The following resources are designed to assist insured parties with minimizing claims and keeping losses to a minimum. They are provided to improve operational performance and optimize risk management practices.

admissionReadmissionChange in ConditionPost-FallQuarterly
Parameter Score Patient Status/Condition
A Level of Consciousness/ Mental Status 0 Alert and oriented X3
2 Alert and oriented X3
4 Alert and oriented X3
B History of Falls
(past 3 months)
0 No falls
2 1-2 falls
4 3 or more falls
C Ambulation/ Elimination Status 0 Ambulatory & continent
2 Chair bound & requires assist w/ toileting
4 Ambulatory & incontinent
D Vision Status 0 Adequate (w/ or w/o glasses)
2 Poor (w/ or w/o glasses)
4 Legally blind
E Gait and Balance ------ Have resident stand on both feet w/o any type of assist then have walk: forward, thru a doorway, then make a turn.(Mark all that apply.)
0 Normal/safe gait and balance.
1 Balance problem while standing.
4 Balance problem while walking.
4 Decreased muscular coordination.
4 Change in gait pattern when walking through doorway.
4 Jerking or unstable when making turns.
4 Requires assistance (person, furniture/walls or device).
F Orthostatic Changes Take resident’s blood pressure and pulse lying down, then again after standing up. 0 No noted drop in blood pressure between lying and standing.
No change to cardiac rhythm.
2 Drop <20mmHg in BP between lying and standing.
Increase of cardiac rhythm <20.
4 Drop >20mmHg in BP between lying and standing.
Increase of cardiac rhythm >20.
G Medications ------ Based upon the following types of medications: anesthetics, antihistamines, cathartics, diuretics, antihypertensives, antiseizure, benzodiazepines, hypoglycemics, psychotropics, sedative/hypnotics.
0 None of these medications taken currently or w/in past 7 days.
2 Takes 1-2 of these medications currently or w/in past 7 days.
4 Takes 3-4 of these medications currently or w/in past 7 days.
1 Mark additional point if patient has had a change in these medications or doses in past 5 days.
H Predisposing Diseases ------ Based upon the following conditions: hypotension, vertigo, CVA, Parkinson’s Disease, loss of limb(s), seizures, arthritis, osteoporosis, fractures
0 Drop >20mmHg in BP between lying and standing.
Increase of cardiac rhythm >20.
2 Drop >20mmHg in BP between lying and standing.
Increase of cardiac rhythm >20.
4 Drop >20mmHg in BP between lying and standing.
Increase of cardiac rhythm >20.
I Equipment Issues 0 No risk factors noted.
1 Oxygen tubing.
1 Inappropriate use of or resident does not consistently use assistive device.
1 Equipment needs:
1 Other
TOTAL SCORE A score of 10 or more indicates high risk for falls. If score is 10 or more, complete page 2.
Additional Services Requested
Skilled NursingPhysical TherapyOccupational TherapyOther:
YesNo
YesNo