Nursing Home Fall Analysis Log by OEaV10

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									Fall Tracking Instructions
This tool is designed to help you track the number of falls per month for your entire nursing home as well as
for specific locations. The first tab following this instructions tab is designated for the ENTIRE home. Following
that tab are a series of other tabs that can be assigned to different customized locations. Follow the
instructions below to easily utilize and customize this tracking tool.
If you have any questions please contact Alexis Roam at aroam@primaris.org.


To Track Falls:
1) Enter information for each resident who experiences a fall. Each fall should be entered as a separate entry. Be
sure to fill out each row in its entirety.

2) Review the spreasheet during each fall investigation, weekly fall meetings and quality assurance meetings
related to falls to determine any recurring issues that could be remedied.




To Customize for Specific Locations:


1) To ADD additional rows: click "Insert", "Insert Sheet Rows".

2) To ADD additional tabs: Right-click on last location tab and select "Move or Copy." Scroll down to "(move to
end)" and check the box that states, "Create a Copy."

2) To CHANGE TAB NAME to indicate location name: Double-click on tab and retype name.




MO-12-03-REST March 2012 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri,
under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
The contents presented do not necessarily reflect CMS policy.
Fall: Analysis Log
Name of Facility: _______________________________ __________________
     Resident Name        Date                                 Time          Place                Place          Fall w/i 5 Ft        Injury                Injury         Contributing Factor   Factor - Environment      Contributing Factor      Factor - Internal     Unmet Need             Unmet Need
                                      Month      Weekday
       (Last, First)   (mm/dd/yyyy)                          (hh:mm)   (Click to Select)   (If Other, Specify)   of Transfer     (Click to Select)   (If Other, Specify)     - Environment -       (If Other, Specify)         - Internal -        (If Other, Specify)   (Click to Select)   (If Other, Specify)

        Doe, Jane       1/20/2012     January    Wednesday   1:30 PM   Resident room                                 Yes              Bruise                                  Low lighting                               Orthostatic hypotension                              Toilet
      Brown, John       2/10/2012     February     Friday    5:15 AM      Bathroom                                    No             Fracture                                  Slick floor                                      Balance                                       Toilet




                                                                                                                                                              MO-12-03-REST
Fall: Analysis Log
Name of Facility: _______________________________ __________________
     Resident Name        Date                              Time             Place                Place          Fall w/i 5 Ft        Injury                Injury         Contributing Factor   Factor - Environment    Contributing Factor    Factor - Internal     Unmet Need             Unmet Need
                                      Month     Weekday
       (Last, First)   (mm/dd/yyyy)                       (hh:mm)      (Click to Select)   (If Other, Specify)   of Transfer     (Click to Select)   (If Other, Specify)     - Environment -       (If Other, Specify)       - Internal -      (If Other, Specify)   (Click to Select)   (If Other, Specify)




                                                                                                                                                              MO-12-03-REST
Fall: Analysis Log
Name of Facility: _______________________________ __________________
     Resident Name        Date                              Time             Place                Place          Fall w/i 5 Ft        Injury                Injury         Contributing Factor   Factor - Environment    Contributing Factor    Factor - Internal     Unmet Need             Unmet Need
                                      Month     Weekday
       (Last, First)   (mm/dd/yyyy)                       (hh:mm)      (Click to Select)   (If Other, Specify)   of Transfer     (Click to Select)   (If Other, Specify)     - Environment -       (If Other, Specify)       - Internal -      (If Other, Specify)   (Click to Select)   (If Other, Specify)




                                                                                                                                                              MO-12-03-REST

								
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