1. FALL REDUCTION PROGRAM

2. DEFINITION OF A FALL An unintentional change in position resulting in coming to rest on the ground or at a lower level FALL RISK ASSESSMENT:

3. Patient and Family or Primary Care Giver Education Verbal Instruction is to be documented in the patient EMR. Written materials or handouts will be appropriate for the education level and culture Modifications or actions taken by staff to reduce fall risk in the home (e.g., removed throw rugs, ordered handrail for bathroom) is to be document in the EMR

4. Patient Fall Reporting Fall interventions are to be implemented immediately by the RN who receives the report that the patient has fallen, to address causative factors of initial fall and reduce risk of future falls Incident Report is to be COMPLETED BY RN who receives the report that the patient has fallen Manager is to provide a copy to QAPI for trending and follow up if needed

5. FALL REDUCTION PLAN QAPI will compile, trend and share data results with appropriate performance interventions to reduce risk of falls and reduce risk of serious injury from falls when falls are inevitable SIGNIFICANT INJURY OR DEATH FROM A FALL: – Reported immediately to manager, QAPI and administration – QAPI to report any unexpected death from fall to the OMI and NM Division of Health Improvement