Fall Audit Documentation

V 2.0

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.

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. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. Alert Charting Assessments - Alert Charting Assessment completed as scheduled. (Q611, Q612, Q613)

    1. Location in PCC:

      1. Assessments

    2.  Business Rule:

      1. IF a resident had a fall incident,
        THEN a series of Alert Charting Assessments must be completed for the resident.
        AND the Alert Charting Assessments must have “Fall” as the selected reason for the assessment.

    3. Due Date:

      1. The day the resident had the fall incident

      2. The day after the resident had the fall incident

      3. Two days after the resident had the fall incident

    4. Is classified as missed on the report:

      1. The end of the day of the due date

    5. Is no longer relevant to the report:

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