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Jul 13, 2008 01:17 PM

horror scene


First off Ive been a nurse for about a year and half now. Im a float at a nursing home where I just started. It was my first day on this particular hall. I had a resident who is noncompliant with her alarms and very unsteady on her feet. I noticed her ambulating in the hallway and directed her back to her bed, showed her the call light, toileted her,increased supervision, blah blah you know the routine. Well they moved her room closer to the nurses station and didnt tell me, I knew she was being moved I just didnt know when. So I went out on a break and all of a sudden I heard the fire truck. Uh oh. I went inside to find the DON, ADON, supervisor and the other nurse standing in my hall with the resident laying face down in her room on the floor with a puddle of blood surrounding her head. My heart dropped. Needless to say shes probably not gonna make it, she was in bad shape before the fall occured as it was. Come to find out shes had a good 7 falls in the past month. Naturally the family is very upset and is doing a "investigation" of the incident. I feel horrible. I love my residents like there my family and I would never want anything to ever happen to any of them. I feel like the family is blaming me. I can not stop thinking about that poor lady laying there with blood everywhere, it looked like a massacre. Any advice would be greatly appreciated


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17 Comments
No. 1
from kharing
Old Jul 13, 2008, 02:26 PM

Default Re: horror scene
I feel for you but have a question.

Was this patient moved to another room during your break or on another shift?

I have a hard time "placing blame" since this person has a history of getting out of bed unassisted.

Accidents happen, but so far I haven't been able to put this together yet.

Sounds like a sitter was needed.
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No. 2
Old Jul 13, 2008, 03:14 PM

Default Re: horror scene
I am sorry that this happened to you and hope that the blame game does not land in your lap. One of the major things I hate about nursing is the miscommunication that commonly occurs and the blames being tossed around like Halloween candy after the fact.

You are entitled to take a bathroom break, you did all you can humanly do to ensure patient safety and you do sound like a great nurse. I pray for both, you and your resident.
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No. 3
from ktwlpn
Old Jul 13, 2008, 04:54 PM

Default Re: horror scene
Originally Posted by NursePeace View Post
Come to find out shes had a good 7 falls in the past month. :
7??!!! In a month? The doodoo SHOULD be hitting the fan over that but YOU are NOT responsible. This incident will have to be reported to the department of health and they'll see this history and hit the roof. Our facility has often had to provide 1 to 1 care round the clock to folks like this(at no extra cost-)Thankfully they usually go through this stage relatively quickly. We have a good number of human service aides qualified to "sit" so it is not usually a major problem....Does the facility have a"frequent falls" protocol? Has she been checked for UTI? Recent med change? These things should have been done after the 2nd fall,IMHO.Let us know what happens...I know you feel bad about this-but it is NOT your fault..
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No. 4
from NursePeace
Old Jul 14, 2008, 01:10 AM

Default Re: horror scene
Thanks for the replies. You know at the other facility I worked at we did foot the sitter. But here I think the family has to pay for it. Which her family was WELL aware of her falls and the alarms. She has a history of falls, thats what put her there. So I dunno, all I can do is pray thanks again
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No. 5
Old Jul 20, 2008, 05:30 PM

Default Re: horror scene
We are often reminded at our nurse meetings when we, nurses, are up in arms over resident's that are non-compliant with safety issues... that the resident actually has the right to fall just as much as they have the right to refuse meds... State is so restrictive about restraining residents. She sounds like she was a resident that in days of long ago would have been "posied to a gerri-chair to keep her safe". No can do anymore!

My state, PA, is even leaning towards saying that chair and bedpad alarms are to be considered restraints!

I feel bad for the situation you lived through. I personally don't see anything that you did wrong. Your report sheet will verify that you didn't get the information of a room change...and I really don't see how that would have changed the scene???? Hang in there and DO NOT CLAIM/act guilty because you are NOT responsible for that incident.

just my 2cents
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No. 6
from softstorms
Old Jul 21, 2008, 03:00 AM

Default Re: horror scene
One of the things that most of us working in "Nursing home/Rehab centers" have tried to stress,,,,is that we can try to help lessen falls, but we can not prevent them. If mom or dad was falling at home or in any other setting, they have the same risk with us. If the pt. was at home with "one on one" and still fell......"if the pt was in a hospital with a sitter" and still fell. Then how can we stop them from falling again?
We can't.....I know you feel bad and believe me, we all do. But sometimes there is nothing you can do. Just follow thru with all your documentation and know you have done your best. I had a lady fall in front of my nurses station, in full view of myself and 4 other staff (within 6 ft.) and get a 2 inch laceration to her forhead. She had a alarm pad under her, that went off the moment she stood, and still we could not reach her in time to keep her from falling. Just trust in the fact you did all you could. That all we can do.
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No. 7
from wolf!
Old Jul 22, 2008, 07:25 PM

Default Re: horror scene
as an lpn you are limited to what you can do. you can gather information and not assess it, you cannot initate care plan or impliment interventions. at least not with how the nurse practice act has been explained to m the reasion yoiu didn't know what to do was because you weren't supposed to do anything except make the pertenant bodies aware of the situation. the rn or md is required to make the intervention. the facility is expected to have a policy for these issues, but apparenty they failed to safeguard the resident, which is apt to get them in trouble.so long as you followed what was in the care plan, and the poweres that be were aware, the feces should hit the proper fan. just my humble opinion in 10 yr nursing home work.
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No. 8
from Hopeslayer
Old Jul 22, 2008, 07:47 PM

Default Re: horror scene
Originally Posted by wolf! View Post
as an lpn you are limited to what you can do. you can gather information and not assess it, you cannot initate care plan or impliment interventions.
That always makes me laugh. Anyway, gravity is a constant where I work. Residents will fall. What we must do is document what happened, what we immediately did to address the situation, and also, care plan what we will continue to do about it in the future.

I would think that the only way you would be to "blame" is if ypou didnt follow the current careplan for that resident. 7 falls in one month is bothersome though. Good luck to you, and remember to document.
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No. 9
from NursePeace
Old Jul 22, 2008, 10:35 PM

Default Re: horror scene
Originally Posted by wolf! View Post
as an lpn you are limited to what you can do. you can gather information and not assess it, you cannot initate care plan or impliment interventions. at least not with how the nurse practice act has been explained to m the reasion yoiu didn't know what to do was because you weren't supposed to do anything except make the pertenant bodies aware of the situation. the rn or md is required to make the intervention. the facility is expected to have a policy for these issues, but apparenty they failed to safeguard the resident, which is apt to get them in trouble.so long as you followed what was in the care plan, and the poweres that be were aware, the feces should hit the proper fan. just my humble opinion in 10 yr nursing home work.
Its not that I didnt know what to do, everything I couldve done was done. The only thing is she shouldve had a sitter, which in my facility the family has to provide. This resident was non-compliant with ALL fall precautions. It was her right to fall, which Ive now came to terms with. Her and her family were warned over and over that she was in danger by being non-compliant. I never want any of my residents to be in any danger and Ill do everything I can to prevent it. But as I stated Ive came to terms with the whole situation.
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