Falls and incident reports in LTC - page 2

:uhoh21: Many nurses in LTC tell me that they don't have time to fill out incident reports each time a patient falls. What about you? Do you always fill out an incident report when a patient falls?... Read More

  1. by   mob2002ph
    Quote from earle58
    in nursing, there's a continuum of priorities. incident reports are on the top of my list because you need to document that the md and pt's family/rp was notified. those are absolutes. it will come back and haunt you someday, trust me.
    can you give me an example of an incident report as well as nurse's note, a.admission note
    b.transfer fron another unit
    c.transfer from agency/hospital
    d.what is DAMA
    thanks!
    marybelle
  2. by   gebe51
    : :angryfire I get so angry sometimes when I have to deal with those darn incident reports.. I have the fun of investigating them until we get an investigator who starts next week praise the lord. They are a royal pain in my tookus. to put if nicely. But you must always, always fill out an incident report like it or not.. To CYA if something should go wrong with the patient. My biggest beef is that when the nurse's fill them out they do not get statements from anyone as to whether or not they knew anything about it or if they saw it or whatever. And you have to have statements. When long term care comes in and you have no statements then shame on you. And then to come in to work in the morning and you have 10 new incident reports. you could just Croak. But still fill out those damn reports. It is essential to you license.
    Quote from etmx5313
    '
    ALWAYS---can I repeat ALWAYS fill out an incident report when someone falls!!! I never want to be caught in a situation where I though that someone fell and did not injure themselves--only to have an injury show up later and YOUR butt is on the line!!! Yes there are times when I don't have time to pee, eat or fart, let alone fill out ANOTHER form. But if I have to stay (later than I usually do) I will do it. It's your license!!!
  3. by   LPN4Life
    Quote from Blackcat99
    :chuckle Thanks for your messages. I agree that incident reports should be done each time a patient falls.Unfortunately, I have had days when there have been so many falls that I only made incident reports on certain residents. I had a choice to either do meds or do incident reports all day. I was the only nurse on duty.
    Believe me, Incident reports are right up there with passing your meds. You don't ever want state to question you on why an incident report wasn't filled out. You may think it was nothing at first, and then 2 days later the resident is in pain, etc. Same as you would fill out a workers comp claim within 24 hrs after hurting yourself on the job, they always tell you even if you don't think you were hurt fill one out to CYA. Even if it means staying over for a little bit, it really is important every time. Believe me the one time you don't will be the one time you wish you had........If it sounds like I speak from experience, its because I am!!!
  4. by   mob2002ph
    Quote from Blackcat99
    :uhoh21: Many nurses in LTC tell me that they don't have time to fill out incident reports each time a patient falls. What about you? Do you always fill out an incident report when a patient falls? Thanks
    yes i always fill out an incident report,bec.thats very important!
  5. by   superbratnurse
    DO IT THEN.... don't leave it for later, don't wait at all if you can avoid it, it just takes 10-15 minutes max, to call family/RP, doc, fill out the form, and chart the details after ya assess and take care of any probs....

    Of course in MY facility, we have to update the care plan then and there, and fill out the post fall investigation report...which takes a little longer, BUT what's worse...leaving late from work, and/or getting chewed out for overtime, or losing your liscence?


    ~Brat
  6. by   buddy5630
    All I have to add to the overwhelmingly ABSOLUTELY YESes that have already been posted to your query is that now a days, with the pitiful nurse-patient ratios that we must contend with in LTC- almost do the documentation BEFORE you worry about getting the meds passed if time is your issue;the entire scene has become surreal and nightmarish, hasn`t it? Families will not hesitate to go to court over such things as grandma`s bruise that becomes evident 2-3 days following a fall. Chart your butt off and make those phonecalls-the meds can wait (they do anyway, what`s another 20 minutes). What a mess this all is anymore...
  7. by   LoriAlabamaRN
    DEFINATELY fill them out, each and every time. If I don't have time right then, I will jot down all info and fill out the report when I have a spare moment. I basically jot down the relative info, example "Jane Doe room 123 FOF (found on floor) 0230, 0 pain, 0 inj, VS 60, 120/60, 98.6, 16." Then when I have a moment to spare, I fill out the proper paperwork. Always find time to do them, you can get in huge trouble if you don't.
  8. by   mewmeow
    I can't imagine NOT filling out an incident report for a fall. No matter how many may occur on a shift. It's your license NOT to mention the resident may have hidden injuries. If you gotta stay longer at work then you gotta stay longer. Been in this situation many times and would never not fill out a report. Finish your meds 1st of course then get busy writing. If you don't have all the details ie: CNA's have already gone home then fill out what you can and explain to your supervisor the next day and finish it then.
  9. by   anniev
    let see falls, bruises ,skin tears something 10 days old that hasn't been documented on yet, post it in the tar, in nurses notes, incident report investigation report, notify Dr. notify family and mini inservice for staff on interventions and statements from anyone who was involved or found areas whew!!!
  10. by   suebird3
    I always writ up incidents....minor and major. Don't feel like dealing with the fall out if State walked in and proceeded to walk all over me. That is, if my boss didn't start on me first...."I who should know better...." You get the drift.

    Suebird
  11. by   LPN1974
    Yes, we have to on my job.
    The requirements on our incident reports are demanding.
    Falls, bruises, skin tears, head injuries, swollen ankles/feet that could possiby be a fracture or any other possible fracture, any kind of injuries around the eyes/face region, anything of UNKNOWN origin must have an incident report filled out. Also, even if we send them to the ED for evaluation of any illness, besides an injury, then it's an incident report also.
    We also do another report called a "Marks Report". This is usually done by the aides who work closely with our people, and they always notify their supervisor that they are filling out a "marks report", so if it COULD be something more injurious/detailed then the nurse gets called in on it to evaluate.
    We do so much documentation and followup reports on my job that we just don't have anything slipping thru the cracks.
    You better fill it out, because tomorrow when the superintendent comes in she's going to ask for that report and it isn't a pleasant thing to have to explain why you didn't do such and such. Better to fill it out and be done with it. CYA.

    My boss says, "If in doubt, fill it out."
  12. by   sd90mac
    Ok.
    I am the risk manager where I work. It is very important to do the incident reports. We had a resident show up with a fractured hip. I had to do an Adverse Incident with the state. On completion of the investigation, the nurse was terminated because she said she didn't think the resident was injured so she did not do one. This was not the first time she had done this. The resident was demented and could not verbalize pain. 2 shifts later, he developed what the nurse thought was belly pain because he cried when the CNA's got him up. A flat plate was negative. The next shift nurse whipped back the covers and found external rotation and shortening of the leg. Any questions? Always always always do an incident report. If something is found later, you have proof you checked the resident and doccumented for 72 hours. It could save your bacon!
    Do it for all skin tears, bruises, etc.

    Marie
    Last edit by sd90mac on Mar 17, '06
  13. by   geriRN1993
    Quote from sd90mac
    Ok.
    I am the risk manager where I work. It is very important to do the incident reports. We had a resident show up with a fractured hip. I had to do an Adverse Incident with the state. On completion of the investigation, the nurse was terminated because she said she didn't think the resident was injured so she did not do one. This was not the first time she had done this. The resident was demented and could not verbalize pain. 2 shifts later, he developed what the nurse thought was belly pain because he cried when the CNA's got him up. A flat plate was negative. The next shift nurse whipped back the covers and found external rotation and shortening of the leg. Any questions? Always always always do an incident report. If something is found later, you have proof you checked the resident and doccumented for 72 hours. It could save your bacon!
    Do it for all skin tears, bruises, etc.

    Marie
    We had a similar incident in my LTC. In our case there was an investigation by the Illinois State Police months later. Believe me it was not fun. The initial incident occurred where the aides said that the resident was lowered to the floor when she nearly fell during a transfer. It was 3 days later that a spiral fracture was identified and looking back there was no incident report and NO documentation. The nurse on duty at the time said that she did assess the resident but felt that there was no injury. Pain started 2 shifts later but the nurses after knew nothing of the "near fall" and didn't even suspect a fracture. So, it is not only important that we do incident reports for falls but near falls also. What I tell my aides is, "If you were not there to catch them and lower them to the floor, would they have fallen?" They now know that the need to report everything that happens.
    Recently, we had a state survey and they sited us for not fully investigating all falls. They want to see that the nurse at the time of the incident identifies the "CAUSE" of the fall. The report must have all of the details of the investigation including any witness statements attached.

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