Introduction

Resident Selection

Residents included

All residents who have had a UDA trigger with ‘Fall’ selected OR residents who have a Progress Note indicating a new fall without a UDA trigger are included in this audit.

Business rules

Tasks

  1. Post Fall Evaluation completed after each fall (Q601)

    1. Location in PCC:

      1. Assessments

    2. Business Rule:

      1. IF a fall occurred,
        THEN a Post Fall Evaluation must have a status of ‘Complete’ within 24 hours of the fall occurring.

    3. Due Date:

      1. Within 24 Hours of the fall

    4. Is classified as missed on the report:

      1. 72 Hours after the fall

    5. Is no longer relevant to the report:

      1. If another fall occurs within 24 hours of the fall

  2. Two Fall Follow-up UDAs completed after each fall (Q602)

    1. Location in PCC:

      1. Assessments

    2. Business Rule:

      1. IF a fall occurred,
        THEN at least 2 Fall Follow-up UDA assessments must have a status of Complete within 24 hours of the fall occurring.

    3. Due Date:

      1. Within 24 Hours of the fall

    4. Is classified as missed on the report:

      1. 72 Hours after the fall

    5. Is no longer relevant to the report:

      1. If another fall occurs within 24 hours of the fall

  3. Neuro checks were completed for unwitnessed incidents, incidents with a head injury, or potential head injury. (Q604)

    1. Location in PCC:

      1. Assessments

    2. Business Rule:

      1. IF a fall occurred,
        AND the fall was either unwitnessed, involved a head injury, or had the potential for a head injury as recorded in the Post Fall Evaluation,

      2. THEN a Neuro Check  assessment must be initiated after the fall and have a status of ‘Complete’ within 117 hours of the fall occurring.

    3. Due Date:

      1. Within 117 Hours of the fall

    4. Is classified as missed on the report:

      1. Within 130 Hours of the fall

    5. Is no longer relevant to the report:

      1. If another fall occurs within 96 hours of the fall

  4. Physician notified of fall/occurrence. (Q605)

    1. Location in PCC:

      1. Assessments

    2. Business Rule:

      1. IF a fall occurred,
        THEN the Post Fall Evaluation must indicate that the physician has been notified of the fall.

    3. Due Date:

      1. Within 24 Hours of the fall

    4. Is classified as missed on the report:

      1. 72 Hours after the fall

    5. Is no longer relevant to the report:

      1. If another fall occurs within 24 hours of the fall

  5. Family/representative notified after fall. (Q606)

    1. Location in PCC:

      1. Assessments

    2. Business Rule:

      1. IF a fall occurred,
        THEN the Post Fall Evaluation must indicate that the family or representative (responsible party) has been notified of the fall.

    3. Due Date:

      1. Within 24 Hours of the fall

    4. Is classified as missed on the report:

      1. 72 Hours after the fall

    5. Is no longer relevant to the report:

      1. If another fall occurs within 24 hours of the fall

  6. Contributing factors for fall risk identified in the Care Plan. (Q607)

    1. Location in PCC:

      1. Care Plan - Focus

    2. Business Rule:

      1. IF a resident had a fall incident,  
        THEN the care plan must include a focus identifying the resident as a fall risk, 
        AND contributing factors must be identified in this focus explaining why the resident is a fall risk.

    3. Due Date:

      1. Within 24 Hours of the fall

    4. Is classified as missed on the report:

      1. 72 Hours after the fall

    5. Is no longer relevant to the report:

      1. If another fall occurs within 24 hours of the fall

  7. Intervention put into Place on Care Plan. (Q608)

    1. Location in PCC:

      1. Care Plan - Interventions

    2. Business Rule:

      1. IF a resident had a fall incident, 
        THEN the care plan must be updated with a new or revised intervention associated with the fall risk focus within 24 hours of the incident.

    3. Due Date:

      1. Within 24 Hours of the fall

    4. Is classified as missed on the report:

      1. 72 hours after the fall

    5. Is no longer relevant to the report:

      1. If another fall occurs within 24 hours of the fall