Transcription of QA: Post Fall Investigation Report - Home - Primaris
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QA: Post Fall Investigation Report - Home - Primaris
QA: post fall Investigation Report Resident name:_____ Room #:_____. Social Security #:_ _____Date of incident:_____ Time of incident:_____. Staff completing Report :_____Date of Report :_____. 1. Does the resident have a history of falls? o Yes o No If yes, list falls for the past 12 months: Date: _____ Time:_____ o AM o PM. Date:_ _____ Time:_____ o AM o PM. Date:_ _____ Time:_____ o AM o PM. Date:_ _____ Time:_____ o AM o PM. Date:_ _____ Time:_____ o AM o PM. Date:_ _____ Time:_____ o AM o PM. 2. Was the resident identified on the care plan as high risk for a fall ? o Yes o No 3. Do you see any patterns with falls? (Check all that apply.). o Greater than 2 falls in the past 2 days o Increased restlessness o Going to the bathroom o Time of day o Specific activity o Location o Physical Factor (shoes, etc.) o Other _____.
QA: Post Fall Investigation Report (page 2) Document available at www.primaris.org MO-08-42-REST August 2008 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.
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