After the Fall LTC/SNF Nursing Know-how 101

[Let's help out]

I know many may want to "file" this question under the "duhhhhhhh, column of basic nursing" but I would like info on the protocol and proceedures of nursing care after a pt falls. Please share how and what your response is. How do you handle falls? What exactly do you do? Also, what are the roles of the CNA's re: pt falls? We had a CNA say, (after she found pt and assisted nurses returning her to bed), that she didn't know she was to do VS on fall pt. Which was pretty much throwing the nurse, not to mention the pt, under the bus. Don't CNA"s learn how to monitor pt p fall in school these days? I realize ea facility is "supposed" to have available policy and proceedure manuals. I've been on a "Where's Waldo?" hunt in my facility to find them. Why aren't the manuals online? Maybe they are properiortory (sp) information . I have heard they may be locked up in the DON's ofc. Which doesnt help PMs and noc nurses. Also, do I dare mention the politics of "what constitutes a fall" some use the term "slid out of bed" how does that work? How to evaluate what is a fall and what is a slide? Thank You Nurses

[IdrilRN, BSN, RN]

the paper work involed where I work is this: incident report, nurses note, fall assesment report (which has information about the scene), call the doc, call the family, do neuro signs if needed.

AS far as neuro signs go Q15 for 1 hour, then Q 1/2 hour for 2 hours then Q 1 hour for 2 hours then Q 4 hours X's 4 then every shift, to equal 72 hours worth of neuro signs. that is for unwitnessed falls, and witnessed with head bumps.

I asses for injury, and if the person can get up on their own they do if they can't we use a lift to get them off the floor.

If they are injured, ie: broken hip, bone or head and need the Er they go to the ER and what ever happens there happens.

if they didn't hit their head then we do vital signs.

We chart every shift for about 4 days if no injury.

I am pretty sure that anyone that falls gets a referal to PT.

The LNA's can get the person up after the nurses ok it.

Wow that made me tired writing about it.

[VivaLasViejas, ASN, RN]

Not necessarily disagreeing with you about it being a good idea but we have many unwitnessed falls and it would be a huge $$ amount in transfer costs as well as CT costs to send them all out. Very important to do an initial neuro assessment as well as follow up assessments per policy. If any doubt..send them out.

Not only that, but there is no way that the average hospital ER will do a CT on every elderly patient who allegedly thumps his/her head. Half the time, they never even make it to the ER because the paramedics won't take them unless they say they want to get checked out. Now, how often do people say they WANT to go to the hospital? Then if they do get transported, the ER docs and nurses just laugh at us for even suggesting a CT, unless of course the resident has a goose egg or other obvious signs of head trauma. And if the resident is on Medicaid, they'd better be posturing or they get sent back to us, even if they have LOC and altered mental status, after a quick eval.

As for the post by handyrn: I'm surprised that not everyone attempts ROM or does neuros and VS before on fallen patients before getting them up (assuming, of course, there are no obvious signs of a broken hip or other body part). That seems like simple common sense to me; why ever would one try to get a patient/resident to stand before assessing VS, ROM, and pain to see if s/he is even able to?

[CapeCodMermaid, RN]

We send them to the hospital if there is a reason...suspected head injury and they're on Coumadin. The hospital usually does a CT scan because we call them and tell them "Mr Jones has had a fall with a suspected head injury. No loss in LOC, but he is on Coumadin and his last INR was done on ____ and it was_____"

The EMTs would never ask the resident if they want to go. If we call for transport they go.

[Nascar nurse, ASN, RN]

We send them to the hospital if there is a reason...suspected head injury and they're on Coumadin. The hospital usually does a CT scan because we call them and tell them "Mr Jones has had a fall with a suspected head injury. No loss in LOC, but he is on Coumadin and his last INR was done on ____ and it was_____"

The EMTs would never ask the resident if they want to go. If we call for transport they go.

Same for us.. I decided after Sunflower girl started two posts directed at me with "I am a hospital nurse" and seeing as how she is brand new to allnurses that it wasn't worth my time to banter back and forth with her. I suspected attitude and choose not to bite (could be wrong about it anyway).

[pixie120]

Having been in LTC for a long time, I must say that we often send out to the ER for any amount of odd things s/p falls, especially as one wise nurse mentioned, resident on anticoagulants, or complains of new pain. WHat happens in the hospital is entirely up to the staff on duty during that time, but as another nurse said, I call to the ER and ask that this /that be done, or have the family meet the loved one at the ER with my instructions (C/O new pain R hip, please also check R elbow and shoulder". I learned to make a copy of my progress note and attach it to the front of the transport packet along with the PCS and brief the transporters with my specific instructions. I have learned over the years that if I don't ask for it, insist on it, it won't get done and I personally have sent residents out who also died within 24 to 48 hours of a fall, in fact, one just happened in July. No apparent head injury on the scene, awake/alert 24 hours later with known 2 fractures, passed away at the hospital in the next 12, probably from a PE, but who really knows? Maybe a latent head injury?

I also know, I have gotten snotty/snarky phone calls from hospital staff and I just stand my ground.

I once, many years ago had a snarky nurse call me with "report" from the ER that went like this "WELL...we are sending back Mrs. bloody forehead, why couldn't YOU Just glue it up? AFter all, that's all we did, we glued her head laceration, right here in the ER, and she is coming back cuz THERE IS NOTHING WRONG WITH HER!!". I had to laugh and then I said "Well, thanks ever so much!". Then I hung up the phone and turned to my fellow nurse and said "Funny, that ER nurse thinks she glued mrs. Bloody forehead up, under her very own scope of practice, plus she believed I could have done the same, if only I had enough brain cells to figure it out. Also, seems she believes I carry that type of glue right in my e-kit. Hell, I might as well of stitched it up accourding to her, cuz there is NOTHING ELSE WRONG WITH HER!". INterestingly enough, there WAS some other stuff wrong with her, and she had the abo to prove it, silly me.....And since I KNOW my scope of practice, and the policies and procedures of my facility, I filed her snarky comments under "to laugh at later".

[DanaTDana]

Interesting thread. A nurse can't be available at all times to witness all falls nor can a CNA so I suspect one does not always know whether the patient has or has not hit his/her head. I work in skilled nursing at this time as a CNA and a good neuro assessment by nurse is difficult at best if the patient/resident has any form of Dementia particularly if it is advanced/aphasia. This coupled with not witnessing the incident makes for murky waters. Day 2 of a patient fall we could see bruising then his vomiting began and he was taken to ER. Don't know what was found but...how am i suppose to get a nurse in such an incident if i'm also suppose to stay with the patient. Ideas?

[jeanbeth, MSN, DNP, RN]

I work in a LTC facility and we do not frequently send out residents for a CT scan after a fall, even if they hit their heads. We do Q-15-minute neuro checks and VS, call the MD, and the decision is made on a case-by-case basis. I will say that any resident who is on Coumadin gets sent out for a scan if it's an unwitnessed fall or if the fall is witnessed and includes a head-bump.

[tnmarie]

We have a whole fall packet: pain assessment form, change of condition form, neurochecks, investigation report, ect. We do the same as everyone has said: CNA stays with patient and calls for nurse. The CNAs take VS while the nurse assesses and then we all get the res in to bed. If the CNA doesn't appear to be getting VS, I'll just politely ask for them :-). Yes the nurse can get them but I find it more efficient to be assessing the res while CNA gets VS simultaneously. Our CNAs also have to write a witness statement of their account of what happened.

Make sure as you are assessing that you are noting everything: what kind of footwear, how is the res positioned, what did they say happened, is the floor cluttered, etc. We have to figure out why they fell and place an immediate intervention.

We do scheduled (and frequent!) neurochecks on every unwitnessed fall. Over the years, I've only sent one res out after a fall d/t abnormal neurochecks. Luckily most of my peeps have been unscathed after a fall. That CT scan after every unwitnessed fall seems excessive. You can generally catch a problem with good assessment skills, imo.

Finally, I've been told to never chart that you "found" a resident in the floor. It makes it sound like you lost them. Instead, chart "observed resident supine in floor ...".

[tnmarie]

@Dana: that is why we do neuros after unwitnessed falls. It is safer to proceed as if they did hit their head since we don't know. As far as getting the nurse in the situation, I don't think I understand what you are asking. Just call the nurse for help and they should take it from there. Finally, there are physical indicators during neurochecks that won't be affected by dementia AND res with dementia can STILL have mental status change.

Tab alarms and pressure alarms do help quite a bit because these devices let us know when someone is getting restless (often because they need to toilet or need a brief change) so we can hopefully prevent the fall.

Our state has started tagging nursing homes for bed/chair alarms. I don't know the details but I just know that we had to go through and d/c all but one in the building. I think if the res hasn't had a fall in 30 days, they can't have any alarms. I had more falls in one shift after that did that than in the entire previous 11 months I worked there. They are such great tools, as you pointed out, especially since it was often just myself and one or two CNAs for the whole building.

[Maddie86]

In our center where I manage a unit in LTC, we got cited for an inappropriate intervention for a fall in our last survey. Our state is going after falls hard and heavily. We treat a fall like a crime scene, that is the key. We involve everyone in the response. When a resident is found on the floor, a "Code Star" is called to the location and dept heads and managers respond including the assigned nurse and CNA and any other CNAs that are available on that unit. We have a form the nurse fills out that answers important questions in order to get to the ROOT cause of the fall. For example, if a resident is found in the floor and unable to verbalize what he or she was doing that caused the fall, we take note of all surroundings and examine the resident to determine the need that was not met. The resident may be found to be soiled and there may be no other clue, so we begin a B&B assessment and start a toileting schedule. I've got the highest fall risk resident in our region on my unit and I have gone so far as to have customized furniture made for her by our maintenance dept. With all of the interventions we began since our new fall program began, we have decreased her falls from 34 in a year to 10 this past year. So, it all works...but it is a real culture change. CMS is heading towards a new world and it is difficult, even for me as a "new school" nurse to change my way of thinking to personalized care from a traditionally run unit that is set up to meet the needs of the staff. If you have any questions, feel free to get back to me!

Meghann