"After the Fall" LTC/SNF Nursing Know-how 101

  1. 0
    I know many may want to "file" this question under the "duhhhhhhh, column of basic nursing" but I would like info on the protocol and proceedures of nursing care after a pt falls. Please share how and what your response is. How do you handle falls? What exactly do you do? Also, what are the roles of the CNA's re: pt falls? We had a CNA say, (after she found pt and assisted nurses returning her to bed), that she didn't know she was to do VS on fall pt. Which was pretty much throwing the nurse, not to mention the pt, under the bus. Don't CNA"s learn how to monitor pt p fall in school these days? I realize ea facility is "supposed" to have available policy and proceedure manuals. I've been on a "Where's Waldo?" hunt in my facility to find them. Why aren't the manuals online? Maybe they are properiortory (sp) information . I have heard they may be locked up in the DON's ofc. Which doesnt help PMs and noc nurses. Also, do I dare mention the politics of "what constitutes a fall" some use the term "slid out of bed" how does that work? How to evaluate what is a fall and what is a slide? Thank You Nurses
  2. Get our hottest nursing topics delivered to your inbox.

  3. 15,056 Visits
    Find Similar Topics
  4. 16 Comments so far...

  5. 3
    Definition of a fall per CMS guidelines is an unexpected change in planes....doesn't matter how it happened. IE: if the slid out of bed, if they were lowered with assist to the floor, if they whacked their rear to the ground. They are all falls.

    CNA's role: Keep the resident down and get the nurse. It is not their job to "monitor" the resident - they are not a nurse and not qualified to assess a situation. (To prevent flaming by the CNA's..there are many good CNA's. I often know how fast to get to the scene based on the tone of their call for help. They are not "legally" allowed to assess, but many really do understand when a situation is emergent vs. no big deal).

    The nurse: I walk into the room asking resident what happened - looking for the level of orientation and assessing if it has changed (do they know who they are, do they know who I am, can they give a reasonable account of what just happened - all in consideration to their prior level of alertness). Asking if they hurt anywhere - that is the first area I will want to assess. If they complain of leg pain I start looking to see if they have rotation of their foot, is one leg shorter then the other, etc. Once I am satisfied that there isn't obvious injury, I have the aide assist me to get them back into w/c or bed or whatever. Then I take vitals (I would never want the aide to do this for me in this situation. I have to answer for this assessment and I don't want to find out later that the vitals I used were incorrect. I have had to many aides hand me blood pressures of 92/130).

    followup: Nurse to monitor every shift for 24 hours if no injury and no head involvement. If they hit their head they have neuro assessment done every shift for 72 hours. I should add here, if you believe they have a head injury of any kind they need sent to the ER for immediate assessment. Also after resident is cared for it is important to try to determine the cause of the fall and careplan an intervention to prevent a fall from reoccurring.

    Hope this helps
  6. 0
    Quote from Let's help out
    I know many may want to "file" this question under the "duhhhhhhh, column of basic nursing" but I would like info on the protocol and proceedures of nursing care after a pt falls. Please share how and what your response is. How do you handle falls? What exactly do you do? Also, what are the roles of the CNA's re: pt falls? We had a CNA say, (after she found pt and assisted nurses returning her to bed), that she didn't know she was to do VS on fall pt. Which was pretty much throwing the nurse, not to mention the pt, under the bus. Don't CNA"s learn how to monitor pt p fall in school these days? I realize ea facility is "supposed" to have available policy and proceedure manuals. I've been on a "Where's Waldo?" hunt in my facility to find them. Why aren't the manuals online? Maybe they are properiortory (sp) information . I have heard they may be locked up in the DON's ofc. Which doesnt help PMs and noc nurses. Also, do I dare mention the politics of "what constitutes a fall" some use the term "slid out of bed" how does that work? How to evaluate what is a fall and what is a slide? Thank You Nurses
    Best practice guidelines: any change in elevation is a fall, nueros on all unwitnessed fall (doesn't matter what the resident tells you, do nueros), don't touch resident without nurse assessment especially for new pain, decreased ROM all joints. C.N.A's work under the license of the nurses, nurses must train and educate, I wouldn't expect the aides to do anything accept leave the resident on the floor, get the nurse and proceed from there and fill out their portion of the incident report. If you train them, they will learn to get the vitals at the scene, but safety comes first before vitals, and if the fall is a repeat offender, initiate tab or pressure alarm asap or move closer to nursing station. There is no reason a nurse can't get the vitals either. Ask for and make referral to PT for fall evaluation, chart, put on alert, call MD and family and DON/Administrator. Look for abuse/neglect: was the patient too close to the edge of the bed, slid out of bed, speciality mattress deflated and patient slid, bed NOT in low position, etc. Train your CNA's not to leave w/c's next to bed of folks who WILL try to climb back out of bed, keep the busy fallers UP as long as possible and entertained, so that when they DO go to bed, they go to sleep.
    Note on the comment "Locked up in the DON" office. This is such a bizarre statement, I have heard it over and over at my building. The ONLY thing I have in my DON office is the filled out incident reports, and ONE policy and procedures manual and ONE purple book for SNF guidelines. THESE are ALL available at each nurses station, easily visible in the chart racks.
    WHAT is this about? WHY do nurses persist in passive-aggressive "I don't know" "I don't have time" attitudes that ultimately HURT them? MEMO to all nurses: IF one really think the DON has all the vital books locked up in her/his office then for HEAVEN"S SAKE go see her/him during office hours and ASK for them. (and CALL in the off hours to find out from the DON where the books are located.

    Seriously, CALL the DON, the Administrator, the owner, the corporate nurse, the MD. TELL the DON what these other nurses are saying and CALL the Staff Development nurse so she/he can schedule an immediate inservice for those NOT in the know.
  7. 1
    I'm in CNA training right now (required for entry to RN program). What we are taught: Do NOT move the patient, call for help, and stay with them until help arrives. The nurse will do any assessment. CNA may then take VS and record/report as often as the nurse or physician orders. It's not part of the CNA protocol to take VS immediately after a fall.
    pixie120 likes this.
  8. 0
    Nursing Care Post Fall:Assess the patient is the #1 priority of the nurse. Make sure they have not lost level of consciousness and are aware of what is going on. Make sure that they are able to move all of their extremities as before. Assess if they hit their head (this is an automatic CT scan). Initiate plan of care related to fall assessment. Institute interventions (which should have already been in place if a patient suspected a fall risk...as everyone of them are including most stablest patient)...most places have have the falling leaf or star on door and the non-skid socks in place to make staff aware. Then evaluate the patient's need for monitoring or assistance. Sometimes we as nurses are so involved with other care that we tend to forget that patient with IV pole may not be strong enough to push it or rooms are not so clutter free as they should be. The patient should be monitored/assessed for 24 hours post fall for decrease in level of consciousness, injury, etc...It should be passed on in report post 24 hr, and of course notify the physician, family, unit manager/director, risk manager via incident report

    What Is The Role Of CNA After Patient Falls: Upon finding a patient who has fallen they must stay with the patient. The nurse does the assessment not the CNA. After the nurse has assessed the patient then the CNA may assist with helping the patient off the floor. CNAs are allowed to take vital signs, but the nurse is the one doing the assessment and is the one who evaluate the vital signs as normal or abnormal. If abnormal vital signs then the nurse must recheck them...not ask the CNA to recheck. After all CNAs are our assistance on the units and they should be capable of taking accurate vital signs or the facility should question their certification for being a CNA.

    What Is Deemed A Fall: Most times the nurse never sees the patient fall. When we see them they are most likely already on the floor. So, I always chart that I found the patient on the floor rather than say I saw the patient fall, then I chart what position they were found in, and if it was near the bed or bathroom or whereever they were found, and my assessment/evaluation of the patient. What deems a fall is really finding any patient on the floor. If the patient says they fell then I chart patient states that they fell and what they stated they were doing at time of fall.

    I have been in practice for a long time and this is usually the standard of care for a patient fall. Hopefully this information is helpful to you and others...love you and keep it safe.
  9. 2
    Quote from sunflowergirl48
    [U][B] Assess if they hit their head (this is an automatic CT scan).[/I]

    That is not true in all places and we do NOT send all of our folks out for a CT if they hit their head. Sunflower - are you in LTC? I have never worked in a LTC that required automatic head CT for all bumped heads.
    BlkQueenLPN and LTCangel like this.
  10. 0
    VS taken q15 minutes post-fall for 24 hours to monitor condition is my facility's procedure to follow. Also, as the CNA, I will get the nurse right away so he/she can assess the resident/situation as it was found, as long as the resident isn't in a position where they are in immediate danger. Tab alarms and pressure alarms do help quite a bit because these devices let us know when someone is getting restless (often because they need to toilet or need a brief change) so we can hopefully prevent the fall.
  11. 2
    The one thing I was taught and continue to do these days, I have not seen anyone address. Ask the pt to do ROM on all 4 extremities before getting them up. If they are unable, then I do passive ROM to make sure there is no pain with movement in any extremity.
    Also, I have always done v/s and a neuro check BEFORE getting them up off the floor. And be sure that you are sitting them up and letting them stay in a sitting position for a couple minutes before standing them up to avoid dizziness. (I find that I have to stop at that point also in order to change MY body's position so that I can properly lift them to their feet.)
    VivaLasViejas and boogalina like this.
  12. 0
    Nascar Nurse I am a hospital nurse. But, I would think if a patient falls and hits their head in a LTC facility a CT Scan should be ordered. I remember having a patient in the hospital a few years ago that fell at a LTC facility out of a wheelchair and hit his forehead. The patient was sent to the hospital a day later lethargic and comatose. He died the next day after hospital admission from a epidural hematoma. So, I did not say all patients at LTC should have a CT of head if fall...I said if they hit their head a CT should be ordered. This is why post fall assessment is very important. We just have to be very careful of head injuries during a fall and very mindful of the patient's neurological status prior to the fall.
  13. 4
    Quote from sunflowergirl48
    Nascar Nurse I am a hospital nurse. But, I would think if a patient falls and hits their head in a LTC facility a CT Scan should be ordered. I remember having a patient in the hospital a few years ago that fell at a LTC facility out of a wheelchair and hit his forehead. The patient was sent to the hospital a day later lethargic and comatose. He died the next day after hospital admission from a epidural hematoma. So, I did not say all patients at LTC should have a CT of head if fall...I said if they hit their head a CT should be ordered. This is why post fall assessment is very important. We just have to be very careful of head injuries during a fall and very mindful of the patient's neurological status prior to the fall.

    Not necessarily disagreeing with you about it being a good idea but we have many unwitnessed falls and it would be a huge $$ amount in transfer costs as well as CT costs to send them all out. Very important to do an initial neuro assessment as well as follow up assessments per policy. If any doubt..send them out.


Top