Text Description of Form
For the person doing the inspect: Label this form and fill it out in the same way as for the Nursing Inspection List.
For the Falls Engineer: A member of nursing staff has checked resident rooms and equipment for safety problems. This is the list of things they have found that you need to inspect and repair. Please do all the tasks that have a √ beside them for each room and bed number. Safety problems in common areas and with common equipment are listed on the back of this page. Refer to the Falls Engineer Instructions for details about how to do each task.
| Unit | Date: | Room Number: | Notes: | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Signature: | Bed: | ||||||||||||||||
| 1. Paths | 1. Make tiebacks for divider curtains. | ||||||||||||||||
| 2. Tie electrical cords out of path (TV, phone, heater). | |||||||||||||||||
| 2. Furniture | 3. Clean, repair, or replace broken bed wheel locks. | ||||||||||||||||
| 4. Fix unstable furniture. | |||||||||||||||||
| 5. Secure loose bathroom handrails. | |||||||||||||||||
| 6. Replace missing rubber tips on bedside commode. | |||||||||||||||||
| 7. Replace missing rubber tips on handrails that rest on floor. | |||||||||||||||||
| 8. Secure raised toilet seat to commode. | |||||||||||||||||
| 4. Lighting | 9. Replace burned out or flickering bulbs. Use max wattage. | ||||||||||||||||
| 10. Repair broken room lights or call lights. | |||||||||||||||||
| 11. Replace broken call light cords or lengthen cords. | |||||||||||||||||
| 5. Floor | 12. Repair or replace floor covering. | ||||||||||||||||
| 13. Replace high, broken, or missing thresholds. | |||||||||||||||||
| 14. Add grading to thresholds between room and bathroom. | |||||||||||||||||
| 6. Equipment | 15. Inspect wheelchair (for all wheelchairs found). | ||||||||||||||||
| 16. Repair cane. | |||||||||||||||||
| 17. Repair walker. | |||||||||||||||||
| Safety Problems in Common Areas With Common Equipment: |
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