OSPITAL NG MAKATI

Sampaguita corner Gumamela Sts., Pembo,

Makati City, Philippines
Tel. +632 882 6316 to 36
PhilHealth Accredited

THE KINDER 1 FALL RISK ASSESSMENT TOOL

Instruction: Please read carefully and check “” “Yes” or “No” to
NAME:
each question
AGE: SEX: Male  Female  RISK ASSESSMENT YES NO
The following group of patients shall be identified as: 1. Presented to emergency department because
LOW RISK FOR FALL of falls (Syncope, seizure, or loss of
 Complete paralysis or completely immobilized consciousness)
2. Altered Mental Status Intoxication with
HIGH RISK FOR FALL alcohol or substance confusion
 Age (65 years old and above and 7 years old and (Disorientation, impaired judgment, poor safety
below) awareness, or inability to follow instructions)
 Patient with possible neurological deficit (e.g., head 4. Impaired Mobility:
injury, spinal cord injury/disease, seizure, etc.) Ambulates or transfers with assistive devices or
 Pregnant women assistance; Unable to ambulate or transfer
 Visual and hearing impaired (with hearing aid, with eye
glasses) 5. Healthcare Provider’s Judgment:
 Patients who use assistive devices (wheelchair, canes, (Bowel or bladder incontinence, diarrhea, urinary
walker) frequency or urgency, Sensory deficits, leg
 Gait and balance impairment weakness, orthostatic hypotension, dizziness or
 Altered level of consciousness vertigo, and medications such as diuretics,
 Physical disability narcotics, sedatives)
 Moderate to severe dementia
 Level 1, 2 and 3 triage
 Patient on Physical and Occupational therapy  LOW RISK
FALL RISK STATUS
 All patients who reportedly had a fall in the past three  HIGH RISK
(3) months
Note:
1. Do not continue with Fall Risk Score if any of the PRINTED NAME AND SIGNATURE OF
conditions are checked. THE ER MEDICAL OFFICER/TRIAGE
DISCLAIMER: This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors
which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to
each individual presentation.
 OSPITAL NG MAKATI
Sampaguita corner Gumamela Sts., Pembo,
Makati City, Philippines
Tel. +632 882 6316 to 36
PhilHealth Accredited

THE KINDER 1 FALL RISK ASSESSMENT TOOL

2. any "YES" to a risk category indicates a high fall NURSE/ ER NURSE
risk. DATE / TIME

ADULT FALL RISK INTERVENTION TABLE
UNIVERSAL FALL PRECAUTION /
LOW RISK PATIENT IMPLEMENT INTERVENTION 1 TO 7
1. 2. Ensure that the call bell is in working condition and
within reach.
3. Place bed in the lowest position with brakes locked.
(If appropriate)
4. Ensure that the upper side rails are raised at all times.
5. Educate the patient / watcher on the usage of call bell.
6. Educate the patient / watcher concerning fall risk.
7. Advise the patient on postural hypotension and its
effects.
8. Advise on the effects of medication / sedation /
anesthesia.
HIGH-RISK PATIENT IMPLEMENT INTERVENTION 1 TO 15
9.
10. Place a Fall Risk signage and educate patient / watcher.
11. Assist the patient with transfer / ambulation.
12. Ensure that the patient has yellow wrist tag.
13. Remain with the patient while the patient is in the toilet.
14. Ensure that all side rails are raised when the patient is in
bed.
15. Advise the relative to inform the nurse if he / she is
leaving the room.
16. Conduct nursing rounds
(4P’s: Potting, Positioning, Proximity of possession,
Pain.) at least twice in a shift.
17. Apply physical restraints if necessary.
PEDIATRIC FALL RISK INTERVENTION TABLE
UNIVERSAL FALL PRECAUTION /
LOW RISK PATIENT IMPLEMENT INTERVENTION 1 TO 10
1. Assess elimination needs, assist as needed
2. Call light is within reach, educate the patient/family on its functionality.
3. Environment clear of unused equipment, furniture’s in place, clear of hazards
4. Orientation to room
5. Place bed in the lowest position with brakes locked.
(If appropriate)
6. Side rails up, assess large gaps, such that a patient could get extremity or
other body part entrapped, use additional safety precautions.
7. Use of appropriate size clothing to prevent risk of tripping
8. Assess for adequate lighting, leave nightlights “ON”
9. Patient and family education available to the parents and patients
10. Document fall prevention teaching and include in the plan of care
HIGH-RISK PATIENT IMPLEMENT INTERVENTION 1 TO 21
11. Evaluate the frequency of medication administration.
12. Remove all unused equipment out of room
13. Protective barriers to close off spaces, gaps in the bed
14. Keep the door open at all times unless specified isolation precaution are in
use
15. Move the patient closer to nurses’ station
16. Ensure that the patient has yellow wrist tag.
17. Place a Fall Risk signage “Humpy Dumpty Poster” in beds and educate
patient / watcher.
18. At a minimum time, check the patient hourly if unattended
19. Assist the patient with transfer / ambulation.
20. Document fall prevention teaching and include in the plan of care
21. For neonates, implement appropriate fall preventive strategies

DISCLAIMER: This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors
which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to
each individual presentation.
 OSPITAL NG MAKATI
Sampaguita corner Gumamela Sts., Pembo,
Makati City, Philippines
Tel. +632 882 6316 to 36
PhilHealth Accredited

THE KINDER 1 FALL RISK ASSESSMENT TOOL

DISCLAIMER: This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors
which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to
each individual presentation.