Documenting on patient falls or what looks like one in LTC

kappykatlpn · May 18, 2012

Hello,

What I usually do is start like this "observed resident on the floor on his/her left side......." and describe exactly what I saw when I entered the room.

loriangel14, RN · May 19, 2012

BTW it's spelled "voila" not wa la. :)

If I found the patient I write " Writer found patient on the floor beside bed...etc "

Sparrowhawk · May 19, 2012

What exactly did you write!?

lumbarpain, ADN, RN · May 19, 2012

Patient found sitting on floor near left side of bed when this nurse entered room. I was TOLD DONT EVER EVER write the word FOUND....I was written up for that......out of all the facilities I have worked in since I graduated this facility was the only one that said that was wrong. Thought it was very strange.

lumbarpain, ADN, RN · May 19, 2012

Oh, forgot this......they said to use the word OBSERVED Instead of the word FOUND....

caliotter3 · May 19, 2012

While the word 'observed' sounds better to me, I doubt that I would have reprimanded you over your use of the word 'found'. If it was that big of a deal, they should have had you rewrite the note or better yet, you should have been informed during your orientation. But a reprimand? No, unless you should have already known better. Sounds to me like you missed reading their minds on this one.

amoLucia · May 19, 2012

I don't understand your reprimand ... altho this was an unwitnessed fall, did you NOT proceed as a 'fall' and only charted in your nsg notes??? That would be a write-up IMO. Any one of your starting entries seem basically OK with me, but soooo much, much, much more documentation is necessary.

ANY, ANY, ANY time, way, or how a pt is on the floor, it's treated as a fall incident, even if unwitnessed. This is basic standard operating procedure in all LTC facilities I know. You follow your facility's P&P for falls, with all the ballyhoo assessments, notifications & paperwork, incl. the incident report and your nsg notes. The one thing I try most intensely to include any explanatory statement by the pt, verbatim, if poss. "I went to answer the doorbell for the pizzaman" or "I'm looking for my pen under the bed" or "didn't I tie the rope into a pretty bow (the call bell !)?". I also chart any observable cues (or clues) that could explain the situation.

So if your handling of the occurence was incomplete and/or your documentation was seriously lacking, there would be a problem. You seemed to start out OK in your notes (pretty much like #1 poster), but you need a whole lot more to it. Was that the issue here for the reprimand?

CapeCodMermaid, RN · May 19, 2012

I spied with my little eye.....Sounds like they are kooky. Who cares what word you use? The rest of the note is more important: what was your assessment of the resident? Any injuries? MD and family updated? And most important: what interventions did you put into place to prevent another fall

Sparrowhawk · May 19, 2012

Well aren't they write up happy.

lumbarpain, ADN, RN · May 19, 2012

Thanks everyone for your responses.....however I did proceed to follow through on what I did FIND out or OBSERVE from this patients incident. He was awake and able to answer questions in regard to the fall, I took vitals, gave him a full body assessment, and FOUND out that he was just trying to get up out of bed and his legs gave out. No dizzyness, pain or anything, just weakness in the legs. He eased himself easily onto the floor when he knew he couldnt support his own weight. No head injury nothing like that. He has been told repeatly to use the call bell( and you know the elderly they want to remain independent or dont want to wait as most of us wouldnt. And decided to do it for himself. All this was documented but the REAL COMPLAINT on my note was the word "FOUND" so being the State was coming in soon, this kind of twisted their gonads a bit and they were super upset. Now, that I was interviewed for another nursing job recently, I ASKED them what word is proper documentation when writing on a fall. They didn't think it was such a big deal....the word FOUND, was fine, so is the word, OBSERVED. These Medical Lawyers seem to picky on word play and instill more things into a already exploding basket of proper legal terms that dont SOUND like this happened or that happening. It's so detailed, which is good in a way, but confusing in another, making nurses so paranoid about writing something they saw and then thinking they will get fired for it. Everyone sees an accident differently. If there were a car accident at an intersection and there were 4 witnesses, one on a bike, one standing at the crosswalk, one with screaming kids at her side and one old guy, you would get a total of 4 Different stories on how that accident occurred. If we just stuck to the basics, plain and simple, all this wouldnt be necessary. Instead of things getting simpler with all our technology, seems to be getting much worse and more complicated.

lumbarpain, ADN, RN · May 19, 2012

sorry for that big wind up there I wrote....but I just get peed off at the system.....I completely followed through with all documentation, incident report, calling the md, family, taking vitals, monitering the patient, alerting the CNA, so....I did all that but it was not good enough.....only that little word...."found" thanks guys, you are all the best.