Fall in the ED!

[wearelegion83]

Hello to all my fellow nurses out there, I need your help! I have been a nurse for close to 3 years, with 18 months in gen med and 11 months in the ED, and 6 months or so as a pedi home health nurse. I don't know what to do in this situation and im kind of worried and mad at the same time. About 3 months ago I had a pt that had a high ammonia level (he is a frequent flyer for the same thing) but he was alert and oriented and followed commands. I helped him to the restroom and told him to not get up. He verbally agreed and I would check up on him (he was a hold patient in the ED cause we were backed up in the hospital). He got up and fell down in the doorway of his room right after I had just left. No injury occurred. That particular matter was settled and nothing came of it. Last night I had a person who came in for a seizure but who was also evidently intoxicated. I put him on all seizure precautions both siderails up, fall risk band, and told my charge who placed him in a room across from the nursing station. He was medicated to stop the seizures (Ativan and loading fospheny) and he went to sleep without incident and had his CT without incident. He comes back to the room and starts having multiple seizures again (at his point after medicating him again I believe these seizures are faked based on presentation) but I treat him like they are real. I go to see a new patient I received and as im walking away a tech tells me this patient is on the floor. Per the pt he crawled out of bed through the bottom because he "wanted to go home" and "didn't belong here". He had no injuries so we placed him back on the stretcher and placed him in restraints. He then breaks the cloth restraints and climbs out again while I am gone. Despite doing everything I could to stop this short of getting a sitter ,which me and the MD, thought was uneccessary due to the restraints, this happened. I was told to not come in the following night by my clinical coordinator (the one who took every opportunity to throw me under the boss) and now I am going to have to go to a meeting with my CNO and medical director of the ER. This ER has treated its nursing staff in general very badly and has had unsafe practices in the past despite nursing objections but I stuck it out. Now I fear they are going to fire me over this incident because the two separate falls are close together. I am at a loss about what to do but I will update after my meeting in the AM. Any help would be appreciated. If it does come down to it maybe I can find a PRN position at another facility or travel.Again, any help or suggestions would be appreciated.

[wearelegion83]

the second patient had a total of 10mg of Ativan in 3.5 hours with a BP that probably wouldn't have tolerated him getting tubed at the time despite 2L bolus of NS. He was still drunk talking after a single push of 4mg of Ativan. I don't know how much more sedation we could have given him besides propofol or maybe just succhs. I am going to call my coordinator at 8 or 9 am central and see whats going on about a meeting. I think I might have to leave.. already applied to another hospital. I will look at the restraint policy for our facility if I end up not getting fired over this. As for the bed alarms it was brought up by the CNO after the first meeting but nothing ever came of it.

I have had problems with this facilities management in the ED for sure. they tried sticking us with 6-9 patients at a time even when we were short staffed, tried direct bedding without triaging people out front first and having the nurse triage their own patients in a room, taking our techs away and putting them as smiling people at the front entrance, all for the sake of improving press ganey scores instead of fully staffing.

[Sassy5d]

I don't know your hospital policies.

At my place, a pt with confusion, elevated ammonia level, regardless of the fact that they tend to be elevated, would never be left alone in a bathroom. It's a fall risk, we can't leave fall risks alone in the bathroom.

The drunk seizure person, would have gotten 4 pt leathers and a security sitter, most people can get out of soft wrists, especially a drunk person. I know not every hospital has security, but what is the policy in your place for leathers?

What I'm learning is even though the ed is sep from the hospital, our #s contribute to the entire place. Falls are huge in our inpt setting, the head boss lady is getting yelled at from her boss, which trickles down. Falls are huge, reportable. You can also be cited and fined for falls.

Unfortunately, I don't think the 'we didn't have enough staff' line holds up in court, which is a reality for us. What is your back up? The doctor didn't want it? Wanna talk throw under the bus? Go to court, the doc will toss you.

IMO, even though you strive for a 'team'. You are floating solo. You need to make sure you're charting tactfully. Charting such things as medicated with Ativan for seizure activity per md, fall risk protocol initiated.

Pt begins to become agitated, chart it, notify md, chart provider aware, no new orders. Notify charge nurse, chart it ect ect you get the picture.

[wearelegion83]

so the meeting with my supervisor went really well and he is chalking it up to making some policy changes in our department. Im not gonna get fired or even written up and he asked my suggestions on how we can change since apparently I wasn't the only incident. As far as leathers go sassy they are reserved only for extremely violent patients. That ammonia pt wasn't left alone in the bathroom he was in his room after I got done taking him to the bathroom. I understand the falls thing management wise. I know the doctor and he is not that type, he would back me cause he knows I practice well. We do work as a team we just handle our patients and chip in on difficult ones then go back to ours. We ask for help when we need it. As far as charting goes we are all electronic and all that is charted and I made a BUNCH of notes about everything that happened. on a separate note they are looking into not doing restraints on intoxicated pts because of an aspiration problem that occurred to someone else. I am worried about when our busy season kicks in how were are going to be having all these sitters etc when we have like 200 pts per day ><. the director really put my fears to rest and clued me in as what hes doing i have say was impressed. moral of story don bother with restraints on a seizure person just go straight sitter if they are intoxicated well. we will start putting drunk patients purple scrubs from now so stand out more. thanks for your input>

[Been there,done that, ASN, RN]

Glad that it turned out well THIS TIME.

It sounds like management is trying to make some positive/workable changes.

However, remember your first instinct was.. you were in trouble, going to be fired, etc.

Wouldn't hurt to keep your eye open for a better work environment.

[canned_bread]

By the sounds of things, you did everything that is correct. If someone wants to fall, they are going to fall. The ONLY thing I can see wrong is that initial patient you shouldn't have left alone (but lets face it, we all have to at some point occasionally). As long as you documented these interventions that you did, tehy actually don't have a leg to stand on. You were NOT negligent in your duties. Simple.