Documenting on patient falls or what looks like one in LTC

lumbarpain, ADN, RN · May 19, 2012

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.!!!

barbyann · May 19, 2012

If someone is "found" than it may lead to questioning along the lines of being "lost" at some point in time. Better to right "this writer entered room to pass PM meds and observed pt sitting on the floor." or "called to room by CNA and saw pt sitting on floor".

The lawyers always ask why you went into the room. Did you hear a noise? Was the bed alarm going off? Was the call bell ringing and you were answering it? If you right the reason you entered the room it becomes more clear legally.

lumbarpain, ADN, RN · May 19, 2012

Thank you Barbyann, i know lawyers look for details and specifics like you mention. When I walk by any rooms I usually glance in if I am going to another room for a specific reason and this was just the case.. I had walked by ...glanced in and saw him on the floor. Thank you so much for the tip. I will keep LOST AND FOUND in my mind the way you described it....Observed is a much better term. I will always ask the facility what their guidelines are for documentation on falls before working for them. Although I try to keep up with how to properly document on incidents all the time. This was a little out of the ordinary for me after 18 years of not hearing a complaint about my notes. In fact, I loved penmanship in school and its always my notes they read because most of the nurse notes are illegible. Shame that we have to struggle with that part also...we should all print our notes....then sign them off, including doctors!!!!

CompleteUnknown · May 19, 2012

I don't know, I've heard it before (on here) that saying 'found on floor' can lead to confusion and questions about the patient being lost but really...... who would imagine that 'found on floor' might actually mean 'Unable to locate patient at 1600 hours. Conducted search of facility and eventually found patient sitting on the floor next to his bed'?

If he'd been 'found on pathway outside facility' or 'found behind boxes in storeroom' I can see that perhaps there would be a question about how he got there, but if he's found in his room why on earth would anyone feel there might be a chance he'd been lost?

PS. I love your proposed entry in the notes and the way you included the bit about the housekeeper being late because of the sausages on the road. I've never seen such a wonderful analysis of the causes of a fall - the satin socks, the strand of hair falling across the eye, the puzzlement and distraction caused by wondering how the slippers could have hopped across the room, the legs that went like wet noodles and the shifting continence aid all came together into a perfect storm of causative factors!!! I can SEE him sitting there grinning at you with his sparkling eyes 'yep, I'm on the floor again!'

ktwlpn, LPN · May 21, 2012

Back in the day (maybe 8 years ago) our admin use to tell us to avoid using certain words in our documentation because they were "red flags" for the surveyors .We were never to document that a resident was "found" or "dis impacted" Those are the two biggies I remember.We were also threatened with being "written up" which would have been a direct violation of our policies as a verbal warning as the first step. Don't you love being ruled through fear? I'm sure a little inservice would work better...

CapeCodMermaid, RN · May 21, 2012

I used to work for Kindred and they came up with a list of words we were supposed to use:Adult diaper=protective undergarment (pu)Patient=guestAdmission= check inDischarge= check outReally?? The new terms lasted about half a day. Ridiculous as is writing someone up for using the woed found.To the OP...you have a future as a novelist!

JZ_RN · May 21, 2012

If management didn't want me to put "found on floor" they'd give me enough staff so I could always have someone around every group of rooms, so if someone fell they would be seen/heard and helped immediately. Unfortunately I sometimes don't "find" out my residents have fallen until rounds, which I can only make after 4 hours of med pass and before treatments, then after, then every once in a while when I am not busy doing paperwork and other things.

As far as the "diapers" I call them briefs or depends.

I always use admission, discharge, expired or passed away (if someone died) BM for poop, urine for pee, buttocks, etc. I mean we are professionals, not kids.

lumbarpain, ADN, RN · May 21, 2012

Maybe I should have been a novelist. Maybe the next life.

i think when I start this NEW JOB AGAIN for the umpteenth time ....I will advise whomever gives the inservices to include proper terminology for Nursing notes and hand it out to the nurses. It would be different if I got reprimanded at a NEW PLACE IN A NEW STATE, but this was my homestate of NJ. Seems strange being I worked in so many different nursing homes there and never had a problem until THAT ONE. AND IN THE SAME COUNTY!!!!! You think all of the nursing homes in that same area would have gotten the same direction from the state about documenting correctly. It all comes down to miscommunication, too much paperwork, and not enough regular full time workers to mess up the consistently of a facility. Even with a regular crew, staff get slovenly at times, but at least they KNOW their patients very well. I do remember something in an inservice years ago about certain terms that should be used. But it wasnt stressed enough so nurses check kept on documenting the way the always did.

CompleteUnknown · May 21, 2012

I'd be willing to bet that, one day, a resident fell and someone wrote an unsatisfactory note that happened to include the words 'found on floor'. Then, a surveyor came along and saw that note (we all know they have an uncanny ability to choose to review exactly the chart you wish could be lost in a fire or swept away in a flood or something :uhoh3: ) and those in charge, instead of explaining why the note was unsatisfactory, made a rule that you must not say 'found on floor'.

Or maybe they did explain why the note was unsatisfactory and maybe 'found on floor' was a bad choice of words in that particular situation but all that has been lost in the mists of time and all anyone remembers now is that the world will end if you write found on floor.

Such is life in LTC!

kids · May 21, 2012

I don't think this is anything new, I was told years ago to chart observed by a State surveyor, the implication of find/found is that the resident was somehow lost or missing. It became the expected phrasing where I worked in WA & OR and is what I've seen so far here in the SE.

As for the 'reprimand'

"If it's not documented it wasn't done" applies to more than just patient care, verbal counseling/reprimands still have to be documented in writing.

I'm sorry the OP was hassled, on the upside, s/he now knows what the employer expects when documenting falls (and possibly their rationale).

lumbarpain said:
You think all of the nursing homes in that same area would have gotten the same direction from the state about documenting correctly.

Seemingly minor things like this usually get communicated during individual facility surveys. With NH Admins & DoNs being such a tightly knit group they often pass on information to others that they were given in their survey.

CapeCodMermaid said:
I used to work for Kindred and they came up with a list of words we were supposed to use:Adult diaper=protective undergarment (pu)Patient=guestAdmission= check inDischarge= check out Really?? The new terms lasted about half a day. Ridiculous as is writing someone up for using the woed found.To the OP...you have a future as a novelist!

Too funny, it was during a survery at a Kindred facility (in WA) that the State surveryor told me/us not to use find/found.

lumbarpain, ADN, RN · May 22, 2012

You guys are the greatest. Thanks for your help on this matter. I think communication is so vital in the medical profession, yet given the telephone effect that we used to play in school, the same communication never turns out the same at the end resulting in confusion and vast negative results in the facility itself. I worked with many different foreign nurses with heavy accents and different ways of expressing their view on patient happenings. When you got report it was like you needed an interpreter like the United Nations has. But....we just forge onward and we do the best we can.

onyx77 · May 22, 2012

I was always told not to write found for the reason that others have stated..... the word "found" could be misconstrude that the resident/pt was actually lost. (which unfortunately does happen from time to time in LTC with wanderers :mad: ) I always write "Resident/pt was discovered laying right side on floor next to bed ..... yadda..... yadda..... yadda..."

I actually had one supervisor give me a gold star when she did a chart audit because I charted that way! :specs: