<p> FACILITY: ______MONTH ENDING: ______Pg. ___ of ___ FACILITY FALLS SUMMARY REPORT FORM CONFIDENTIAL DOCUMENT FOR QUALITY IMPROVEMENT ANALYSIS ONLY Data is not risk adjusted and should not be used to compare among facilities</p><p>Location of Incident D Time Mental Med Restraint Equipment Injury Injury Resident RR resident room A Status Code In Use Code Identifier HW hallway Y D day Y/N Code Y/N BR bathroom E evening N normal/ DR dining room N night oriented OD outdoors C confused O other D disoriented R H B D O O D E N N C D R W R R D</p><p>CODE KEYS: MEDICATION EQUIPMENT IN USE INJURY CODE A Antihypertensive G Geri chair C Change in service/care plan ANL Analgesic HP Hip protector FX Fracture ABO Antibiotic LAP Lap buddy H Hospitalization C Cardiac R Restraint S Suture D Diuretic SR Side Rails O Other H Hypnotic TAB Tab monitor(s) L Laxative O Other NEW Medication in last 5 days P Psychotropic S Sedating antidepressant/ antihistamine MONTHLY SUMMARY FACILITY: ______MONTH ENDING: ______Pg. ___ of ___ FACILITY FALLS DATA SUMMARY CONFIDENTIAL DOCUMENT FOR QUALITY IMPROVEMENT ANALYSIS ONLY Data is not risk adjusted and should not be used to compare among facilities</p><p>1. Total number of falls …………………………………………………………………………………………………………….</p><p>2. Total number of falls with injury …………………………………………………………………………………….. </p><p>3. Total number of residents who fell …………………………………………………………………………………. </p><p>4. Total number of residents with two or more falls ……………………………………………………….</p><p>5. Total number of falls per resident computed only for residents who fell: …………….. (#1 above divided by #3 above) </p><p>6. For the month, total resident days: ………………………………………………………………………………..</p><p>(average daily census x number of days in this month)</p><p>7. Falls per 1,000 resident days: ………………………………………………………………………………………….. (#1 above x 1,000, divided by #6 above)</p><p>8. Falls with injury per 1,000 resident days: ……………………………………………………………………..</p><p>(#2 above x 1,000, divided by #6 above) FACILITY: ______MONTH ENDING: ______Pg. ___ of ___</p><p>Note: For the purposes of this report, “injury” means any fracture, any sutures, any need for hospitalization or other immediate medical attention, and any changes in functional ability requiring a change in the service/care plan. Injury does not include minor skin tears or bruises.</p>