Preventing Falls in Long-term Care: A Model Recreation Therapy Program
Q.A. Falls risk checklist:
Peer observer please fill out one form for each R.T. program participant.
Name__________________
Program_____________________________________
Diagnosis_______________
Program location:______________________________
Medications:_________________________________________________________
| Program area risk assessment | Problems |
| ___ Adequate lighting | ___Needs more light |
| ___ No glare on tables, floor, counters | ___Glare is present |
| ___ Shelves and cupboards eye height | ___ Shelving too high |
| ___ No objects on floor | ___ Rugs, cords, objects on floor |
| ___ Furniture is stable with arm rests | ___ Unstable furniture or no arm rests |
| ___ Door sills are flush with floor | ___ Door sills are raised |
| ___ Empty wheelchairs removed or locked | ___ Empty wheelchairs in program area |
| ___ No excessive clutter | ___ Clutter on tables, counters, storage areas, halls |
| ___ Stairway well lit with 2 hand rails | ___ Stairway needs light or hand rails |
| Outdoor Program Areas | |
| ___No rocks or loose gravel | ___Rocks or gravel impede path |
| ___No wet leaves or ice | ___Wet leaves/ice on walkways |
| ___Area free of holes, cracked | ___Holes in lawn, cracks in pavement |
| ___Walkways and entrances well-lit | ___Needs outdoor lighting |
| Participant | |
| ___ Properly fitting non-slip footwear | ___ Improper or missing footwear |
| ___ Has glasses(clean) and is wearing | ___ Glasses missing |
| ___ Steady gait | ___ Unsteady gait |
| ___ Able to transfer to chair | ___ Unable to safely transfer to chair |
| ___ Alert and aware of environment | ___ Confused, wandering |
| ___ Positioned properly for program | ___ Slides out of chair |
| ___ Mobility aids accessible | ___ Mobility aids out of reach |
Completed by:______________________ Date:_____________
Did the participant seem to be at risk for a fall during your observation:
Recommendations: