Documenting on patient falls or what looks like one in LTC

  1. 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 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.!!!!
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    About lumbarpain

    Joined: Mar '11; Posts: 324; Likes: 238
    Homecare RN; from US
    Specialty: 17 year(s) of experience in Geriatric/Sub acute/home care


  3. by   kappykatlpn

    What I usually do is start like this "observed resident on the floor on his/her left side......." and describe exactly what I saw when I entered the room.
  4. by   loriangel14
    BTW it's spelled "voila" not wa la.

    If I found the patient I write " Writer found patient on the floor beside bed...etc "
  5. by   Sparrowhawk
    What exactly did you write!?
  6. by   lumbarpain
    Patient found sitting on floor near left side of bed when this nurse entered room. I was TOLD DONT EVER EVER write the word FOUND....I was written up for that......out of all the facilities I have worked in since I graduated this facility was the only one that said that was wrong. Thought it was very strange.
  7. by   lumbarpain
    Oh, forgot this......they said to use the word OBSERVED Instead of the word FOUND....
  8. by   caliotter3
    While the word 'observed' sounds better to me, I doubt that I would have reprimanded you over your use of the word 'found'. If it was that big of a deal, they should have had you rewrite the note or better yet, you should have been informed during your orientation. But a reprimand? No, unless you should have already known better. Sounds to me like you missed reading their minds on this one.
  9. by   amoLucia
    I don't understand your reprimand ... altho this was an unwitnessed fall, did you NOT proceed as a 'fall' and only charted in your nsg notes??? That would be a write-up IMO. Any one of your starting entries seem basically OK with me, but soooo much, much, much more documentation is necessary.

    ANY, ANY, ANY time, way, or how a pt is on the floor, it's treated as a fall incident, even if unwitnessed. This is basic standard operating procedure in all LTC facilities I know. You follow your facility's P&P for falls, with all the ballyhoo assessments, notifications & paperwork, incl. the incident report and your nsg notes. The one thing I try most intensely to include any explanatory statement by the pt, verbatim, if poss. "I went to answer the doorbell for the pizzaman" or "I'm looking for my pen under the bed" or "didn't I tie the rope into a pretty bow (the call bell !)?". I also chart any observable cues (or clues) that could explain the situation.

    So if your handling of the occurence was incomplete and/or your documentation was seriously lacking, there would be a problem. You seemed to start out OK in your notes (pretty much like #1 poster), but you need a whole lot more to it. Was that the issue here for the reprimand?
  10. by   CapeCodMermaid
    I spied with my little eye.....Sounds like they are kooky. Who cares what word you use? The rest of the note is more important: what was your assessment of the resident? Any injuries? MD and family updated? And most important: what interventions did you put into place to prevent another fall
  11. by   Sparrowhawk
    Well aren't they write up happy.
  12. by   lumbarpain
    Thanks everyone for your responses.....however I did proceed to follow through on what I did FIND out or OBSERVE from this patients incident. He was awake and able to answer questions in regard to the fall, I took vitals, gave him a full body assessment, and FOUND out that he was just trying to get up out of bed and his legs gave out. No dizzyness, pain or anything, just weakness in the legs. He eased himself easily onto the floor when he knew he couldnt support his own weight. No head injury nothing like that. He has been told repeatly to use the call bell( and you know the elderly they want to remain independent or dont want to wait as most of us wouldnt. And decided to do it for himself. All this was documented but the REAL COMPLAINT on my note was the word "FOUND" so being the State was coming in soon, this kind of twisted their gonads a bit and they were super upset. Now, that I was interviewed for another nursing job recently, I ASKED them what word is proper documentation when writing on a fall. They didnt think it was such a big deal....the word FOUND, was fine, so is the word, OBSERVED. These Medical Lawyers seem to picky on word play and instill more things into a already exploding basket of proper legal terms that dont SOUND like this happened or that happening. Its so detailed, which is good in a way, but confusing in another, making nurses so paranoid about writing something they saw and then thinking they will get fired for it. Everyone sees an accident differently. If there were a car accident at an intersection and there were 4 witnesses, one on a bike, one standing at the crosswalk, one with screaming kids at her side and one old guy, you would get a total of 4 Different stories on how that accident occurred. If we just stuck to the basics, plain and simple, all this wouldnt be necessary. Instead of things getting simpler with all our technology, seems to be getting much worse and more complicated.
  13. by   lumbarpain
    sorry for that big wind up there I wrote....but I just get peed off at the system.....I completely followed through with all documentation, incident report, calling the md, family, taking vitals, monitering the patient, alerting the CNA, so....I did all that but it was not good enough.....only that little word...."found" thanks guys, you are all the best.
  14. by   lumbarpain
    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 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.!!!!!!!!!