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. 

• Use the specified Fall Investigation/Assessment Tool for documentation. 

• Witnesses, if any, must be documented on the report along with their contact information. 

• The Administrator and Director of Nursing Services (DNS) must be informed of all falls and review completed reports. 

• 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. 

• 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. 

• The Administrator will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstances of the incident. 

• 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. 

• Completed Fall Investigation/Assessment Tool and Investigation forms must be submitted within 24 hours to the Administrator and DNS. 

• Documentation in the Nurse's Notes is done timely. 

• 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: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS 

• Guidelines for Fall Investigation and Reporting, CMS