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