Mrs. P has no evidence of injury resulting from her two falls on 4/1/04 at this time. Resident does not complain of pain and there is no evidence of grimacing or pain upon movement. She has had no more falls. She is restless and agitated, especially at night.
VS-100/60, 80, 20, 98.6. Blood glucose=80.
Falls Assessment completed and discussed with falls team and family. Staff to increase surveillance of resident-monitor patient every 30 minutes, toilet every 2 hours or more frequently, ensure resident wears non-skid socks and use position change alarm while resident is up in chair or in bed. Other interventions to be determined based on further assessment and interdisciplinary evaluation.