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Post Fall Conference

Patient Number: / Date and time fall occurred:
Witness(es): / Patient attended by staff: Yes or No
Census at time of fall:
Was staffing adequate per guidelines: Yes No / # of staff on the unit at time of fall:
___Nurses ___Ancillary Staff ___Sitters___1:1 pts
Time of last round or patient visualization:
Time of last toileting: / On protocol: Yes or No
Interventions documented every two hours:
Yes or No
Last Fall Assessment Score:______
Time since last risk assessment:  > 0 to 12 hours  > 48 to 72 hours
 > 12 to 24 hours  > 72 hours to 1 week
 > 24 to 48 hours  > 1week
Admitting diagnosis: ______/ Pt. age: ______
Time of last VS:______Temp.______HR______RR______BP______
Medications patient received EIGHT hours prior to falltime given:
 Analgesic ______ Antihypertensive ______Benzodiazepine ______
 Cardiovascular ______ Antihistamine ______
 Antipsychotic ______ Sedative/Hypnotic ______
 Anticonvulsant ______ Diuretic ______
 Laxative ______ Anti-HYPOtensive ______
 Narcotic ______ Tricyclic Antidepressant ______
 Anticholinergic ______ New medication(s) w/ in past 24 hours
Please list new medications:
  • ______
  • ______

Identify reason for fall:
 Medication
 Environment
 Health
 Assisted fall
 BR or BSC related
Staff continually present at pt. side while
up to BR/BSC
 Found on floor. Indicate where found: ______
 Other______
______/ Contributing factors:
 Sensory impairment:
Neuropathy Dementia Depression Vision Hearing
Other:______
 Dizziness/vertigo
 Anticoagulant med./bleeding disorder
 Weakness
 Non-compliance
 Altered elimination ______
 Procedure within last 24 hours
 Receiving dialysis
 Depression
Interventions in place at time of fall:
 Bed in lowest position
 Yellow ID band
 Non-slip slippers on feet
Treads in proper position
 Bed alarm on
 Sign on door
 Other: ______/ Additional safety measures implemented:
______
______
______
______
______
______
Description of how patient was found:
______
Patient comment on why fall occurred:
______
______
Family notified: Yes or No / Physician notified: Yes or No
Level of injury as a result of the fall:
None
Minor (1)= Injuries that involve little or no care, formal intervention or observation such as abrasions,
contusions, small skin tears, or minor lacerations that do not require suture.
Moderate (2)= Injuries that require some medical and/or nursing intervention or observation. These
include sprains, large or deep lacerations, skin tears, or minor contusions that require ice packs, ace wraps,
suture, or splints.
Severe (3)= Injuries that require medical intervention or consultation. These include fractures, loss of consciousness, changes in mental or physical status, or death.
Do you think this fall could have been prevented? If so, how?
______
______
______
Staff members involved in post fall conference:
______
______
Additional comments:
______
______
If a fall resulted in the head being struck then the following should be completed: Family notified and explained the additional testing, neuro checks q 15 minutes X 1 hour, q 30 minutes X 2 hours, q 1 hour X 4 hours, q 4 hours X 24 hours, Physician notified with orders for Head CT
Form completed by: Date: