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Long Term Care Falls Investigation Toolkit

In response to the number of adverse event reports related to falls, the Patient Safety Commission and community partners developed a simple, easy-to-use guide to investigate and reduce recurrence of such falls. The guide is structured around Root Cause Analysis (RCA) and incorporates other evidence-based quality improvement principles.

Falls Investigation Toolkit: How-To Guide

The Falls Investigation Guide Toolkit offers long term care providers tools and resources to strengthen their falls investigation process. By integrating evidence-based quality improvement principles into investigations, organizations will be able to better understand the most basic reasons why falls occur and design interventions to improve patient safety outcomes.
    Download the full Falls Investigation Toolkit: How-To Guide

Falls Investigation Guide
This guide, which follows the RCA process, serves as a roadmap for the investigation indicating the sequence of events post-fall, through action plan development and monitoring for effectiveness. During the “Analyze” portion of the investigation, the guide refers the investigator(s) to three “Drill-Down” guides to assist with identification of contributing factors related to the following areas:
• Environment and equipment
• Medications
• Communication
    Download the Falls Investigation Guide»

Falls Investigation Guide for First Responders
This is a condensed version of the guides, which walks a first responder through the initial steps of the investigation process. The intent is that the investigation will be handed off to another individual, based on facility structure and policy, who will follow the investigation though completion.
    Download the Falls Investigation Guide for First Responders»

Sample Falls Investigation Forms

Example #1: Falls Investigation Form (Download Example 1 form)
Developed by the Nursing Home Expert Panel
This form follows the investigation process outlined in the Falls Investigation Guides. It was developed to use as a comparison tool for your current investigation forms/processes or to be incorporated into individual facility investigation forms and modified as necessary to meet facility needs while maintaining critical investigation components recommended in this guide. A Word version of this form is available so you can insert your individual facility name and make it your own. Note that both nursing home and CBC staff position titles are used side-by-side in the form. Your facility may choose to revise the form to reflect your facility specific staff position titles.

Example #2: Nursing Facility Falls Investigation Form (Download Example 2 form)
Provided courtesy of Rose Villa, Portland, OR
As a pilot participant testing the guides, Rose Villa created their own falls investigation form based on their experience using the Falls Investigation Guides. This form is available in Word format only. You are encouraged to insert your individual facility name and make it your own.

Example #3: CBC Falls Investigation Form (Download Example 3 form)
Provided courtesy of Mount Angel Towers, Mount Angel, OR
Also a pilot participant testing the guides, Mount Angel Towers created their own falls investigation form based on their experience using the Falls Investigation Guides. This form is available in Word format only. You are encouraged to insert your individual facility name and make it your own.

 

Disclaimer: All data and information provided on this website is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.

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