FALL RISK ASSESSMENT FORM Resident Name- Check off reason for assessment Initial Assessment Re-Assessment after fall Re-Assessment (periodic) Change in Status Circle reference Total reference Categories number(s) in Descriptions numbers by each category category NO FALLS in past 3 months Recent Fall History 1 - 2 FALLS in past 3 months 3 OR MORE FALLS in past 3 months AMBULATORY/CONTINENT Ambulation / Continence CHAIR BOUND - Requires assist with elimination AMBULATORY/INCONTINENT ALERT (oriented X 3) OR COMATOSE (no voluntary or involuntary movement) Mental Status DISORIENTED X 3 at all times INTERMITTENT CONFUSION / forgets limitations ADEQUATE (with or without glasses) POOR (with or without glasses) LEGALLY BLIND To assess, have resident stand on both feet without holding onto anything; walk straight forward; walk through a doorway; and make a turn. Gait/Balance normal Balance problem while standing Balance problem while walking Decreased muscular coordination Change in gait pattern when walking through doorway Unstable when making turns Requires use of assistive devices (i.e., cane, w/c, walker, furniture) Inappropriate use of assistive device / footwear NO NOTED DROP between lying and standing Drop LESS THAN 20 mm Hg between lying and standing in Blood Pressure (Systolic) 3 minutes Drop MORE THAN 20 mm Hg between lying and standing in 3 minutes Diuretics (somnolence, volume depletion, electrolyte disturbance, urgency to rush to bathroom), Psychoactives: Benzodiazepines (i.e. Ativan, Halcion), Phenothiazines, Antidepressants, and antipsychotics (i.e., Mellaril and Haldol), Narcotics, Anticonvulsant stabilizers, Cardiovascular medications, Corticosteroids (can adversely effect muscle function), or any medication that adversely affects muscle function, coordination, and physical stability. NONE of these medications taken currently or within last 7 Medications days TAKES 1 - 2 of these medications currently and/or within last 7 days TAKES 3 - 4 of these medications currently and/or within last 7 days If resident has had a change in medications and/or change in dosage in the past 5 days = score 1 additional point Gastrointestinal: Bleeding, Diarrhea, Defecation Syncope, Postprandial Syncope, Genitourinary: Micturition syncope, Incontinence, Nocturia (80% of the elderly experience nocturia and going to the bathroom at night is a major risk factor), Cardiovascular: Myocardial infarction, Arrhythmia, Orthostatic Hypotension, Musculoskeletal disorders: Arthritis, Predisposing Conditions Inflammatory Joint Disease, Osteoarthritis Proximal Myopathy, Deconditioning, Neurologic: Parkinsonian, Dementia, Stroke, Transient Ischemic Attack, Delirium, Myelopathy, Vertebrobasilar Insufficiency, Carotic Sinus Supersensitivity, Cerebellar Disorder, Peripheral Diseases Neuropathy, Diabetes, B12 Deficiency, Multiple Myeloma, Vasculitis, Chronic dehydration NONE PRESENT 1 - 2 PRESENT 3 OR MORE PRESENT A TOTAL SCORE OF 10 OR MORE INDICATES A TOTAL SCORE---> RESIDENT "AT RISK" FOR FALLS.
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy. 10SOW-NY-AIM7.2-11-24
FOR IMMEDIATE RELEASE Press Contact: Breema at the Science & Nonduality Conference: Explore the Role of the Body in Conscious Living and Self-Understanding Breemaʼs “Art of Being Present” balances body, mind and feelings, nurturing presence in any moment. San Rafael, Calif., September XX, 2010 – The Science & Nonduality Conference in San Rafael, October 2
DOWN GORGEOUS a one-person kugel cantata PIETER-DIRK UYS PROLOGUE What I want to celebrate tonight is being South African. My father Hannes Uys was an Afrikaner; my mother Helga Bassel was a German Jew. So that makes me a Jewish Afrikaner! At least I belong to both chosen people. I’ve spent most of my time illuminating the Calvinist Afrikaner side of me through Mrs Evita Bezu