Fall Incident Event
All Forms
Fall Inicident Event
Section 1: Initiator Details
Initiator name
*
Initiator's email
Initiator department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Date of occurrence
*
Time of occurrence
*
Other Initiator Department
*
Location of occurrence
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Other
*
Room #
Additional details
Occurrence related to
*
Patient
Visitor
Employee
Contractor
Name
*
DOB
FIN number
Name
*
Related patient name
Phone
*
Address
Name
*
Department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Name
*
Related department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Phone
*
Company name
Section 2: Occurrence Details
What position was the person found in?
*
Describe mobility or range-of-motion of extremities following incident
*
Is assessed mobility or range-of-motion a change?
*
Yes
No
Describe
*
Injury
*
None
Laceration
Skin Tear
Abrasion
Hematoma
Swelling
Other
Other Injury
*
Describe and locate on diagram
Vital Signs
B/P Lie
*
Temp
*
B/P Sit
*
Pulse
*
B/P Stand
*
Resp
*
Other
BG Accu Check
*
Pulse Oximetry
*
Neuro Checks
*
Treatment
*
Examined at Hospital
Admitted to Hospital
Xray Done
First Aid Administered
Name of Person(s) Administering Treatment
*
Add Names
Investigation
Exact location of Incident
*
Patient Room
Hallway
Bathroom
Nursing Station
Lobby
Shower
Other
Other Location of Incident
*
Incident Witnessed
*
Yes
No
Incident Un-Witnessed
*
Yes
No
Name of Witness
*
Address of Witness
*
Person Who Discovered Incident
*
Description of Incident
*
Person(s) Involved
*
Statements About Incident
*
Add Person Involved
What was the involved person attempting to do?
*
Getting out of bed
Standing Still
Walking
Wheeling in W/C
Reaching for object
Transferring To/From Chair or W/C
Going to the Bathroom
Need for Dry Incontinent
Unwitness
Other
Other
*
Equipment Involved
*
Cane/Crutch
Wheelchair
W/C Wheels Locked
W/C Wheels Unlocked
Walker
Geri-Chair
G/C Back Reclined
G/C Back Upright
G/C Wheels Locked
No Bedrails
Other
N/A
Other Equipment Involved
*
Environment
*
Wet Floor
Wet Floor Sign in Place
No Sign
Object in Walkway
Poor Lighting
Recent Room Move
Call Light not in Reach
Alarm On Bed/Chair
Alarm Off Bed/Chair
Rug in Walkway
Foot Ware
Other
N/A
Specify Footware Detail
*
Other Environment
*
Diagnosis or Conditions
*
Vision Deficit
Hearing Deficit
Hx of Falls
Hypotension
CVD
Cognitive Deficit
Wt. Loss
Dehydration
Hx CVA
New Fx
Parkinson's
SOB
Hypertension
Diabetes
Neuropathy
Drop in ADL's
Other
Other Condition
*
Medications
*
Which Action Taken
*
Department Manager Notified
Pharmacy Notified
Physician Notified
Patient moved to different room
Patient placed on 1:1
Why did this incident occur? (In Your Opinion)
*
What was done immediately? (To Prevent Reoccurence)
*
Patient moved to new room
Name of Person(s) Completing Report
*
Add Names
Additional Comments
Family/Caregiver notified
*
Yes
No
Name
Relation
Date
Time
Reason
Physician notified
*
Yes
No
Physician name
Select
Matab Singh MD
Romona Dolan PA
William Bichai MD
Juan Sosa MD
Ravi Kapadia MD
Ruben Nieto MD
Mandeep Bagga MD
Mushtaq Ahmed MD
Oriente Esposo MD
Other
Type of physician intervention
Change Patient Care Plan
Use of Restraint
Seclusion
Patient Assessment
Close Monitoring
Medication Escalation
Other
Other Physician Name
Other Physician Intervention Type
Date
Time
Reason
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