Quote from JettaDP
I am a first year nursing student and I have a learning issue that I need to get some information on.
I am trying to find out what your employers policy on documenting falls are and who gets notified.
I am mainly just trying to compare the different policies out there.
At a nursing home in my area, if someone falls and gets injured, they just fill out an incident report and then they put it on the assistant DON's desk.
If you are okay with giving me some information, I will need what type of facility you work in, the policy, and what state you're in.
Thank you so much for everyone's help.
Typical fall documentation at a nursing home in my area (Central OK):
Nurse assesses fallen resident for injury and provides appropriate care. Vital signs are taken and documented, incident report is filled out, the doctor is notified. How the physician is notified depends on the severity of the injury. If injuries are minimal, by FAX, and if there's suspected head trauma or hip injury, the doctor is called (if the injuries are obviously severe, to the point where moving the resident may be dangerous, 911 will probably be called). The resident's responsible party is notified.
A nurse's note is documented describing the known facts regarding the resident's fall and any interventions. However, most nursing instructors and facilities will tell you, do NOT document anything about an incident report in the nurse's notes.
If head trauma is known or suspected, neuro checks are done and documented per the facility's protocol (usually q15min x 1 hour, q 30 min x 2 hours, q 1 hour x 2 hours, q 2 hours x 4, q 4 hours x 4, q 8 hours x 4. I don't remember the common protocols anymore.
Usually, the resident is charted on at least once a shift for 72 hours, noting if the resident is having any continuing problems r/t the fall, pain, pain control measures, wounds, etc.