Falls Risk Assessment Audit

Audit template for verifying falls risk assessment completion, scoring accuracy, intervention planning, signage, bed alarm use, and family education.

Assessment Completion

• Falls risk assessment completed on admission or transfer
• Falls risk assessment is current and completed within required timeframe
• Required assessment fields are fully documented
  Check for documented history of falls, mobility status, gait/balance, cognition, toileting needs, medications, and assistive device use.
• Assessment reflects observed patient condition
  Observed mobility, cognition, and assistance needs match the documented assessment findings.

Scoring Accuracy

• Falls risk score calculated correctly from the tool used
• Documented risk category matches the score
• Any score changes are supported by reassessment documentation
• Reassessment performed after change in condition or fall event

Intervention Plan

• Interventions are documented for identified fall risks
• Interventions match the patient’s risk level and deficits
• Mobility assistance level is clearly specified
  Examples include one-person assist, two-person assist, standby assist, or use of gait belt/walker.
• Toileting and rounding plan is documented when indicated
• High-risk precautions are clearly communicated in the care plan

Environmental Controls and Signage

• Falls risk signage is posted per facility policy
• Signage is visible, legible, and placed in the correct location
• Call light, personal items, and mobility aids are within reach
• Bed is in lowest position and brakes are engaged

Bed Alarm and Family Education

• Bed alarm is in use when indicated by risk level or care plan
• Bed alarm is functioning and audible at the point of care
• Patient and family education on fall prevention is documented
• Education includes when to call for assistance and use of mobility aids