Nursing Home Fall Prevention Plan Template

1. Resident Information

Name: Date of Birth: Room Number: Assessment Date:

2. Risk Assessment

Fall Risk Factors: Mobility Status: Independent Needs Assistance Uses Mobility Aid Bedbound History of Falls:

3. Prevention Interventions

Environmental Modifications: Assistive Devices (e.g., walkers, canes): Medication Review/Adjustments: Staff Actions:

4. Resident & Family Education

Education Topics Covered: Date and Method of Education:

5. Monitoring and Follow-Up

Monitoring Plan: Review Dates: Responsible Staff:

6. Additional Notes