Fall Risk Assessment Form

  • Date Format: MM slash DD slash YYYY
    PARAMETER:
    A. Level of Consciousness/Mental Status

    RESIDENT STATUS/CONDITION & SCORE
    ALERT (oriented X 3) OR COMATOSE = 0
    DISORIENT:ED X 3 at all limes = 2
    INTERMITTENT CONFUSION = 4
  • PARAMETER:
    B. History of Falls (past 3 months)

    RESIDENT STATUS/CONDITION & SCORE
    NO FALLS in past 3 months = 0
    1-2 FALLS in past 3 months = 2
    3 OR MORE FALLS in past 3 months = 4
  • PARAMETER:
    C. Ambulation/ Elimination Status

    RESIDENT STATUS/CONDITION & SCORE
    AMBULATORY/CONTINENT = 0
    CHAIR BOUND -Requires restraints and assist with elimination = 2
    AMBULATORY/INCONTINENT = 4
  • PARAMETER:
    D. VISION STATUS

    RESIDENT STATUS/CONDITION & SCORE
    ADEQUATE 9 (with or without glasss) = 0
    POOR (wilh or witihou t glasses) = 2
    LEGALLY BLIND = 4
  • PARAMETER:
    E. Gait/Balance

    To assess the resident'sGait/Balance, Have him/her stand on both feet without holding onto anything;walk straight forward; walk through a doorway; and make a turn.

    RESIDENT STATUS/CONDITION & SCORE
    Gait/Balance normal = 0
    Balance problem while standing = 1
    Balance problem while walking = 1
    Decrease muscular coordination = 1
    Change in gait pattern when walking through doorway = 1
    Jerking or unstable when making turns = 1
    Requires use of assistive devices (i.e.cane, w/c, walker, furniture) = 1
  • PARAMETER:
    F. Systolic Blood Pressure

    RESIDENT STATUS/CONDITION & SCORE
    NO NOTED DROP between lying and standing = 0
    Drop LESS THAN 20 mm HG between lying and standing = 2
    Drop LESS THAN 20 mm HG between lying and standing = 4
  • PARAMETER:
    G. Medications

    Respond below based on the following types or medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics,Psychotropics, Sedatives/Hypnotics.

    RESIDENT STATUS/CONDITION & SCORE
    NONE of these medications taken currently or within last 7 days = 0
    TAKES 1-2 of these medications currently and/or within last 7 days = 2
    TAKES 3-4 of these medications currently and/or within last 7 days = 4
  • If a resident has had a change in medications and/or change in dosage in the past 5 days = score additional point = 1
  • PARAMETER:
    H. Predisposing Diseases

    Respond below based on the following predisposing conditions: Hypotension, Vertigo, CVA, Parkinsons's disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, Fractures

    RESIDENT STATUS/CONDITION & SCORE
    NONE PRESENT = 0
    1 - 2 PRESENT = 2
    3 OR MORE PRESENT = 4
  • Total Score of 10 or above represents HIGH RISK