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[thisnurse123]

Briefly who is at fault if a patient coded at a LTC facility 8 hours after shift change? Let’s say for example the patient had a few falls on the prior shift. Neuro’s were initiated patient was alert 1 hour prior to shift change. Then during morning shift patient declined and was sent out at shift change. Would NOC shift be held accountable?

[JKL33]

Is there a particular reason you believe someone is at fault for something?

I guess I'd start with whether or not a particular wrongdoing was involved.

[Pepper The Cat, BSN, RN]

Why are you assuming someone is “at fault”?
Why are you trying to assign blame to someone?

A person fell, was monitored and then had a change in status. 
The person was then sent out. Sounds like a brain injury? Those can take hours to show up. That’s why we monitor people post fall.

 

[thisnurse123]

I would t blame someone but the family/facility might and that’s OK…

*would not

[Delia37, MSN]

...Rather than try to find someone "to blame"; take this unfortunate situation as a learning experience and figure out ways to improve your fall precaution protocol and assessment follow up.

[thisnurse123]

I wasn’t finding someone to blame I think all of us nurses did the right thing but I feel management would still blame us…if this makes any sense even though the patients vitals and neuros were normal and were honestly checked by three different nurses. 

[JKL33]

34 minutes ago, thisnurse123 said:

all of us nurses did the right thing but I feel management would still blame us

Well, for your own benefit you should change your thinking a little. Instead of worrying whether it's going to be you that management unfairly blames, you should maintain the belief that it isn't okay to blame anybody when no one has done anything wrong, and carry yourself with the expectation that you're not going to be treated that way.

Your train of thought contributes to nurses looking for reasons to unfairly  criticize each other, gets in the way of actual improvements and problem-solving, and gives unfair/unthinking managers fodder with which to continue their unfair and unthinking ways.

 

4 hours ago, Delia37 said:

figure out ways to improve your fall precaution protocol and assessment follow up.

Starting with fixing gravity, weakness, dementia, disease in general and LTC staffing!!

[Been there,done that, ASN, RN]

"the patient had a few falls on the prior shift." A few falls!?!  If the resident  keeps falling down... the resident has a neuro problem going on. Resident should have been transferred to a higher level of care on the previous shift.

[thisnurse123]

Falls are common in the elderly that’s why LTC facilities do neuro checks and it’s the providers choice. Actually it’s a state tag for unnecessarily sending patients out for care a facility can provide and the patient did not have a head injury or hit their head during the fall.

 

[thisnurse123]

The falls were also witnessed and their was a prior history of falls without getting into too much information due to privacy. They had at least 6 and probably were appropriate for hospice which was discussed multiple times with family and patient. 

[thisnurse123]

6 falls within a 1-3 month period… and had several hospital visits  the hospital said they needed hospice but the family continued to refuse…it was a sad situation all around