Post fall root cause analysis report...

[NurseQT]

Anyone have any pointers on this? I have to fill one out on a fall from almost 2 weeks ago and I have never done one of these before!! It's a 5 whys analysis. The resident who fell is very confused and attempted to crawl out of bed. When asking him what he was doing and/or why his responses made no sense, he doesn't usually answer questions at all! You ask him what color the sky is and he'll respond with something like "well no he didn't go down to the coffee shop yesterday.." So finding out why he was crawling out of bed is next to impossible. I am able to get why#1 and why#2 and nothing more!! The resident is incontinent and his brief was dry. It was 0500 when it happened and he had been checked on a few minutes before the fall. Can anyone help me with this?!

[ClearBlueOctoberSky]

With all due respect, you are working with Residents who have Dementia. They don't know what a call light is for. If you are doing a RCA and decide that he couldn't use a call light and that's why he fell, then you are being lazy about it.

There will ALWAYS be a reason why they fell.

[misstrinad]

On my dementia unit we look at the basics...hunger, thirst, toileting, pain, noise, lighting level, med refusals, uti, bed height, etc. Perhaps the wear glasses and waking in the middle of the night not being able to see they try to find them, not that they could tell you that at all. But when falls become chronic there is always something that can be done to help decrease it, sometimes you have to get really creative. I had one dementia res that would crawl out and hit the floor if heaven forbid any light but one specific light was left on or if he was put to bed in a tee shirt not a gown. Little things can make a difference, confer with your CNAs if you haven't already for ideas/thoughts.

[Maddie86]

Hi there, I am a Unit Manager at a facility that was cited for a fall intervention for our last survey. I completely understand this issue. I have become our facility's "fall guru" in working on our correction plan, etc. If you have a resident that has no awareness and is completely unable to provide information for the 5 Whys, start thinking outside the box. Start a social history on him, get his family and social services and activities involved. He maybe worked 3rd shift or had a habit of getting up at a certain time of the night for a snack. Look at the last time he ate, last BM, etc. I train my nurses and CNAs to look at the site of the fall as a crime scene upon finding the resident. We all gather and go through our fall intervention huddle sheet and work together to come up with as much info as possible. Try a med reg review on him, see if there have been any changes lately. Also have your nurses monitor his sleeping pattern for a week or so to try to find a individualized, person-centered plan for his falls. Be certain that this is all on his careplans and documented in the nurses notes in a specific way, tying it all in. Hope this helps!