Documentation Of A Fall

[PatricksRNMommy]

I work at a hospital on a PCU/Tele floor in FL... When a pt falls, we have to

1) Fill out an incident report

2) Write a note about it

3) Notify the MD

4) Notify the nursing supervisor

5) Notify a family member

[nerdtonurse?, BSN, RN]

I'm on a ICU stepdown / telemetry unit.

If someone falls, and doesn't need anything more than first aid, we:

1) Call the doc

2) Enter the incident into the risk management software, detailing where the pt fell, were they on fall precautions, seizure precautions, psych history, blind, dementia, sundowner -- anything that could explain why the person took a header. Also, was the fall witnessed, or pt found down. We NEVER say the pt fell unless someone actually saw them fall. You'd be shocked how many people will be perfectly fine then you find them in the floor the morning before discharge -- and they're wanting their stay "free."

3) Call the family/POA.

4) If they are from a nursing home/SNF, we make sure they know about the fall before they go back home.

Now if someone falls and is seriously injured (makes it out of bed and takes a header down the stairs, for example), we:

1) Call the doc, get orders for CT/MRI/xray, etc.,

2) Call the admin rep

3) Call the family; sometimes the doc calls them directly, but we document that the MD's calling the family.

[lpnflorida]

First notify charge nurse, assessment for injury is done on the patient.

Patient is either placed into bed or in wheelchair.

Depending on cause of fall restraint might be instituted such as a lap belt on wheelchair , or 4 side rails up on bed.

Most often no restraint is needed.

Call is placed to doctor who is then informed of incident, informed on what steps have been taken so far.

He gives orders .

Person who discovers the fall, writes incident report,

Documentation of fall and what step were taken are charted in patients chart.

Under no circumstances as I am sure you are already aware of chart that a incident report was made, ( for the benefit of students who may not be aware of this part)

Case manager of patient is notified of fall either by talking to them or leaving a voice message, family is notified of the fall.

Document all people you have contacted such as case manager, doctor, family etc.

Our supervisor always receives a copy of the incident report via computer system.

[CT Pixie, BSN, RN]

I work LTC in Connecticut. When a fall happens, we fill out a form (computerized), notify the family of the resident and the resident's doctor.

If its past a certain time of night (9:30PM), unless its a major injury, I think it is, we just leave the info on the nursing supervisiors desk and she/he calls the family and the doc 1st thing in the morning.

Facilities have different policies regarding falls, incidents, etc and how its to be documented and who is to be notified.

ETA: We also follow a protocol. We have the charge RN do an assessment, if head injury is suspected we do neuro checks (usually q15min x 1 hour, q 30 min x 2 hours, q 1 hour x 2 hours, q 2 hours x 4, q 4 hours x 4, q 8 hours x 4), we chart on the pt q shift x 3 days.

Basically, we follow what all the others have posted. I was just giving the quickie answer with my first post :)

[Xbox Live Addict]

JettaDP said:

I am trying to find out what your employers policy on documenting falls are and who gets notified.

I am mainly just trying to compare the different policies out there.

Typical fall documentation at a nursing home in my area (Central OK):

Nurse assesses fallen resident for injury and provides appropriate care. Vital signs are taken and documented, incident report is filled out, the doctor is notified. How the physician is notified depends on the severity of the injury. If injuries are minimal, by FAX, and if there's suspected head trauma or hip injury, the doctor is called (if the injuries are obviously severe, to the point where moving the resident may be dangerous, 911 will probably be called). The resident's responsible party is notified.

A nurse's note is documented describing the known facts regarding the resident's fall and any interventions. However, most nursing instructors and facilities will tell you, do NOT document anything about an incident report in the nurse's notes.

If head trauma is known or suspected, neuro checks are done and documented per the facility's protocol (usually q15min x 1 hour, q 30 min x 2 hours, q 1 hour x 2 hours, q 2 hours x 4, q 4 hours x 4, q 8 hours x 4. I don't remember the common protocols anymore.

Usually, the resident is charted on at least once a shift for 72 hours, noting if the resident is having any continuing problems r/t the fall, pain, pain control measures, wounds, etc.

[linzz]

I am from Canada so my answer may differ but here the RPN does a range of motion assessment, head injury assessment, pain assessment, vitals, notifies the RN in the building who writes an incident report.

Most times the patient is sent out to hospital for X-rays if there is even a slight chance of injury. The family is then notified.

Of course there is lots of charting after a fall.

[SunnyAndrsn]

We inform the DON, fill out a state incident report, and an internal incident report.

The MD and/or hospice is updated, and the family is updated.

We do a 3-day fall follow up, which includes pain assessment and vitals each shift.

Initially, vitals are taken, and if it's suspected (or confirmed) that the pt. hit their head, then we do neuro checks for 24 hours. A complete skin assessment is done to check for bruising. X-rays, if a break is suspected, can be done in house.

JettaDP said:

Hello all!

I am a first year nursing student and I have a learning issue that I need to get some information on.

I am trying to find out what your employers policy on documenting falls are and who gets notified.

I am mainly just trying to compare the different policies out there.

At a nursing home in my area, if someone falls and gets injured, they just fill out an incident report and then they put it on the assistant DON's desk.

If you are okay with giving me some information, I will need what type of facility you work in, the policy, and what state you're in.

Thank you so much for everyone's help.

[Daytonite, BSN, RN]

Documentation in the chart should clearly state:

• How the patient was discovered and all known facts regarding the fall
• Assessment of the patient
• Notification of the patient's physician
  • Any orders that were given have been carried out and patient's response to them.
  • Then, notification of the patient's family and nursing managers.
• Follow up assessments of the patient at facility specified intervals (q shift x 72 hours) addressing none or any specific injuries the patient might have sustained

Incident reports are generated but are never part of the patient's chart and mention is never made in the nursing documentation in the chart that an incident report was made. These reports go to management.

[loriangel14, RN]

I am in Canada as well. I am an RPN and I assess for injury, fill out an incident report, let the family know and do a focus note on the computer and report sheet for the next shift.

[CoffeeRTC, BSN, RN]

LTC response...we do all of the above mentioned, but also with all of our incident reports we make a copy and give it to therapy, don, adm, social service and dietary. Just as a heads up. It would also be placed on our 24 hr book and an alert sticker is placed on the chart. I would also put in a notice to therapy to screen them for safety or positioning devices. We also have a sticker system placed on the door for high risk fallers.

As far as notifications....family must be called. Doc is also notified.

[yeSICU]

Patients never fall per say... They are "found on the floor"...lol

[Xbox Live Addict]

yeSICU said:

Patients never fall per say... They are "found on the floor"...lol

Yes, because no one saw them "fall." I'd forgotten all about that.