AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Electronic Reports
Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit
On-Time Quarterly Summary of Falls Risk Factors by Unit
Nursing Unit: ________________________________________________________________
Date: ___/___/___
High-Risk Existing Conditions | |||||||
---|---|---|---|---|---|---|---|
Mental: Unsafe Behaviors |
Mental: Cognitive Impairment |
Gait and Balance Instability |
Fall: 8-30 Days |
Fall: 31-180 Days |
Psychoactive Medications |
Other High-Risk Medications |
|
Apr-11 | |||||||
# falls | 7 | 9 | 8 | 4 | 6 | 7 | 4 |
% (of monthly total falls) | 44 | 56 | 50 | 25 | 38 | 44 | 25 |
May-11 | |||||||
# falls | 5 | 5 | 6 | 4 | 5 | 5 | 4 |
% (of monthly total falls) | 45 | 45 | 55 | 36 | 45 | 45 | 36 |
Jun-11 | |||||||
# falls | 5 | 7 | 7 | 2 | 0 | 6 | 6 |
% (of monthly total falls) | 36 | 50 | 50 | 14 | 0 | 43 | 43 |
Unit Quarterly TOTALS | |||||||
# falls | 17 | 21 | 21 | 10 | 11 | 18 | 14 |
% (of quarterly total falls) | 41 | 51 | 51 | 24 | 27 | 44 | 34 |
Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit (continued)
High-Risk Change in Condition | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Acute Mental Status Change | Behavior: New Unsafe |
New Gait/Balance or Device Order |
New Fall | Med: New Med or Dose Change | Orthostatic Hypotension/ Dehydration |
Vertigo/ Dizziness |
Syncope/ Fainting |
Hypogly- cemia |
Possible Infection | New Seizure Activity |
New Admission | |
Apr-11 | ||||||||||||
# falls | 1 | 0 | 0 | 4 | 2 | 8 | 2 | 2 | 0 | 1 | 0 | 3 |
% (of monthly total falls) | 6 | 0 | 0 | 25 | 13 | 50 | 13 | 13 | 0 | 6 | 0 | 19 |
May-11 | ||||||||||||
# falls | 1 | 0 | 0 | 5 | 2 | 4 | 0 | 2 | 0 | 2 | 0 | 1 |
% (of monthly total falls) | 9 | 0 | 0 | 45 | 18 | 36 | 0 | 18 | 0 | 18 | 0 | 9 |
Jun-11 | ||||||||||||
# falls | 1 | 0 | 0 | 3 | 0 | 5 | 2 | 2 | 0 | 1 | 0 | 1 |
% (of monthly total falls) | 7 | 0 | 0 | 21 | 0 | 36 | 14 | 14 | 0 | 7 | 0 | 7 |
Unit Quarterly TOTALS | ||||||||||||
# falls | 3 | 0 | 0 | 12 | 4 | 17 | 4 | 6 | 0 | 4 | 0 | 5 |
% (of quarterly total falls) | 7 | 0 | 0 | 29 | 10 | 41 | 10 | 15 | 0 | 10 | 0 | 12 |
Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit (continued)
New Contributing Risk Factor | Additional Info Within 30 Days | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Pain: New or Uncontrolled chronic |
Urinary Incontinence: New or Increase |
Mobility: More Independent | Room Change | Bed Mobility | Transfer | Toileting | Depression Score | Monthly BMI <18.5 kg/m2 |
Significant Wt Change | Vitamin D Order | Osteoporosis | Diabetes | Visual Impairment | |
Apr-11 | ||||||||||||||
# falls | 1 | 3 | 2 | 6 | 0 | 2 | 3 | 2 | 3 | 2 | 1 | 1 | 6 | 8 |
% (of monthly total falls) | 6 | 19 | 13 | 38 | 0 | 13 | 19 | 13 | 19 | 13 | 6 | 6 | 38 | 50 |
May-11 | ||||||||||||||
# falls | 1 | 3 | 0 | 3 | 0 | 2 | 2 | 3 | 3 | 1 | 1 | 1 | 6 | 4 |
% (of monthly total falls) | 9 | 27 | 0 | 27 | 0 | 18 | 18 | 27 | 27 | 9 | 9 | 9 | 55 | 36 |
Jun-11 | ||||||||||||||
# falls | 1 | 1 | 2 | 3 | 0 | 2 | 4 | 2 | 0 | 0 | 2 | 1 | 6 | 4 |
% (of monthly total falls) | 7 | 7 | 14 | 21 | 0 | 14 | 29 | 14 | 0 | 0 | 14 | 7 | 43 | 29 |
Unit Quarterly TOTALS | ||||||||||||||
# falls | 3 | 7 | 4 | 12 | 0 | 6 | 9 | 7 | 6 | 3 | 4 | 3 | 18 | 16 |
% (of quarterly total falls) | 7 | 17 | 10 | 29 | 0 | 15 | 22 | 17 | 15 | 7 | 10 | 7 | 44 | 39 |
Table 4. Sample Quarterly Summary of Falls Risk Factors by Unit (continued)
Injury | Totals | ||||
---|---|---|---|---|---|
Fall With Major Injury |
Fall With Minor Injury |
Total Residents Who Fell |
Total Residents With >1 Fall |
Total Falls |
|
Apr-11 | |||||
# falls | 3 | 13 | 11 | 3 | 16 |
% (of monthly total falls) | 19 | 81 | |||
May-11 | |||||
# falls | 2 | 9 | 10 | 1 | 11 |
% (of monthly total falls) | 18 | 82 | |||
Jun-11 | |||||
# falls | 1 | 13 | 9 | 3 | 14 |
% (of monthly total falls) | 7 | 93 | |||
Unit Quarterly TOTALS | |||||
# falls | 6 | 35 | 30 | 7 | 41 |
% (of quarterly total falls) | 15 | 85 |