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Working together to prevent fall

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					 Individual environmental
 and equipment checklist

                                              Working together to prevent falls




Environmental checklist developed by: Peninsula Health Falls Prevention Service
The thee-page individual environmental and equipment checklist, developed by the Peninsula Health
Falls Prevention Service, complements the general environmental assessment.                    It is a
comprehensive tool that considers the resident’s bedroom and bathroom/toilet as well as mobility
aids, personal aids, wheelchairs, beds, chairs/commodes, mobile furniture, call-buttons, footstools,
footwear, clothing and orientation. It has an action plan for staff to detail what actions are required
to minimise the identified environmental risks and whether they have been completed or not.
                                                                                       (Downloadable)


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In 2005 the Department of Human Services funded the National Ageing Research Institute to review and
recommend a set of falls prevention resources for general use. The materials used as the basis for this
generic resource were developed by the Peninsula Health Falls Prevention Service under a Service
Agreement with the Department of Human Services. This and other falls prevention resources are available
from the department’s Aged Care website at: http://www.health.vic.gov.au/agedcare.
                                                        Working together to prevent falls

                                                        UR ……………………………..…………………....

                 INDIVIDUAL                             SURNAME …………………………………………
                                                        GIVEN NAMES ………………………………….…
  ENVIRONMENTAL & EQUIPMENT
                                                        DOB …………………………………………………
                  CHECKLIST                             Fill in if no resident label available


                  To be completed as part of assessment for resident needs
                                           (Please Tick Appropriate Response)                    Yes   No   N/A
Bedroom:
General environment issues assessed and is adequate*
        Flooring
        Circulation
        Visibility
        Lighting
        Rails
Bedspreads clear from floor
Bathroom/toilet:
Non-slip flooring
Step-less shower base
Room for seat near to shower
Room for seat in shower
Rail in shower/near toilet
Lightweight door/easy to use
General environmental issues assessed and is adequate*
        Flooring
        Circulation
        Visibility
        Lighting
        Rails

* Note: Use the ‘General Environmental Checklist’ to assess adequacy of flooring, circulation,
visibility, lighting & rails.

                                             (Please Tick Appropriate Response)                  Yes   No   N/A
Mobility aid (if used):
        Condition: Rubber tips in good condition
                    Absence of rust or metal fatigue
                    Brakes, if present, working and in good condition
              Use: Appropriate height for resident
                    Known recent review of type of aid to suit needs
Personal aids:
              Use: Long handled aids provided and accessible, if required
                    Resident able to use
Wheelchair (if used):
        Condition: Brakes working and in good condition
                    Footplates easy to move
                    Tyres with good tread, wheels move freely (not buckled)
              Use: Suitable for the intended person
                    Used safely by resident as intended
                    Resident educated re: wheelchair safety
Beds:
        Condition: All brakes working properly
              Use: Appropriate height for individual

                                                                                          Continued overleaf
                                            (Please Tick Appropriate Response)   Yes   No   N/A
Chairs/commodes:
        Condition: Arms well secured
              Use: Chair/commode height and design appropriate for
                   individual
                   Person can rise/sit with ease
                   Base of support is adequate to prevent tipping sideways
                   Commode recommended
Mobile furniture/shower chairs/over-bed frames etc:
        Condition: Rolls easily
                   Brakes/wheels regularly maintained
                   All mobile aids of adequate design to prevent tipping
              Use: Resident instructed not to lean on mobile furniture (or
                   furniture removed)
                   Stored in separate area when not in use
Call-Buttons:
        Condition: In reliable working order
              Use: Button easy to push/resident knows how to use
                   Within easy reach when lying in bed
                   Accessible from sitting position in toilet/shower
Footstools:
        Condition: In good repair, stoppers in good condition
              Use: Person can safely move the footstool before transferring
                   Person can reach footstool when required
                   Out of walkway when not in use

                                           (Please Tick Appropriate Response)    Yes   No   N/A
Other issues:
Footwear:           Appropriate/safe; non-slip sole; wide heels.
Clothing:           Not too long
Lighting:           Lighting sufficient for night toileting
Orientation;        Resident can read signs/knows where toilet is from bed
                    etc
                    Extra signs/strategies required to aid orientation


                 Note: A No response indicates action is needed.
                              Complete the Action Plan overleaf.
Action Plan:

ACTION/S REQUIRED:                                                                 BY WHOM                    Completed:
                                                                                                              (Date & Sign)




Any additional comments:




Assessed by: _____________________________________________                                       Date: _________________



In 2005 the Department of Human Services funded the National Ageing Research Institute to review and recommend a set of falls
prevention resources for general use. The materials used as the basis for this generic resource were developed by the Peninsula Health
Falls Prevention Service under a Service Agreement with the Department of Human Services. This and other falls prevention resources are
available from the department’s Aged Care website at: http://www.health.vic.gov.au/agedcare.

				
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