Patient name
Address / home
Assessment date
Completed by
Next review date
⚠ Three highest-risk areas in dementia home care:
1. Stove — leading cause of kitchen fires |
2. Medications — double dosing causes silent serious harm |
3. Falls — most common cause of hospitalization. Address these first.
HOW TO USE — For each item: ✓ Safe | ! Needs attention | ✗ Action taken (note what was done)
🍳 KITCHEN
| Item | ✓ Safe | ! Needs attn | Action taken |
|---|---|---|---|
| Stove knob covers installed or knobs removed | ☐ | ☐ | |
| Automatic stove shut-off device | ☐ | ☐ | |
| Cleaning supplies locked away | ☐ | ☐ | |
| Sharp knives stored out of reach | ☐ | ☐ | |
| Expired food removed from fridge/pantry | ☐ | ☐ | |
| Fire extinguisher accessible and charged | ☐ | ☐ | |
| Smoke detector working (test monthly) | ☐ | ☐ | |
| Kitchen floor clear of tripping hazards | ☐ | ☐ |
🛁 BATHROOM
| Item | ✓ Safe | ! Needs attn | Action taken |
|---|---|---|---|
| Grab bars beside toilet and in shower | ☐ | ☐ | |
| Non-slip mat in shower/tub | ☐ | ☐ | |
| Non-slip mat on bathroom floor | ☐ | ☐ | |
| Water heater set to ≤49°C (120°F) | ☐ | ☐ | |
| Door lock removed or replaced (no locking in) | ☐ | ☐ | |
| Raised toilet seat if mobility limited | ☐ | ☐ | |
| Medications removed from bathroom cabinet | ☐ | ☐ |
🛏 BEDROOM
| Item | ✓ Safe | ! Needs attn | Action taken |
|---|---|---|---|
| Night light on path to bathroom | ☐ | ☐ | |
| Bed at safe height (not too high) | ☐ | ☐ | |
| Bed rails if fall risk during sleep | ☐ | ☐ | |
| Loose rugs removed | ☐ | ☐ | |
| Cables and cords secured out of pathway | ☐ | ☐ | |
| Window locks functional (wandering risk) | ☐ | ☐ |
🏠 LIVING AREAS & HALLWAYS
| Item | ✓ Safe | ! Needs attn | Action taken |
|---|---|---|---|
| All pathways clear of furniture/clutter | ☐ | ☐ | |
| Loose rugs removed or secured | ☐ | ☐ | |
| Adequate lighting in all rooms | ☐ | ☐ | |
| Night lights in hallways | ☐ | ☐ | |
| Unstable furniture secured or removed | ☐ | ☐ | |
| Stairs have secure handrails both sides | ☐ | ☐ | |
| Stair gate if needed (late stage) | ☐ | ☐ |
💊 MEDICATIONS
| Item | ✓ Safe | ! Needs attn | Action taken |
|---|---|---|---|
| All medications in locked box or dispenser | ☐ | ☐ | |
| Timed medication dispenser in use | ☐ | ☐ | |
| Expired medications disposed of | ☐ | ☐ | |
| Complete medication list up to date | ☐ | ☐ |
🚪 ENTRYWAYS & WANDERING RISK
| Item | ✓ Safe | ! Needs attn | Action taken |
|---|---|---|---|
| Door alarm on all exterior doors | ☐ | ☐ | |
| GPS tracking device worn consistently | ☐ | ☐ | |
| MedicAlert Safely Home bracelet registered | ☐ | ☐ | |
| Trusted neighbour knows the situation | ☐ | ☐ | |
| Car keys secured if driving is stopped | ☐ | ☐ |
📋 EMERGENCY PREPAREDNESS
| Item | ✓ Safe | ! Needs attn | Action taken |
|---|---|---|---|
| Emergency numbers posted visibly (large print) | ☐ | ☐ | |
| Personal alarm / call button accessible | ☐ | ☐ | |
| Neighbour has spare key | ☐ | ☐ | |
| Medical information card in wallet/purse | ☐ | ☐ |
PRIORITY ACTION LIST — Items needing attention (transfer from above)
| Item needing attention | Action required | Who will do it | By when / Done date |
|---|---|---|---|
BC resources: MedicAlert Safely Home 1-800-432-5223 · RoadSafetyBC (driving report) 1-800-950-1498 · Fraser Health Access Line 1-877-935-5669 · Free care navigation call: gurjotnarwal.com/how-i-can-help