patient.                              
Instruct staff to place cane, walker, or w/c within safe reach.                              
5. Floor Instruct staff to wipe up all spills quickly.                              
7. Foot Care and Footwear Ask nurse for podiatry consult.                              
Instruct staff and resident to use specific shoes/slippers.                              
Instruct staff and resident to use nonskid socks.                              
Instruct SW to ask family to provide safe footwear.                              

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Engineer Inspection List (Text Description)

For the person doing the inspect: Label this form and fill it out in the same way as for the Nursing Inspection List.

For the Falls Engineer: A member of nursing staff has checked resident rooms and equipment for safety problems. This is the list of things they have found that you need to inspect and repair. Please do all the tasks that have a √ beside them for each room and bed number. Safety problems in common areas and with common equipment are listed on the back of this page. Refer to the Falls Engineer Instructions for details about how to do each task.

Unit Date: Room Number:               Notes:
Signature: Bed:                              
1. Paths 1. Make tiebacks for divider curtains.                              
2. Tie electrical cords out of path (TV, phone, heater).                              
2. Furniture 3. Clean, repair, or replace broken bed wheel locks.                              
4. Fix unstable furniture.                              
5. Secure loose bathroom handrails.                              
6. Replace missing rubber tips on bedside commode.                              
7. Replace missing rubber tips on handrails that rest on floor.                              
8. Secure raised toilet seat to commode.                              
4. Lighting 9. Replace burned out or flickering bulbs. Use max wattage.                              
10. Repair broken room lights or call lights.                              
11. Replace broken call light cords or lengthen cords.                              
5. Floor 12. Repair or replace floor covering.                              
13. Replace high, broken, or missing thresholds.                              
14. Add grading to thresholds between room and bathroom.                              
6. Equipment 15. Inspect wheelchair (for all wheelchairs found).                              
16. Repair cane.                              
17. Repair walker.                              

 

Safety Problems in Common Areas With Common Equipment:

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