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Healthcare Facility Compliance 15 items

Fall Prevention & Pressure Injury Prevention Audit

Bedside audit of fall-prevention and pressure-injury-prevention practices covering risk assessment, individualized interventions, repositioning, and monitoring.

CMS 42 CFR 483.25(b)-(d)TJC National Patient Safety GoalsNPUAP/EPUAP Guidelines

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Fall Risk Assessment

  • Is a validated fall risk assessment completed on admission and reassessed after status changes? *
  • Is fall risk communicated (e.g., signage, wristband, handoff) to the care team? *
  • Is a post-fall assessment and huddle conducted after any fall, with cause analysis? *

Fall Prevention Interventions

  • Are individualized interventions in place for at-risk patients (bed alarm, low bed, non-slip footwear)? *
  • Is the call light within reach and are personal items and the environment de-cluttered? *
  • Are medications reviewed for fall-risk-increasing drugs (e.g., sedatives, antihypertensives)? *

Pressure Injury Risk Assessment

  • Is a validated skin/pressure injury risk assessment (e.g., Braden) completed on admission? *
  • Is a head-to-toe skin assessment performed on admission and at defined intervals? *
  • Are existing pressure injuries staged, measured, and documented accurately? *

Pressure Injury Prevention Interventions

  • Is a repositioning schedule implemented and documented for at-risk immobile patients? *
  • Are pressure-redistribution support surfaces used for at-risk patients? *
  • Are nutrition and hydration status assessed and addressed to support skin integrity? *
  • Is moisture/incontinence managed with a skin protection program? *

Monitoring & Reporting

  • Are fall and pressure injury rates tracked and reported through the QAPI program? *
  • Are facility-acquired pressure injuries (Stage 3, 4, unstageable) reviewed as adverse events? *

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