"Found on Floor" Documentation

[stephanienicole87]

i work in ltc and recently have been assigned to the demenia unit. alot of these rsdts have poor safety awareness and falls are frequent here. string alarms are used on most rsdts but some rsdts can unclip them from clothing, take batteries out or other things to make them not sound. soft belts and self release belts are infrequent and being phased out completely.

when someone is "found on floor" i know to document vitals, neuro check, c/o, s/s or denies injuries, floor dry + lighting appropriate (if they were), md notified or attempt to notify, family notified or attempted to notify, if the string alarm was goin off i note it was sounding, any restraints on or near the scene, where the rsdt was and any statements they can make.

what i am having touble with is writing what they were doing before a fall, which my facility request but cannot quite explain (or i cant understand them). we chart by execption so i might not have charted on that rsdt all shift. even if i just gave them medications 15 min. ago and noticed they were in wheel chair with a string alarm on dinning room how do i know when they are lying on the floor between bed and w/c in room what they fell from. did the cna put them to bed, on the toliet, did they stand and then fall or try to tie shoe and topple over....or they were just found on floor so maybe they just got out of w/c and laid down on the floor.

also how do i document i just saw them a few mins prior without lying about the time i am writing? and i had an occasion i called a md to notify him the rsdt fell but no injuries seen, vitals ok, neuro check ok, and he got an attitude and said, "why are you calling me?" i replied, " to notify you of the fall, see if you have any new orders or wanted to eval pt." he said, "from now on just check the little box that says md notified when someone falls unless it is an emergency." i didn't try to be ****** and make him look bad i just put "md notified no new orders." if someone calls agian i feel like i should call the md anywayz but i don't want him to be annoyed by me i have to deal with him all the time at this job and he could make things hard.

any help would be greatly appreciated.

[Whispera, MSN, RN]

You can't check the little box if you didn't notify the MD. That would be false documentation, AND if something went wrong afterwards, you would be in deep deep doo-doo. Even if he rips your ear off when you call, you still must call him.

[arelle68]

Follow facility protocol, and call the MD. It may be appropriate to fax an MD after hours on a non-injury, or minor injury fall, if your facility allows that. Otherwise call him, and let him rant. You need your job. You don't need to be getting wrote up because you didn't do what you were supposed to do. You don't need to be falsifying documentation for his convenience, either. What if there is a serious injury that you don't see? (Closed head) What if this is the first sign of a TIA that is going to lead into a major stroke? Do you think the doc will say, "Oh, yeah. She called me. It's all good"? Don't put yourself in a situation where your license and your hind-end are on the line. Don't do anything in any situation that could be construed as neglectful or dishonest. Doctors get all kinds of calls at all kinds of times. That's why they pay them the big bucks. If a doctor is rude to you, tell your manager. Do what you're supposed to do, regardless of what anyone else says. You don't want to be getting fired in this economy.

[pednursedeb]

It sounds like you're charting everything your're supposed to. I personally do not like charting by exception. I think it opens you up for problems. You should have a flow sheet though or assess/intervene documentation that you document on every 2-4hr that will at least show how the pt was neurologically or what was happening. If your facility doesn't have this your may need to speak up and get it going.

[VivaLasViejas, ASN, RN]

We usually fax the MD. They don't have time to come to the phone every time one of their hundreds of patients has a non-injury fall or FOF, so we just send them an FYI and all they have to do is sign the fax and return it. This satisfies the notification requirements and provides us with written documentation that says the PCP is at least aware of the incident.

[morte, LPN, LVN]

It sounds like you're charting everything your're supposed to. I personally do not like charting by exception. I think it opens you up for problems. You should have a flow sheet though or assess/intervene documentation that you document on every 2-4hr that will at least show how the pt was neurologically or what was happening. If your facility doesn't have this your may need to speak up and get it going.

depending on the patient load, this may not be feasible

[leslie :-D]

if i need to call an md per facility protocol, i often leave a message w/secretary or answering service (always getting the name with whom i'm leaving a message).

please, don't ever falsify documents, no matter how seemingly benign.

we must always aspire to our highest standards of care, which includes practicing w/integrity.:)

leslie

[jnrsmommy]

Like others have said, if it's ok to fax the MD, do that instead, and write on there a short recap of what happened, current V/S, any complaints from resident. I work nights, so if it's a "minor" fall or injury (small skin tear, bruise) I fax a note to the doc or my day nurse is wonderful about notifying for me. Otherwise, you bet I call.

As far as documentation goes, even if it's a dementia unit, still ask them what they were doing and document what they say. I will document more of my conversation w/ the resident to show that there is dementia/confusion. Otherwise, what you say you write is dead on.

[mykidzmom]

even in nursing, there are short cuts we take at times--some harmless, some risky. most of us will say "well, maybe some nurses, but NOT ME-- I don't take short cuts ever!"but in time, we all do sometimes. however, keep in mind WHEN and WITH WHAT you decide to skim over something. saying you called a doc when you didn't would be one of those things i would put on the list of things i would NEVER do. and when you decide to take a short cut, decide whether the possible repercussions are worth it (you might say it is) and also, what would happen if you got caught, even if there were no adverse effects to what you did or didn't do. would it look like a lie or an accident?

i remember years ago, a nurse doing charting and it the assessment form was all check boxes. the patient's condition hadn't changed, she was doing well, so the nurse just ran down the check boxes, checking off WNL on each thing. she really HAD done the assessment properly, but checked the both pedal pulses were palpable. unfortunately the pt. was a bilateral amputee! we all got a laugh about it, the next nurse found it and brought it to her attention--it truly was an accident, just getting carried away with making all those checks, but i am sure you can think of many situations where making that accidental (or not) check could come back to haunt you. and saying you called the doc when you didn't would be high on the list.

we have a doc in our clinic who gets annoyed at questions that he feels don't warrant his time and we usually agree with him and say "i know, i hate it too, but i have a license i need to keep and if they say i gotta call, then i gotta call"

[systoly]

I have another issue with this kind of documentation. I have read many narrative entries that say "... found on floor..." and I'm never comfortable with it. "Found on floor" is just not good wording from a legal stand point. It implies that the patient was lost and not properly monitored. I prefer "observed on floor" or simply "...is on floor".

[RuRnurse?]

That MD is being PAID to be on-call...if he/she doesn't like it, tough nuts! Call anytime you need to, and be sure to document everything. If he/she continues to give you "attitude", then contact the medical director and complain.

[stephanienicole87]

Yeah I will DEFINITLY call the MD when it is protocol, or nessesary. I am still wondering any ways to write what the pt was doing before they ended up on the floor. I saw on reply that said to talk to and quote the pt although they are dementia pt's, which I will do, but if I saw them in the chair just a few minutes before I found them on the floor how can I saw that in charting, like can I say, "rsdt lying on floor at this time, last seen in w/c before found on floor." or something so that effect? That is what someone from work suggested but I just don't know if I like it. Opinions??