Having the "Right to Fall"

TheCommuter, BSN, RN · Mar 12, 2008

I've also seen mats on the floor which is the pt's bed. Has anyhone else seen this?

Yes. If the mattress is sitting directly on the floor with no bedframe, and the patient rolls off the bed onto a rubber mat sitting adjacent to the mattress, it is not considered a fall.

goldeneyes181 · Mar 12, 2008

Toddlers are a bit more resilient that my brittle-boned old folks.
One of our ladies went head first out of her wheelchair a few weeks ago. Broke her neck. Died over the weekend of pneumonia and weakness and misery.

Of course, you are right. They (toddlers) are also closer to the ground and Elders have further to fall, thereby increasing speed and momentum. It breaks my heart that you had a resident die in such a horrible mishap. It must have been terrible for you.

I have a few questions, not argumentative or oppositional questions (not the Spanish Inquisition:wink2:) -- just questions that may save my residents and staff from going through what you and yours did.

Was there an updated fall assessment?

Was this particular resident assessed as being high risk?

Did this resident have any other falls in the past 90 days?

Were new intervention(s) implemented with each fall? What fall precautions were currently on the care plan? Were they being followed?

Did she have any med changes in the 7 days proceeding the fall?

(And again, this is NOT a loaded question, we all know that EVERY SINGLE INTERVENTION is not followed to the nth degree every moment of every day!!!)

If you answered "No" to the 2nd and 3rd questions, then you probably wouldn't have had her restrained anyway. So, I guess what I'm asking is... what went wrong? What do I need to be alert for? How can I learn from this terrible incident and improve the care I provide?

I went to a wonderful workshop once where the speaker suggested all high risk residents should be padded!! Hip pads! Helmets! Landing mats at bedside! Knee pads! Elbow pads! LOL!

I love these ideas! :yelclap: My goals are to assist residents to reach/maintain their "highest practicable level of functioning", their independence, and their dignity. I may not be able to keep anyone from falling, but I can sure help reduce the risk of injury when they do fall!!

If anyone has some really inventive fall precautions or interventions to reduce injuries, I would LOVE to learn more-please share!

Thanks to all!

**And just in case anyone is going to ask the inevitable question, "How is dignity preserved if you let them fall?" Stop and ask yourself how long it takes from beginning to end of a fall, and how that compares to sitting tied to a chair for hours on end, day in and day out.

CapeCodMermaid, RN · Mar 12, 2008

Yes. If the mattress is sitting directly on the floor with no bedframe, and the patient rolls off the bed onto a rubber mat sitting adjacent to the mattress, it is not considered a fall.

I think you better go back and read the MDS RAI definition of a fall. What you describe IS indeed considered a fall.

SuesquatchRN, BSN, RN · Mar 12, 2008

Was there an updated fall assessment?
Was this particular resident assessed as being high risk?
Did this resident have any other falls in the past 90 days?
Were new intervention(s) implemented with each fall? What fall precautions were currently on the care plan? Were they being followed?
Did she have any med changes in the 7 days proceeding the fall?

Everything was in place. What we NEED are more aides and POSEY BELTS.

crazdmomof4 · Mar 14, 2008

I don't think there is any solution to this issue. Residents are going to fall, regardless of how many interventions we implement. We are talking about adults who are cognitively regressing in dementia / disease process. They are not aware of what they are doing and for the most part most have very poor impulse control. All of the alarms, anticipatory needs in the world will not prevent every fall.

For instance we have a lady who fell monday night. At the hospital before DC she was a 1:1 because of poor impulse issues. We have had her 2 weeks. When she first came I had her on an alarm and at the nurses station. The powers that be took her off the alarm and let her cruise around the facility and she was doing great. Monday night she kept closing her door to her room and puttering around. At around midnight we hear a crash, and try to go into her room, only she's fallen against the door. Pushing our way inside, I find a pool of blood on the floor and her moaning on her side. Long story short she hit the bridge of her nose and that was the source of blood. Could this fall have been prevented? With this resident probably not... we could have tied her to something and she would have fell.

We have adults who have been doing it their way for umpteen years and though they have regressed to another less cognitive level, they still have the habits of doing it their way. Sometimes there is just no way to really prevent falls. We can only do the best we can, and when you combine poor impulse control residents with staffing shortages and policy constraints enforced by facilities and government agencies, there is no way we as nurses can jump through all of those hoops successfully. But that is just my opinion.

elkpark · Mar 14, 2008

I don't think there is any solution to this issue. Residents are going to fall, regardless of how many interventions we implement. We are talking about adults who are cognitively regressing in dementia / disease process. They are not aware of what they are doing and for the most part most have very poor impulse control. All of the alarms, anticipatory needs in the world will not prevent every fall.
For instance we have a lady who fell monday night. At the hospital before DC she was a 1:1 because of poor impulse issues. We have had her 2 weeks. When she first came I had her on an alarm and at the nurses station. The powers that be took her off the alarm and let her cruise around the facility and she was doing great. Monday night she kept closing her door to her room and puttering around. At around midnight we hear a crash, and try to go into her room, only she's fallen against the door. Pushing our way inside, I find a pool of blood on the floor and her moaning on her side. Long story short she hit the bridge of her nose and that was the source of blood. Could this fall have been prevented? With this resident probably not... we could have tied her to something and she would have fell.
We have adults who have been doing it their way for umpteen years and though they have regressed to another less cognitive level, they still have the habits of doing it their way. Sometimes there is just no way to really prevent falls. We can only do the best we can, and when you combine poor impulse control residents with staffing shortages and policy constraints enforced by facilities and government agencies, there is no way we as nurses can jump through all of those hoops successfully. But that is just my opinion.

Thank you for your post. You're right, it's a very complicated issue. However, I think it's important to remember (mention again :)) that, as you point out, restraining people does not necessarily prevent falls or keep people safer.

withasmilelpn · Mar 18, 2008

I've seen those same residents! (Do you work with me?) But seriously, many of those residents we've seen are going to topple right over whether they're belted in or not. I, for one, would rather they be protected with hip pads/helmets and fall to the floor by themselves, rather than falling to the floor and having the wheel chair they are tied to fall on top of them.
Interestingly, toddlers are another group that fall quite a bit, but most parents don't tie them up. They "child-proof" the house, i.e., sharp edges on furniture are padded, sharp objects put out of reach so they won't be fallen on, gates placed at stairs, etc.
I fall at least once a week (Ok, the secret's out--I'm a clutz!), but I don't think that I need 1:1 supervision OR to be tied up. I think we need to treat everyone with dignity and protect them as best we can. The best fall prevention technique I've ever seen is "anticipating the resident's needs". If they aren't in a hurry to meet a physical or psycho-social need, falls are naturally less frequent.

We do restrain, though when they are in a stroller or cart. Serious injuries have happened to children who were not restrained. Children are also less likely to break a bone when they fall, unlike an adult. To take it a step further,when I have had children with disabilities, very frequently they had to be restrained whenever they were seated due to low muscle tone, spasticity, or seizures for example. They quite simply could not sit in a chair if they were not restrained. The no restraints ideal is one that I feel is unrealistic and can not be applied to all residents. I do feel looking to how we care for our children in one way is realistic - the same ratios of caregivers to children ought to apply in nursing.

(As far as falling every week, that may be more than clumsiness. You should probably let your physician know. Even in LTC, that many falls would warrent a physical workup.)

witchypoo · Mar 20, 2008

We do restrain, though when they are in a stroller or cart. Serious injuries have happened to children who were not restrained. Children are also less likely to break a bone when they fall, unlike an adult. To take it a step further,when I have had children with disabilities, very frequently they had to be restrained whenever they were seated due to low muscle tone, spasticity, or seizures for example. They quite simply could not sit in a chair if they were not restrained. The no restraints ideal is one that I feel is unrealistic and can not be applied to all residents. I do feel looking to how we care for our children in one way is realistic - the same ratios of caregivers to children ought to apply in nursing.
(As far as falling every week, that may be more than clumsiness. You should probably let your physician know. Even in LTC, that many falls would warrent a physical workup.)

They may require a physical and may have a uti, but what happens when there is nothing other than dementia. I have a lovely little fresh lady {she is rude to the point of being humorous, the filter is gone and what ever she thinks comes out of her mouth}. who has a body alarm. She went out to a doctors appointment, with an escort and an ambulance driver, they left her in her room because that is where she wanted to go, actually she told them to her house . I was not at the desk to tell the escort to either put her in the dayroom or by the nurses station, which is what is care planned. she had been fall free for a year and a half. she got out of the chair alarm sounding and fell before the aid got there and i ran down the hall. Luckily no broken bones, or injuries. not even a bruise, just the mountain of paperwork. {maybe we should use that to cushion the falls} . when asked why she told me because she was not home. the sob's drove right past my house,{and knowing where her home had been and where she went they did drive right past it}

If she was a child we would have the right to use a seat belt or other safety equiptment. lets face it many of the residents are mentally like children. this woman is pretty much like a 2 year old { like when your child told your MIL that you thought the gift she gave you for your birthday was the ulgyest thing you ever saw, aka no filter}. we make care plans and precautions but different factors sometimes intervene. the ambulance is now told to avoid the street she lived on. and they are instructed that she is to be left at the dayroom, where there is supervision.