Fall Interventions Plan (Text Description)
Resident: ____________________________________________ Room: ___________________
Directions: Check all interventions that apply.
Risk Factor: Medications |
Risk Factor: Mobility |
Selected Interventions
For changes in psychotropic meds:
__ Monitor and report changes in anxiety, sleep patterns, behavior, or mood
__ Monitor and report drug side effects
__ Behavior management strategies
__ Sleep hygiene measures
__ no caffeine after 4 p.m.
__ up at night with supervision
__ comfort measures
__ pain management
__ regular exercise, limit napping
__ relaxing bed routine
__ individualized toileting at night
__ safe bathroom routine
For changes in digoxin:
__ Monitor apical heart rate; if <50, notify PCP. |
Selected Interventions
__ Increase staff assistance
__ early morning
__ to and from toilet
__ during all transfers
__ during ambulation
__ other: ________________________
__ Correct height of bed, toilet, or chair
__ Keep bed at correct height as marked on footrest or wall
__ Use raised toilet seat
__ Use cushion in lounge chair
__ Lower lounge chair
__ Increase bathroom safety
__ Use adequate handrail support
__ Use easy to manage clothing
__ Promote wheelchair safety
__ Use individualized, labeled wheelchair
__ Check brakes and instruct pt on use
__ Seating modifications
__ Use all prescribed seating items
__ Other: _______________________________ |
Risk Factor: Orthostatic Hypotension |
Risk Factor: Unsafe Behavior |
Selected Interventions
__ Low blood pressure precautions
__ Instruct pt to change position slowly
__ Instruct pt to sit on edge of bed and dangle feet before standing
__ Instruct pt to use dorsiflexion before standing
__ Instruct pt not to tilt head backwards
__ Provide staff assistance in early AM and after meals
__ If medication change:
__ Take postural VS __ day X 3 days. If systolic drops ≥20 mm Hg on day 3, notify PCP
__ Promote adequate hydration
__ TED hose
__ Other: _________________________________ |
Selected Interventions
__ Behavior management strategies
__ Increase assistance and surveillance
__ Position or pressure change alarm
__ Movement sensor
__ Locate patient near station
__ Intercom
__ Toilet at regular intervals
__ Increase activities involvement
__ Other ___________________________
__ Reduce risk of injury
__ Low bed
__ Floor mat
__ Helmet, wrist guards, hip protectors
__ Nonslip mat
__ Nonskid strips or nonskid rug
__ Nonskid socks
__ Lower or remove side rails
__ Increase comfort
__ Pain management
__ Frequent rest periods
__ Recliner or chair with deep seat
__ Rocking chair
__ Wheelchair seating items
__ Exercise
__ Cradle mattress
__ Sheepskin, air mattress or pillows
__ Other: _________________________________ |
Risk Factor: Vision |
Selected Interventions
__ Low vision precautions
__ Use maximum wattage allowed by fixture
__ Increase lighting in room
__ Use adequate lighting at night
__ Add high-contrast strips on stairs, curbs, etc.
__ Use signs with large letters or pictures
__ Use high contrast to offset visual targets
__ Reduce glare
__ Corrective lenses
__ Keep eyewear within easy reach at all times
__ Encourage patient to wear glasses
__ Other: _________________________________ |
Signature: __________________________________________________ Date: ______________
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Fall Interventions Monitor (Text Description)
Resident: _____________________________________________ Room: ____________________
Directions: Monitor staff implementation and effectiveness of the Fall Intervention Plan each week. Revise interventions as needed and record below. Use one sheet for every 2 weeks.
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Date: |
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Date: |
Medications |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
|
Medications |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
|
Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
|
Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
|
Vision |
Are interventions effective: ___
Yes ___ No
Changes:
Comments:
|
Vision |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
|
Mobility |
Are interventions effective: ___ Yes ___ No
Changes:
Comments: |
Mobility |
Are interventions effective: ___ Yes ___ No
Changes:
Comments: |
Unsafe Behavior |
Are interventions effective: ___ Yes ___ No
Changes:
Comments: |
Unsafe Behavior |
Are interventions effective: ___ Yes ___ No
Changes:
Comments:
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Signature: _________________________________________ Date: ___________________________
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