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

Appendix B12: Fall Interventions Monitor

Fall Interventions Monitor Form. Text Description is below.

Text Description

Resident: _____________________________________________   Room: ____________________

Directions: Monitor staff implementation and effectiveness of the Fall Intervention Plan each week. Revise interventions as needed and record below. Use one sheet for every 2 weeks.

  Date:   Date:
Medications

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

 Medications

Are interventions effective: ___ Yes ___ No

Changes:

Comments:
Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

 Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments:
Vision

Are interventions effective: ___
Yes ___ No
Changes:

Comments:

 Vision

Are interventions effective: ___ Yes ___ No

Changes:

Comments:
Mobility

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

 Mobility

Are interventions effective: ___ Yes ___ No

Changes:

Comments:
Unsafe Behavior

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

 Unsafe Behavior

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Signature: _________________________________________   Date: ___________________________

Publication:
None

Page last reviewed February 2023
Page originally created February 2010

Internet Citation: Appendix B12: Fall Interventions Monitor. Content last reviewed February 2023. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6txt.html

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