Documenting on patient falls or what looks like one in LTC

  1. 0
    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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  2. 27 Comments...

  3. 1

    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.
    LTCangel likes this.
  4. 0
    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. 0
    What exactly did you write!?
  6. 0
    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. 0
    Oh, forgot this......they said to use the word OBSERVED Instead of the word FOUND....
  8. 4
    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.
    IowaKaren, VivaLasViejas, LTCangel, and 1 other like this.
  9. 0
    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. 1
    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
    VivaLasViejas likes this.
  11. 1
    Well aren't they write up happy.
    LTCangel likes this.

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