Title Page
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Site conducted
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Conducted on
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Prepared by
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Quality Assurance Falls Committee Conveaned
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Initials of Resident who fell
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When did the fall occur?
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Where did the fall occur?
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Was the fall witnessed or unwitnessed?
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Was the Initial Neuro Checks Completed per policy?
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Was 1:1 Education Completed re: Neuro Checks with Falls
- Yes
- No
- N/A
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Employee's Name:
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Was there any injuries due to the fall?
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Would this be considered a Major Injury?
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Did the resident receive emergent care at another facility?
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Has the ER Record been uploaded into the Resident's Record?
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What event led to the fall of the resident?
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Why?
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Why?
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Why?
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Why?
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Why?
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What interventions were put into place to keep the resident safe and free from potential injury?
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Was the Care Plan Updated to reflect these interventions?
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Why not?
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Falls Score Updated?
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Did the score increase to a higher level of prevention needed?
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Root Cause #1
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Root Cause #2
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Root Cause #3
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To validate Root Causes, ask the following: If you removed this root cause, would this fall have been prevented?
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Please re-examine the interventions to prevent the root cause.
Untitled Page
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J Gerontol A Biol Sci, 2020, Vol. 75, No.5, 946-951 ; CMS Five Whys Tool for Root Cause Analysis - QAPI
