Thirteen suggestions to investigating falls or incidents involving residents
1. Ask the resident involved what happened - write down verbatim what they say.
2. Inquire if anyone in the area witnessed the incident or heard anything. Write down who you talked to and what was said with the date and time.
3. Survey the environment where the incident happened.
4. Make a list of possible contributing factors, such as time of day, lighting, temperature, activity prior to incident etc.
5. Review resident's diagnoses and allergies.
6. Review resident's medications. Are there any new medications causing interactions? side effects?
7. Interview family members. They could know a piece of the puzzle and not realize it.
8. Interview the person that completed the report.
9. What was the mental/emotional status of the resident? Were they upset prior to the incident, are they experiencing confusion?
10. Was the resident doing something out of the ordinary? If so why?
11. Evaluate the data. Can you answer WHO, WHAT, WHERE, WHEN, WHY.
12. Was the incident caused by lack of knowledge or skill of the caregiver?
13. Develop preventative strategies based on the evaluation and data of the investigation.
This is just a starting point of suggestions. Doing an in depth investigation requires time and experience.
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