Staff Menu Menu Timesheet Reference – Form Application Form – Nurse Application Form – Carers Logout Clover Healthcare Services Falls Checklist Step 1 of 4 25% Name of Person Supported First Last Date MM slash DD slash YYYY Incident RefCompleted By First Last Question and Guidance Section1. Does this person we support have a health concern that requires immediate attention in the event of a fall? (Support Plan) Yes No If YES, seek medical advice/ call 111 or 9992. Are they breathing normally? Yes No If NO, call 999.3. Have they suffered a bang to the head? Yes No Minor Minor/ NO visible injury: Kindly Monitor. If any doubt seek medical advice.4. Have they fallen more than 1 metre? Yes No If YES, call 111 or 9995. Do you suspect that they have suffered a serious injury i.e. fracture or dislocation? Yes No If YES, call 111 or 9996. Are they bleeding or do they have a skin tear? Yes No If YES, request a District Nurse or GP visit. Consider how much bleeding, if excessive call 111 or 999.7. Are they experiencing any pain (different to what is usual to them)? Yes No If YES, consider controls listed above and level of pain , if HIGH call 111 or 999.8. Are they able to weight bear if you proceed with a manual manoeuver? Yes No If NO, use equipment, or call 111 or 999 if equipment is not part of their support plan.9. Are you recommending the attendance of a GP or Ambulance Yes No If YES and individual refuses to give permission then consult your service manager/ on-call 10. If you are satisfied that it is safe and appropriate to proceed with moving and handling techniques, can the hoist be used? Yes No If NO, state why hoist could not be used and what equipment you did use i.e. belt/ slide sheet (these should only be used for assistance not to lift)11.a Hoist Not Used due to lack of space Yes No Comments to lack of space11.b Hoist Not Used due to personal dignity Yes No Comments to personal dignity11.c Hoist Not Used due to dangerous position Yes No Comments to dangerous positionAdd Any Other Comments to the above12. If moved, was a handling belt used? Yes No Comments to handling belt usage 13. Has the level of pain altered during the manoeuver ? Yes No If YES, consider GP/ 111/ 99914. If the person we support is normally able to walk, are they now able to stand from a chair and walk several steps? Yes No If NO, call 111 or 999Additional actions/ comments (Complete an associated incident Report if all the actions are on there) Is there an obvious immediate cause to the fall? Defective premises Poor layout of premises Poor housekeeping Medication/ Fatigue/ Alcohol Health related Behaviour Related Lack of suitable supervision Lack of training/ knowlwdge/ skill Other (Please state) You may be asked to complete a witness statementIf "Other" immediate cause to fall
