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    Athena Fall Risk Assesment

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    staffdev
    This document provides instructions for evaluating a resident's fall risk upon admission, annually, with changes, quarterly, and post fall using an assessment that scores various risk factors and conditions. A score of 10 or greater indicates a resident is at high risk for falls and an intervention should be initiated. The assessment evaluates factors like consciousness, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure changes, medications, and predisposing diseases.

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    Athena Fall Risk Assesment

    Uploaded by

    staffdev
    70 views2 pages
    This document provides instructions for evaluating a resident's fall risk upon admission, annually, with changes, quarterly, and post fall using an assessment that scores various risk factors and conditions. A score of 10 or greater indicates a resident is at high risk for falls and an intervention should be initiated. The assessment evaluates factors like consciousness, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure changes, medications, and predisposing diseases.

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    This document provides instructions for evaluating a resident's fall risk upon admission, annually, with changes, quarterly, and post fall using an assessment that scores various risk factors and conditions. A score of 10 or greater indicates a resident is at high risk for falls and an intervention should be initiated. The assessment evaluates factors like consciousness, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure changes, medications, and predisposing diseases.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    70 views2 pages

    Athena Fall Risk Assesment

    Uploaded by

    staffdev
    This document provides instructions for evaluating a resident's fall risk upon admission, annually, with changes, quarterly, and post fall using an assessment that scores various risk factors and conditions. A score of 10 or greater indicates a resident is at high risk for falls and an intervention should be initiated. The assessment evaluates factors like consciousness, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure changes, medications, and predisposing diseases.

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    FALL RISK EVALUATION

    Instructions: Upon admission, annually, with significant changes, quarterly and post fall, evaluate the resident status
    and the response. If this score is 10 or greater, the resident should be considered at HIGH RISK for potential falls, and
    an intervention should be initiated.

    RESIDENT NAME: ROOM #:

    PARAMETER SCORE RESIDENT STATUS/CONDITION 1 2 3 4

    A. LEVEL OF 0 ALERT – (oriented x3) OR COMATOSE


    CONSCIOUSNESS
    2 DISORIENTED x3 at all times
    MENTAL STATUS
    4 INTERMITTENT CONFUSION

    B. HISTORY OF 0 NO FALLS in past 3 months


    FALLS
    2 1-2 FALLS in past 3 months
    (past 3 months)
    4 3 or MORE FALLS in past 3 months

    C. AMBULATION/ 0 AMBULATORY/CONTINENT

    ELIMINATION 2 CHAIR BOUND – assist with elimination

    STATUS 4 AMBULATORY/INCONTINENT

    D. VISION STATUS 0 ADEQUATE (with or without glasses)

    2 POOR (with or without glasses)

    4 LEGALLY BLIND

    E. GAIT/BALANCE 0 Gait/Balance

    1 Balance problem while standing

    1 Balance issue while walking

    1 Decreased muscular coordination

    1 Change in gait pattern when walking through doorway

    1 Jerking or unstable when making turns

    1 Requires use of assistive device (cane, walker, w/c,


    etc.)

    2 NOT APPLICABLE – Unable to perform any of above


    F. SYSTOLIC 0 NO NOTED DROP between lying & standing

    BLOOD 2 Drop LESS THAN 20 mm Hg between lying & standing


    PRESSURE
    4 Drop MORE THAN 20 mm Hg between lying & standing

    G. MEDICATIONS Respond below based on the following types of meds: Diuretics,


    Narcotics, Sedatives, Hypnotics, Psychotropics, Cathartics,
    Anesthetics, Antihistamines, Antihypertensives, Antiseizure,
    Benzodiazepines

    0 NONE of these meds taken currently or within the last 7


    days

    2 TAKES 1-2 of these meds currently and/or within the


    last 7 days

    4 TAKES 3-4 of these meds currently and/or within the


    last 7 days

    1 If resident has had a change in meds and/or doses in


    the past 5 days. TAKE THIS ADDITIONAL POINT

    H. PREDISPOSING Respond below based on the following conditions:


    DISEASES Hypotension, Vertigo, Parkinson’s Disease, Seizures,
    Loss of Limbs, Arthritis, Fractures, Osteoporosis, CVA,
    Neurological D/O

    0 NONE PRESENT

    2 1-2 PRESENT

    4 3 OR MORE PRESENT

    TOTAL SCORE Total score of 10 or more HIGH RISK FOR FALLS

    Evaluation SIGNATURE/ TITLE/DATE Evaluation SIGNATURE/TITLE/DATE

    1 3

    2 4

    Athena Health Care Systems 4/15

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