Hello all

I work at an assisted living and have 60 residents there.

Just recently, we send a patient to the hospital because he was having trouble breathing. Turns out he had pneumonia.

I went to visit him in the hospital, because I like to always check up on my residents. I guess he apparently also has two small bleeds in his brain and the hospital reported our facility to adult protective servies.

Our nurse consultant went through and looked at our communication log (which lets all the caregivers know what happened). It stated in the book at one point he fell on his butt thinking he was on a toilet but was actually in his room. His roommate saw it and said he didn't hit his head or anything and was fine. He also ran into a wall one day and ended up with two small scratches on his face on a different day. Neither of these occurences would have warranted bleeds on the brain I think. My nurse consultant said that I should have been charting on all this and that I will get written up. But an actual fall is not listed.

Most of the staff thinks he fell some other time and told no one. He didn't have a LOC change or anything.

Have I made an error here? And if so, how big of one? I never had any formal training at this facility, I've been playing it all by ear.

Any info would be great thanks.

Any falls/injuries should be documented, no matter how minor. Particularly in LTC...between the fragility of the pts. and the countless rules and regs, yes, you document everything. Better to have documented unnecessarily than not to have documented and have a situation such as yours.

Consider it a hard lesson learned.

One thing to consider: he could have already been having bleeding in the brain when he started having these falls. The falls could have been a clue that something was going on with the pt.

Live and learn.

Can I ask to obvious? Does this resident have a history of thinking he's on the toilet and hitting the floor? Does he routinly walk into walls? If the confusion was new- that would certainly qualify for further investigation. In the facilities I've worked in- a roommate's account of a fall is not good enough unless witnessed by a staff member. We would have had to do the Neuro checks anyway.

I'm so sorry you are having to go through this. I hope the resident comes out ok. Good luck.

Hi, the resident has Alzheimers - early stages, It was the first time he tried to "sit on the toilet" in his room. He was stable. His daughter is the only one who thought he appeared more confused than usual.

So far though, we've had no visit from adult protective services or anything and it's been almost a week. We'll just see how it all pans out.

Thanks for the response.

You need to chart on everything that happens/injuries to a res. no matter how simple it is.

Worked in an ALF for 4 years, hear ya! LONG post, but hopefully helpful to you!

First...since this is an ALF, it doesn't fall under many of the rules as LTC or SNF! Assisted Living...not nursing home. Sadly people try to make it out to be more like a nursing home as far as the rules and documentation that is needed...this is why ALF is very difficult to work for, why nurses can't nail down their own roles in these facilities, and I feel that the rules need to be changed as far as admitting and when a patient SHOULD be discharged to a skilled facility!

Assisted living SHOULD be just that...a stable or fairly stable patient who just needs assistance with certain ADL's and medication administration. Once they deteriorate and needs exceed having a CNA or nurse come in once or twice in a shift...they should be advanced to a LTC or SNF. This never happens because of the money situation (why give up a patient if the facility can charge more for more assistance?? UHGGGG!), families misunderstanding that ALF isn't a perm solution and that patient will need increased assistance in another facility later, and the fact that assisted living places look appealing to folks (in fact the facility spends much of its money on making the facility look homey so that more people are attracted to it and more people come to live there!!!). I call it the beautiful cake syndrome...gorgeous frosting and design..but take a bite and it is concrete!.

With that said, the falls should have been investigated and charted fully with an Incident report. It is very important to also have a tracking log of falls to see patterns in residents that may be falling more than normal. So speak to managment about that! Once a week we had a nurse come in and log all falls and do some investigation...best idea down the pike for a long time! (we had 140 residents!). Implementations, continued assessment, care plan...all must be documented.

HOWEVER, I do know that many times these falls are NOT reported by the patient or other residents because of the investigations and all the hoopla the patient has to go through after a fall (its embarresing enough to fall...let alone go through shift VS, investigations, possible changes to their rooms like items being removed for safety, escorts to meals, occupational/physical therapy and MD visits...and this lasted at least a week per fall! I don't blame them for keeping falls hush hush!). So these falls may have gone totally unnoticed...so if they did that fact needs to be investigated and documented!

And remember...it could have been the bleed that was causing this all...or vice a versa. Only an MD will be able to determine that even if it can be determined. Your role as the RN is NOT to diagnose, but to communicate changes of conditions to the MD, provide safety and comfort to the patient, provide safe tx and medication administration, and investigate probelms as they come.

They can NOT fault you for the Dx! You don't have MRI vision or the skills to Dx! The only thing that you could do is alert the MD of changes in condition, like falling or hitting walls frequently...IF you actually knew about them!!!...and wait for MD orders regarding what to do next!

Did you know about the falls as they were occuring??? If so and nothing was charted or implementations and MD consult/communication weren't documented or done, then there is cause for the Nurses there to be under investigation considering that is the Nurses job...so if that is the case I would speak to your DON about it, and what needs to change...

Good luck to you and feel free to ask questions in regards to ALF's to me! Been there, done that, yelled and screamed about it..LOL, changed some rules, made some excellent new implementations (like the fall log book)...and have lots of nurse friendly ideas!

My advice to you can be contained in three words:

Document!

Document!

Document!

As an ALF nurse myself, I would never expect you, as a caregiver, to chart the way I would; nor are you bound by the regulations that govern my practice as a licensed professional nurse. However, to protect both yourself and the facility (not to mention the residents! ) you have to write something down each and every time there is an unusual occurrence. This includes---but is not limited to---skin tears, bumps, bruises (which could be signs of abuse), suspected falls, or changes in behavior/elimination patterns/level of consciousness/vital signs/interactions with staff or other residents/appetite/weight/fill in the blank.

It's also good practice to note these issues in a communications book which should be read daily by each shift prior to beginning work, as well as the facility nurse whenever she or he is in the building. Since many ALFs are not fortunate enough to have a full-time nurse, it's largely up to the staff to make sure incidents are reported in a timely manner (within 24 hours maximum) so that the RN, LPN or whoever is in charge of investigations is fully informed.

It looks bad when the state comes in and the administration is caught flat-footed ("Nobody told US that Mrs. Smith has been falling"), but more so, a lack of documentation and follow-up makes the facility appear negligent, and THAT is what gets buildings in trouble. As a caregiver, you may not be held to the standard that a licensed nurse would be, but you do have a duty to report all unusual occurrences, and you will be held to that standard.

So---document, document, document! Think of it as giving yourself credit for the hard work that you do every day, and for noticing changes in your residents that may be warnings of an impending catastrophe, or may simply be just what they appear to be---a bump, a bruise, or a head cold.

Good luck to you, and thank you for doing a poorly paid and often thankless job---caring for some of our most vulnerable citizens.

do everything you need to do,document,document document everything,so you could cover your butt :chair:

I appolgize...I thought she was a nurse. Well take that response I gave and give it to the nurse there..LOL!!!!

I fully agree with Mjlrn97 with the role of CNA in this! And I too thank you very very much for your hard work!

You didn't mention how old this patient was, however, elderly people are frail and they can get a small cranial bleed with the smallest bumps that may not be detected for a couple of weeks. You need to be aware that assisted living facilities are not as closely regulated as nursing homes. That is why they can get away with the lower staffing levels that they do. Actually, many assisted livings only utilize nurses to pass medications and that is it. Therefore, to be on the safe side you really should be more vigilant since more and more people are putting their relatives into assisted living because it is less expensive than the nursing home even though they need nursing home type care. Two scratches on the face, another patient witnessing a bump against the wall are definitely things that should have been charted on and incident reports made.

While adult protective services will probably do some sort of investigation, it will most likely be difficult for them to trace the source of any injury. Is it possible that medication could be responsible for his bleeding? In any case, don't be fooled that because these patients are in assisted living that they need any less watching or nursing care than nursing home patients. You are working in a very hazy area of nursing care.

It's a bit crap for you when no one bothers to actually give you training for the job you're doing! They really shouldn't be too surprised when situations like this occur, and should be supporting instead of chastising. Anyway, I'll climb of my high horse and say i agree with all the other posts.... for the sake of yourself and your clients, DOCUMENT EVERYTHING! (don't mean great long stories, just the facts in a straight to the point manner )