My Negligence Caused a Fall

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    I was ready to hand in my name tag today. It started out pretty normal.....6 am my first get-up is an 83-year-old lady who has been going downhill for the past few weeks. She can no longer walk and is getting dangerous to transfer because her legs buckle so easily. She weighs about 180 lb. The routine is to get her toileted, dressed, do her oral care, and place her tray full of face cream and make-up in front of her so she can do that herself before breakfast as she waits in her wheelchair. Her wheelchair is alarmed with an RN sensor on her seat and a 'tabs' alarm attached to her blouse so she won't try to get up unassisted. When I left her room at 6:40 am to take care of my other residents, I had her RN sensor on but not the tabs, which I managed to forget. 7:10 am I go back to her room to help her finish putting on her makeup and take her to the dining area for breakfast. She is in the middle of the floor lying on her side, her eyes blank. She seemed happy as a clam and not even aware that she'd just fallen. Her chair alarm hadn't gone off to alert us to her trying to stand ( apparently the alarm was working properly but the sensor she was sitting wasn't working). The worst part was I realized that I'd forgotten to put her tabs alarm on -- at least if she'd had that on we would have heard her trying to get up even without the chair sensor going off. As it was we didn't even know how long she'd been lying there.

    My co-workers were kind and reassuring, but I'm being pretty merciless on myself. I'm not brand new at this and I'm not dumb....but to forget something that basic is inexcusable. I was close to tears the rest of the day I was so mortified. The lady wasn't hurt other than a big bump on her head, and later on that day she seemed to have no recollection that anything had happened because she tried to do it again.

    This makes me want to quit so badly, however I cannot afford to unless I have another job to go to. It scares me how easily this happened, how I could be so mindless. I've caught other aides forgetting to put alarms on from time to time as well as myself, but so far we caught it before anyone fell. I'm going to have a hard time forgiving myself, even though this lady's daughter was also very kind and understanding to me about it. I was afraid she'd 'fire' me from taking care of her daughter again. I'll just have to work this out of my system.
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  4. 10 Comments so far...

  5. 0
    You don't need to quit your job. Everyone makes mistakes. Everyone. No one is perfect. I forget to do things too. However, I no longer condemn myself like I did when I was younger. This is the way I see it. I go to work and I always try to do my very best. And that's all I can do. Yes, I am sometimes forgetful. Yes, I sometimes make mistakes too.
    Welcome to the human race!!!!!! Hang in there. You are going to be OK.
  6. 1
    I know it's upsetting, but don't continue to beat yourself up. I had a similar thing happen years ago - I had a 14 year old girl manage to slip out of her soft restraints while sitting in the wheelchair (no alarms then). She had slipped down almost to the floor and I felt so awful. A good thing - you will always have a heightened awareness of this which makes it very likely you won't ever do it again. ((hugs))
    interceptinglight likes this.
  7. 2
    You know what? I have been an aide for 5 years now, and I have forgotten to attach those tab alarms before. I once didn't even know a resident was supposed to HAVE a chair alarm (they kept it in his bedside table when he was in bed, and I'd never cared for him before - he ended up trying to get up, and he fell.

    Just recently, I forgot to turn on a door entry alarm on one of my residents. She walks fine, but we have to be alerted when she exits her room because she wanders, she tries to drink water when she is NPO, and once, she got to the nurse's cart and ate some pills that were sitting on top. She also sometimes claws at and pulls the hair of other residents.

    Anyway, a few weeks ago, I was toileting her and one of our seizure lights went off. We don't have call lights (it's a facility for the severely developmentally disabled, we have only one resident who uses a call light, so when an alarm goes off, we know it's an emergency light.) I walked her back to bed, ran out of the room and didn't even think about the alarm, I was so focused on the emergency light. She ended up wandering all the way down to the other end of the facility and trying to drink out of a toilet (luckily we caught her in time).

    My point is, we're human. It's normal to feel horrible and beat yourself up about these things, lord knows I did and do...but don't quit your job over it. The fact is, we're mere mortals doing a very stressful job, and as much as you'd like to never forget anything, sometimes it happens.

    The good news is, the lady is fine. And you will never forget to attach a tab alarm again.
  8. 0
    You all are so nice. Yes I know I need to stop kicking myself in the butt. If this lady's chair sensor had been working properly this may not have happened. And yes they quickly rounded up a brand new sensor pad, luckily the State inspectors weren't around to see this. I'll get over this, but I'm going to be super paranoid about making sure alarms are applied whenever necessary.
  9. 0
    Quote from yousoldtheworld
    You know what? I have been an aide for 5 years now, and I have forgotten to attach those tab alarms before. I once didn't even know a resident was supposed to HAVE a chair alarm (they kept it in his bedside table when he was in bed, and I'd never cared for him before - he ended up trying to get up, and he fell.

    Just recently, I forgot to turn on a door entry alarm on one of my residents. She walks fine, but we have to be alerted when she exits her room because she wanders, she tries to drink water when she is NPO, and once, she got to the nurse's cart and ate some pills that were sitting on top. She also sometimes claws at and pulls the hair of other residents.

    Anyway, a few weeks ago, I was toileting her and one of our seizure lights went off. We don't have call lights (it's a facility for the severely developmentally disabled, we have only one resident who uses a call light, so when an alarm goes off, we know it's an emergency light.) I walked her back to bed, ran out of the room and didn't even think about the alarm, I was so focused on the emergency light. She ended up wandering all the way down to the other end of the facility and trying to drink out of a toilet (luckily we caught her in time).

    My point is, we're human. It's normal to feel horrible and beat yourself up about these things, lord knows I did and do...but don't quit your job over it. The fact is, we're mere mortals doing a very stressful job, and as much as you'd like to never forget anything, sometimes it happens.

    The good news is, the lady is fine. And you will never forget to attach a tab alarm again.
    That's hilarious about that drinking out of a toilet thingie. Maybe I shouldn't laugh, but it sounds so comical.
  10. 2
    Everybody makes mistakes. I bet you will be super careful about checking now, which is a GOOD thing!
    Last edit by JDZ344 on May 14, '14
    Dondie and KimberlyRN89 like this.
  11. 0
    Quote from interceptinglight
    You all are so nice. Yes I know I need to stop kicking myself in the butt. If this lady's chair sensor had been working properly this may not have happened. And yes they quickly rounded up a brand new sensor pad, luckily the State inspectors weren't around to see this. I'll get over this, but I'm going to be super paranoid about making sure alarms are applied whenever necessary.

    And that is a good thing
  12. 2
    Just take it as a lesson learned. It seems, if you quit, this place and it's residents would be missing one very caring CNA!!!
    interceptinglight and JDZ344 like this.
  13. 0
    You're learning from your mistake and that is the best thing you can take from the situation. We all know how hard this job is and stuff like this happens. Be thankful that she wasn't hurt worse and just make sure the alarms are on next time. That's all you can do.

    You seem like a good CNA and those residents would be missing out on a lot if you quit. At the end of the day, it's about them. Do the best you can do and that's all anybody can expect.


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