Policy Manual sample

MDT Home Health Care Agency, Inc. INCIDENT REPORT - FALLS Patient ___________________________________ Date of Fall _______________________ Number of falls in past 3 months: ________________ Witnessed by Agency staff? Yes No Location of fall: Bathroom Bedroom Other:___________________________________________ Contributing Factors: Transferring Lost Balance Fell out of bed Fell out of chair Dizzy Did not use assistive device Mental Status changes Clutter in fall area Throw rug/loose rug Lack of adaptive equipment Water on floor Improper foot wear Trip hazard - wires, catheter, etc. Describe the fall and situation surrounding the fall: _____________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Ortho BP check done Sitting/Lying_______________ Standing __________________________ Injury: _________________________________________________________________________ None Noted Possible Fracture Altered level of consciousness Bruising Soreness Pain Skin tear/laceration Abuse/neglect suspected? Describe injury and treatment: ____________________________________________________ Dr. notified? Yes No Response ___________________________________________________ Education Provided ____________________________________________________________ Need for use of assistive device and/or supervision Request for PT Referral __________________ Orthostatic hypotension precautions Request for OT Referral _____________________________ Environmental Changes Needed Request for SW Referral ________________________________ Request for Dietician Referral _____________________________________________________ Other:__________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________ Staff member signature: ______________________________________ Date: ______________ Home Health Agency Nursing Care & Procedures K-126