A&I - Fall Investigation/Assessment Tool (Confidential Peer Review/Quality Improvement Document)
Fall Investigation/Assessment Tool
Standard
All falls occurring on the facility’s premises must be reported, documented, and thoroughly investigated to ensure the safety and well-being of residents, in compliance with CMS Requirements of Participation and the State Operations Manual (SOM) guidelines for long-term care facilities (LTC).
Policy
To ensure prompt and thorough investigation of any fall, identify contributing factors, and implement measures to prevent recurrence, maintaining a safe environment for residents.
Practice Guidelines
Fall Investigation/Assessment Tool
(Confidential Peer Review/Quality Improvement Document)
Resident Name: _________________________________________________
Date of Incident: ___________________________
Time of Incident: ______________
Vital Signs:
BP Sitting: __________________
BP Standing: ____________________
OR
BP Lying: ___________________
BP Sitting: ______________________
CNA Assigned: ___________________________
Nurse Assigned: _________________________
Resident Interview:
(What does the resident state happened?)
Witnessed: ☐ No ☐ Yes
Name(s) of Witnesses: ____________________
What do you think the resident was trying to do?
(Interview staff and obtain statements as needed.)
When was the resident last seen? ______________________
By Whom? _______________________
Time last toileted? ____________________
Potential or Actual Cause(s) of Fall:
(Consider listed causative factors on back page and give the rationale for your response/analysis.)
Intervention:
CNA Card Updated? ☐ Yes ☐ No
Care Plan Updated? ☐ Yes ☐ No
Nurse Signature: ____________________________________
Date: __________________________
Supervisor Signature: _______________________________
Date: __________________________
Documentation and Investigation Action:
-
The charge nurse and/or department director/supervisor must document the incident and conduct an immediate investigation.
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Use the specified Fall Investigation/Assessment Tool for documentation.
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Witnesses, if any, must be documented on the report along with their contact information.
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The Administrator and Director of Nursing Services (DNS) must be informed of all falls and review completed reports.
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If the fall is of a serious nature, it shall be reported by telephone regardless of the time or day. Follow the policy/procedure for Reporting to Government Agencies and Investigation of Abuse Practice Guidelines.
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The Administrator must notify the Director of Clinical Services and Director of Operations immediately, regardless of the time of day, if the fall is of a serious nature.
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The Administrator will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstances of the incident.
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The Administrator is responsible for coordinating the investigation and assuring appropriate action is taken, including conducting interviews and collecting written statements from all staff involved.
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Completed Fall Investigation/Assessment Tool and Investigation forms must be submitted within 24 hours to the Administrator and DNS.
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Documentation in the Nurse's Notes is done timely.
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The resident is monitored for 72 hours post-incident with Nurse's Notes every shift, including vital signs and documentation of any ill effects.
References:
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Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM)
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Requirements of Participation for Nursing Homes, CMS
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Guidelines for Fall Investigation and Reporting, CMS
