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Provided by the MU MDS and Quality Research Team August 2010
RESIDENT FALL RISK AND PREDICTION - DATA RETRIEVAL WORKSHEET
Date: ______________ Nurse Completing Audit: ____________________________
Unit: _______________ Shift Completed: __________________________________
Falls and fall risk can be symptoms of multiple disease processes and should be
seriously considered with any assessment. A program that includes policies and
procedures to identify residents who are at risk of falls immediately after admission and
ongoing during their stay should be present in any formal care setting. Components
include identification of risk level, areas of and reasons for increased risk. An
interdisciplinary approach including the resident and direct care workers whenever
possible must be used to design and implement individualized interventions based on
assessment findings. Good ongoing communication, feedback and teamwork are
essential to the success of any fall risk prevention program.
Observation=O, Record Review=RR, Interview=I, Assessment=A
Type of
Data
Retrieval Monitoring Criteria Y/N N/A Incomplete Comments
A, O, RR, I 1. All residents are evaluated for
fall risk on admission, quarterly,
with new fall episode, and with
change in status
A, O, RR, I 2. Immediately on admission,
quarterly, with fall or change,
evidence based fall-risk scales
are part of overall process to
identify residents at risk, their
areas of risk, and changes in
risk factors/level. Use general
tools for general information,
specific tools for specific
problems/information:
a. Examples
1. Morse
2. RCCT
3. Tinetti Balance Subscale
4. Berg Balance Scale
5. MDS Section G0300
6. Hendrich II
A, O, RR, I 3. Resident evaluation includes
a. underlying conditions
b. functional status
c. neurological status
d. psychological factors
e. environmental factors
