FALL INCIDENT REPORT (Confidential in accordance with Title 38 U.S.C.

5705) DO NOT INCLUDE THIS FORM IN THE PATIENTS MEDICAL RECORD SECTION A: To be completed by clinical staff

Location at time of fall (ward, clinic, service, etc.): ___________________________ Date of fall: Time of fall(military):

Inpatient

Outpatient

Name of Physician/ARNP/PA notified: For inpatients, Date admitted/transferred to this ward: Description of the event, including any obvious fall-related injuries (e.g., head trauma, change in ROM, pain, bruises, lacerations) and describe what was patient doing or trying to do that may have contributed to the fall: Found on floor Staff lowered patient to floor Patient lowered self to floor

Was next of kin notified?

Yes

No (If no why not?)

Contributory Factors (check all that apply): Mobility: Cognitive & Functional factors: Up ad lib Bed rest Incontinent (circle appropriate choice(s): bowel or bladder) Wheelchair Ambulate with wheelchair Confused/memory impaired Ambulate with assistance Ambulate with walker Altered gait/balance Restraints Other_________________ Altered ADL Environmental/Equipment (check all that apply): Floor wet Lighting poor Needed item out of reach Cluttered area Foot wear Bed side rails (circle appropriate choice(s): all up or down 1 up (left right) top half up (left right) bottom half up (left right) Equipment faulty: Shower chair/commode chair Cane Walker Wheelchair Unavailable grab bars Stretcher Bed Other, please specify ____________________________________ Assistive Devices: Assistive Devices involved in fall? No Yes If Yes, please complete the following: Assistive device(s) not appropriate? No documentation of patient education in proper use? Needed transfer/mobility equipment NOT within reach? Equipment not correctly or safely used by patient? Other, please specify: ____________________________ Preventive Measures prior to incident (check all that apply): Interdisciplinary Fall Prevention Care Plan implemented & communicated to entire team Increase level of observation Fall Alert Identifier (e.g., green armband, signage, computer alert) Patient close to nurses station Motion alarm Call light/bell in reach Gait/Safety training Patient/family involved in care plan Witnessed/Reported by: Name: Position/Title: Report prepared by: Title: ADDRESSOGRAPH

VICE VA Form 10-2633-3

516

3/01

11QS

SECTION B: To be completed by nurse MORSE FALL SCALE Circle all that apply at the time of this fall CHOOSE HIGHEST APPLICABLE SCORE FROM EACH CATEGORY HISTORY OF FALLING NO 0 YES 25 SECONDARY DIAGNOSIS No 0 (more than one diagnosis) Yes 15 AMBULATORY AID None, on bedrest, uses W/C, or nurse assists 0 Crutches, cane(s), walker 15 Furniture 30 IV/HEPARIN LOCK OR SALINE PIID No 0 Yes 20 GAIT/TRANSFERRING Normal, on bedrest, immobile 0 Weak (uses touch for balance) 10 Impaired (unsteady, difficulty rising to stand) 20 MENTAL STATUS Oriented to own ability 0 Forgets limitation 15 Total Morse Fall Scale score at the time of fall (High Risk >50) Date of last fall assessment: Morse Fall Scale score at last assessment: Nursing physical assessment and examination findings (if not completed in Section A):

Date:

Signature and Title:

SECTION C: To be completed by Nurse Manager/Supervisor (check all that apply) Patient was not assessed for fall risk prior to falling Equipment was used incorrectly by: Patient Staff Staff needs education on the fall prevention protocol Restraints use was not monitored and documented Staff lack or misinterpreted information regarding patient care needs Staff distracted/interrupted Patient condition was not documented and communicated to staff Patient care environment/equipment unsafe or contributory to fall Maintenance program for involved equipment was not current Workload was a factor If yes, complete the following: Unit/area extremely busy Some staff worked overtime Float staff Change of shift Actual staff/patient ratio at time of fall _______ Corrective/Preventive measures taken to reduce risk of reoccurrence post fall: Patient/family education Staff education Nursing Care Plan revised Staffing adjusted Rehab Consultation Biomedical Engineering notified Patient placed in rehab program. Specify type_____________________________ Date: Signature and Title:

Equipment replaced/repaired Enhanced safety observation SPD notified Fall prevention team notified

Revised March 2001 (FALL INCIDENT REPORT)

SECTION D: To be completed by physician or individual, e.g. ARNP or PA with appropriate credentials Physical Assessment and Examination findings:

Rash/erythemia ROM impairment Change in LOC Change in mental status: Bruise(s) _________________________________________

Pain _________________________________________ Minor abrasion (s)______________________________ Bleeding _____________________________________ Laceration (s) _________________________________ Fracture (s)____________________________________

Injury from fall: No Injury Minor Injury Major Injury Death Post Fall Plan of Care: No follow-up indicated Lab ordered Keep under observation X-ray First aid given PM&RS consultation Pain Management Sutures________________________________________ Other____________________________________________ Date of exam: Time: Signature/Title: SECTION E: To be completed by Attending Physician (Review and Comment) Attending Physician Review/Comments:

Corrective/Preventive measures taken to reduce risk of reoccurrence: No change in treatment indicated Treatment Plan modified (How?) Medication adjusted _______________________________________________________________________________________ Date: Signature and Title:

Revised March 2001 (FALL INCIDENT REPORT)

SECTION E: Service Chief/SHG Leader: Please review the information regarding this incident and provide your comments, e.g. current status of patient, recommendations/action taken or no further action No further action indicated

Date: Chief of Staff: No further action

Signature and Title:

Investigation indicated: (check type)

Physician Peer Review Mortality & Morbidity Review Root Cause Analysis Administrative Board of Investigation Other (see comments)

Comments and recommendations:

This event is reportable to: (check all that applies) VISN Date reported: ______________________________ Date: Director: No further action required Comments: Signature:

VA Headquarters

JCAHO

Investigate incident and submit report and recommendations to me by (date) __________________.

Date: Risk Manager: Forwarded for ABI Case closed

Signature of Director:

Mortality & Morbidity Review Other (please specify)

Root Cause Analysis

Physician Peer Review

Date:

Signature:

Revised March 2001 (FALL INCIDENT REPORT)