Home Fall Risk Assessment and Prevention Plan

Inspection template for assessing fall hazards in the home environment and documenting prevention interventions, patient education, and follow-up actions.

Inspection Setup and Resident Context

• Inspection date, location, and inspector recorded
  Document the home address or unit identifier, date of visit, and inspector name/role.
• Reason for assessment documented
  Select the primary reason for the home fall risk assessment.
• Mobility aid use and baseline ambulation status documented
  Record current mobility supports used in the home.
• Recent fall history reviewed
  Confirm whether falls, near-falls, or loss of balance in the past 12 months were reviewed.

General Home Environment Hazards

• Walkways and common paths are free of clutter
  Inspect hallways, entry paths, and frequently used routes for boxes, cords, shoes, and other tripping hazards.
• Floor surfaces are dry, even, and free of loose rugs
  Check for wet floors, uneven transitions, curled edges, unsecured mats, and loose throw rugs.
• Lighting is adequate in all frequently used areas
  Measure or estimate light level in key walking areas; note if additional lighting is needed.
• Electrical cords and hoses are secured away from walking paths
  Verify that extension cords, charging cables, and hoses do not cross or obstruct walkways.
• Pets and pet items do not create trip hazards
  Check for pet bowls, toys, beds, or animals in pathways that could contribute to falls.

Room-by-Room Safety Check

• Bathroom has grab bars or other stable support near toilet and shower/tub
  Assess whether stable support is present where transfers are performed.
• Bathroom floor and shower/tub surfaces are non-slip
  Verify presence of non-slip mats or adhesive strips and absence of slick surfaces.
• Bedroom path to bathroom is clear and accessible
  Inspect the route from bed to bathroom for obstacles, poor lighting, or narrow clearances.
• Stairs, steps, and thresholds are marked and in good condition
  Check handrails, step edges, threshold height, and visibility of transitions.
• Kitchen and laundry areas are free of spill and reach hazards
  Look for wet floors, frequently used items stored too high or too low, and unstable step stools.

Mobility, Transfer, and Assistive Device Safety

• Assistive device is present, appropriate, and in good condition
  Confirm that cane, walker, or other device matches current needs and shows no visible damage or instability.
• Footwear is supportive and appropriate for indoor use
  Verify that the resident uses well-fitting shoes or non-slip footwear rather than socks or loose slippers.
• Transfer technique and need for assistance reviewed
  Document whether transfers were observed or discussed and whether assistance is required.

Patient Education and Prevention Plan

• Fall prevention education provided
  Select all education topics reviewed with the resident and/or caregiver.
• Home modifications or interventions recommended
  Document specific recommendations such as removing loose rugs, adding grab bars, increasing lighting, or rearranging furniture.
• Follow-up plan established
  Record follow-up date, responsible party, and any referrals (e.g., PT/OT, primary care, home safety resources).

Findings, Corrective Actions, and Sign-Off

• Deficiencies documented with corrective actions
  Summarize all observed deficiencies, the associated risk, and the corrective action plan.
• Inspector signature
  Inspector attests that the assessment was completed and findings are accurate.
• Resident or caregiver acknowledgment
  Capture acknowledgment of education and recommended prevention actions when applicable.