The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

1. Fax Cover Sheet

Facility: _______Greystone_Manor____________________
Address: _________1254_Martin Lane________________
City/State: ______Wilkes,_TN_04321_________________
Telephone: ______(423)_403-4881___________________
Fax: ______(423)_403-3312________________________

Date: ____4_____ / _____4____ / ____04____

Primary Care Provider: _____Dr._Tom_Roberts_______________ Fax #: __(432)_311-4054__

Resident Name: __________Mrs. P___________________ Unit/Room: ___401-A____________

This resident was identified in our Falls Management Program as having a high risk of falls, and underwent a Falls Assessment per our protocol. Attached are the following:

1. Falls Assessment Report and suggestions for further assessment and/or intervention.
2. A form for you to Fax Back Orders on which you can indicate those that you select for this resident.

Please review the Falls Assessment Report and return the Fax Back Orders form the next business day. Thank you.

Falls Coordinator: _____Susan_Brown_LPN__________________ Phone number: __(423)_403-4881__

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