Vanderbilt Hearing and Speech Sciences Pi Beta Phi Rehabilitation Institute HOME SAFETY ASSESSMENT
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1 Vanderbilt Hearing and Speech Sciences Pi Beta Phi Rehabilitation Institute HOME SAFETY ASSESSMENT Patient's Name: Date: PATIENT'S GOALS/AREAS OF CONCERN: Walkways 1. Smooth and level, including transitions? 2. Steps along walkway clearly visible? 3. Handrails available? 4. Obstruction by shrubs, etc.? 5. Steeply inclined? Driveway 1. Is the slope a barrier? 2. Smooth and evenly paved? 3. Could the client use their assistive device safely here? Entry Ways/ Landings/ Doors (front/ rear/ other) 1. Have all potential tripping hazards been removed? 2. Is the landing large enough to safely open the door?
2 3. Is the doorbell easily reached and visible? 4. Does the landing/ porch have railings/ barriers to prevent someone from stepping or falling off? 5. Is there a non-slip surface on the porch/ deck? 6. Are doormats secure without upturned corners? 7. Are locks/ latches/ handles to doors easy to 8. Do glass sliding doors have decals at eye level? 9. Is adequate lighting available? Hallways 1. Free of clutter? Clear pathway? 2. If throw rugs are present, are they secured with tape or slip-resistant backing? 3. Is carpeting secure and level? 4. Level with no more than ½ beveled transitions? 5. Are loose cords/ wires present? 6. Are hallways wide enough to accommodate a wheelchair? 7. Is there adequate lighting? Stairs and Steps 1. Are steps free of clutter? 2. Is carpeting secure? 3. Are steps broken/ uneven/ slip resistant? 4. Is lighting adequate? (Light switches at both top/ bottom of steps) 5. Hand-rails loose or broken? 6. Hand-rails available on both sides? 7. Are the height of steps a barrier/ uneven?
3 Kitchen 1. Are commonly used items easily accessible? 2. Is the step stool unsteady? 3. Are dials labeled on the stove and easy to 4. Are the countertops free of rough or sharp edges? 5. Is there adequate lighting where food is cut/ sliced? 6. Do garbage cans, pet bowls, etc. block a pathway? 7. Is the counter height accessible? 8. Are sink faucets easy to reach? 9. Is the microwave easy to read, reach, and 10. Is there a close resting place for hot items coming out of the oven? 11. Is the flooring level/ secure? 12. Are throw rugs secured? 13. Is stove free of excess grease/ fire hazard? 14. Is there safe access to refrigerator/ freezer doors/ shelving? 15. Is the trash can accessible and easy to 16. Are there safety guidelines/ limitations that should be in place for kitchen activities? Bathroom 1. Is there a non-slip mat or surface in the tub/ shower? 2. Is support needed to step over into the tub/ shower? 3. Is the sink easily accessible? 4. Is the lighting adequate/ switches accessible? 5. Is a night light available?
4 6. Is the flooring non-slip, non-skid? 7. Are throw rugs secured? 8. Are mirrors at an appropriate height? 9. Are toiletries within easy reach? 10. Is there a hand-held shower head? 11. If needed, is there a tub/ shower seat? 12. Can individual transfer safely on/ off toilet? 13. Are grab bars in place and if so, can patient use safely? Bedroom 1. Is the bed at the appropriate height for independent transfers? 2. Are bed linens and curtains clear from the floor to avoid tripping? 3. Is the light reachable from the bed? 4. Is there a place to sit and get dressed, if needed? 5. Can dresser/ bureau drawers be reached easily? 6. Is there an unobstructed pathway through the room? 7. Are floor coverings secure/ non-slip? 8. Is there a phone within reach of the bed? 9. Ashtrays, smoking materials are located away from bed/ bedding? 10. Is there support for getting in/ out of bed if needed? 11. Are cords/ wires off the floor? Living/ Dining Rooms 1. Is the lighting adequate? 2. Is there at least one seat in each room that is easy to come to/ from standing? 3. Are any plastic carpet runners or throw rugs tacked down?
5 4. Is the flooring slip resistant, in good repair? 5. Are there any table corners that are sharp/ of concern? Closets 1. Are shelves/ clothes poles easy to reach? 2. Are clutter/ tripping hazards off the floor? 3. Is lighting adequate? 4. Are closet doors easy to open? General Household Safety Issues 1. Can household members contact someone in case of emergency? (i.e. medical alert device, names/ numbers by phone, etc.) 2. Fire extinguisher/s in home? Should more than one be in place? 3. Safe place to hide key outside for emergency entry? 4. Functioning smoke detector in home/ checked every six (6) months? 5. Is at least one accessible phone available on each level of the home? 6. Are flashlights accessible/ functional if needed? 7. Are medications stored in an accessible area? 8. Is a first aid kit available and accessible? 9. Are portable heaters, candles, etc. away from flammable objects? 10. Are towels/ curtains located away from stove/ heaters? 11. Copy of current medications is in wallet/ purse? 12. Emergency escape route/ 2 exits available? 13. Medication box that is easy to read and 14. Safe footwear? No scuffs, loose footwear, socks? 15. No loose/ long clothing, i.e. robes that one could trip on?
6 16. Assistive devices, i.e. canes, walkers, wheelchair in good working order? 17. Is there a system in place to remember to take medications? 18. Is hot water heater set at 120 degrees or lower? 20. Are there safety guidelines in place for outdoor activities? SUMMARY OF FINDINGS: RECOMMENDATIONS: RESOURCES PROVIDED TO PATIENT/ FAMILY: Note: While this is a comprehensive home safety assessment, it may not cover all situations or environments. References: 1. Check for Safety: A Home Fall Prevention Checklist for Older Adults Home Safety Assessment Checklist Cougar Home Safety Assessment Initial Visit Fall Prevention Project, Pima Council on Aging. Tuscon, AZ Gerontological al Modifications. Weill Medical College of Cornell University.
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