Documenting on patient falls or what looks like one in LTC

[lumbarpain]

I have gotten reprimanded INTENSELY for writing a nursing note in regard to a patients fall.

Of course all you LTC nurses out there have been in this scenario.....you are walking into a patients room and wa la...there they are ON THE FLOOR. Could I ask all of you to answer me this? HOW do you start your Nursing note.......PATIENT FOUND ON FLOOR WHEN THIS NURSE ENTERED ROOM,, PATIENT OBSERVED ON FLOOR WHEN ENTERING ROOM, PATIENT SITTING OR LYING ON FLOOR WHEN THIS NURSE ENTERED ROOM? I am curious to see what the answers would be .....thanks.....I will let you know what I put after I get my answers.!!

[VivaLasViejas, ASN, RN]

lumbarpain said:

I thought of this nurses note just for fun..

...This nurse wearing a white uniform with her hair tied straight back with a pair of new white and blue Sketcher sneakers on and a brand new shocking shade of glossy lipstick on, glanced into room 222 as she stood inside the badly painted door frame of the patients room as the call bell light flashed vigorously on and off above her head.

She gazed across the well lit patients room where she Observed patient Mr. No name seated firmly with both buttocks securely adhered to the nice clean polished floor. His right arm extended across the top of the bed that had crumbs in all different sizes and shapes from Mount Rushmore to the Easter Island Statues resting on the hairs of his arm. Mr No Name was wearing brightly colored satin socks and a nice new pair of denim Gap jeans with freshly combed dark brown very thinning hair, smiling broadly without his dentures , as his ocean blue eyes sparkled with delight as I approached him cautiously, with enduring loving care. On the left side of the new automatic turbo bed the patient had bought personally for himself and delivered by Medical/Surgical Devices.com was just purchased on May 15, 2012. The bed was freshly made by the CNA at 9am this morning with, a pale blue /a tasteful comforter bought from Pier One Imports with small teeny weeny flowers on them and a low sugar mint made by M&Ms place neatly on the pillow in a small Plastic Ziplock bag.

He offered no complaints as I assessed him. He did comment on the distaste he had for the extremely runny farm fresh organic brown eggs and toast for breakfast which the kitchen had left neatly placed on his bedside tray table which was just cleaned with the facilities disinfectant that smelled like Mr. Clean. He stated that his Wonder bread white toast had crumbled in his arthritic stricken calloused in need of a manicure hand and the toast resembled the side of a burned down barn that just passed through a F5 Tornado that hit Jovi, Illinois back in the 70s at 4;30pm in the afternoon. He pointed to a pale pink soupy looking yoplait yogurt with chunks of indescribale lumps of possible dehydrated strawberries, low in fat and calories , which was poured generously ontop of his newly pressed pants resulting in a stain that Tide with bleach wouldnt get out. He smiled broadly without his new effervescentedly cleaned dentures made downtown at the bargain basement denture making factory located at 123 Maple Street near the dunkin donuts that burned down on Valentines Day back in 1999..

His slippers were pushed out of his view under his bed by the housekeeper Shirley who came in very late this morning due to traffic on the expressway caused by a overturned Sausage company truck resulting in sausages all over the rain slicked highway during rushhour. While he shaved in the bathroom with his new Gilettle razor and Edge shaving cream he mistakenly sprayed the cream all over the new Sears water proof wallpaper that maintenance put up on May 1st 2012 at 12:30pm. He stated his balance went slightly off to the right when he bent down to see where they were under his bed. His one strand of hair on his balding head had dropped over his one left cataract stricken eye which Doctor Eyestein had examined on March 3rd who stated to continue eye drops as previously ordered, as his legs bent on a 90 degree angle, he felt a tightness in the crouch part of his pants causing a shift of his (not changed yet by the aide) diaper impairing his ability to properly coordinate his right knee which turned toward the sunlite window of his room making his legs weak like a wet noodle so he stated. He also said that his washable well intact On 'sale Walmart bunny slippers that were a cool blue with non skid soles and funny bunny ears.."had hopped away from me" disturbing his morning routine and making him depressed which he refused medication for. He also questioned how could bunnies hop without any legs? Referring to his slippers. Will call and inform Dr Psycholo on that statement in 5.5 minutes from now.

While I attended to his now disgusting dried up yogurt on his pants, I had noticed that 2 hours had passed since I had walked through that badly painted patient room door with the call bell flashing vigorously over it, that had the patient sitting on the floor with both buttocks securely seated to the nice clean polished floor wearing brightly colored socks. etc etc etc........Hope you all enjoyed this.!!!....thank The Lord we dont have to be so detailed.!!!

THAT has to be one of the funniest things I've ever read!!! ROFLMBO!!

[lumbarpain, ADN, RN]

Ok, with everyones help here the 3 words that can describe a patients fall in NNs are.....".Found"( which I will never use again)

"discovered",(great word, never thought of that one) and" Observed".......Thanks Lumbarpain

[lumbarpain, ADN, RN]

ps, glad you guys enjoyed my little tidbit of a Overblown Ficticious Funny Nurses Note. We need to laugh more in this world......Truly, we do.

[cvr1998]

Hi everyone, Just looking for some advice. A friend works as a CNA in a nursing home on rehab. There are supposed to be 3 CNAs for 40 residents 11-7 overnight shift. One night there were only 2 ( this happens a lot) 1/2 way through the shift the supervisor told the other CNA she had to go to another unit to help out for an hour because they were short staffed. While she was gone, one of her assigned residents fell so my friend was the one responsible and had to do an incident report. She stated what happened including the fact that they were short staffed. The DON told the supervisor to tell her that she had to change her statement and remove any reference to staffing as she may be fired. My friend does not want to because they are always working with not enough staff and things like that happen a lot. Can she get fired? does she have any recourse?

[CapeCodMermaid, RN]

Most of us are at will employees so we can be fired at any time.

I'm not sure why they have a CNA doing an incident report- that usually is a licensed job.

If they do root cause analysis of why the fall occurred, it would be helpful to know the staffing pattern on that particular night.

--if they want you to remove the part about shirt staffing what else might they want you to be less than honest about?

[VivaLasViejas, ASN, RN]

They're wanting your friend to falsify documentation because the state surveyors will eat them alive when they see the IR.

She should NOT change her documentation. Like CapeCodMermaid said, if management wants her to change that, what else might they hiding?

[CapeCodMermaid, RN]

--if they want you to remove the part about shirt staffing what else might they want you to be less than honest about?

They might want you to falsify pants staffing...sorry for the typo