Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Fall risk assessment
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On admission, fall risk assessment done
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Does the patient risk assessment reveals vulnerable category
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Oriented patient on fall prevention safety measures in the bedside - Side rails, Using Call bell
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Upon admission, education given on fall prevention to Patient & Attender and documented
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Ensure about Environment - Inadequate lighting, Wet Toilet Floor, Uncleared Clutters.
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Patient participation - Patient with no attendent, Pateint left the bed without asking for help, Unavailability of eye glasses, hearing aids
Accuracy of Checking in :
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Patient Information - Age more than 60, Language Barrier, Impaired Hearing,
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Clinical Information - History of Fall, Secondary diagnosis ≥ 2 Medical diagnosis in Chart ((Associated with incontinence, vision problems, Multiple Medicines, Orthostatic hypotension), Intravenous Therapy/ IV Channel
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Mental Status - Oriented at all times or Comatosed, Confused / Forgets / Over estimates limitations / Agitated,
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GAIT - Normal/Bed rest/Wheel Chair, Weak, Impaired
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Ambulatory Aid - Normal/Bed rest/Wheel Chair, Crutches/Cane/Walker, Furniture
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Defined the RISK - Low risk, Moderate Risk, High Risk.
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Every shift Fall risk assessment done & Documented
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Every shift Fall risk Prevention education done & got signed by Attender
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On Admission Assessment done By S/N
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Counter signed By I/C
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Is it Accuracy attained in admission Assessment.
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Number of staffs involved. & Their Names
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Findings :
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Detail of Spot Teaching
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Name & Sign of Staff who attined Non Compliance
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Name & Sign of Incharge.
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NAME & SIGNATURE OF AUDITOR
