Incident Reports- VS six times, asking the same q's repeatedly

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Hi. At my workplace, we were given new incident report forms to fill out. These forms require the nurse to take vital signs six times: immediately after the incident in the supine, sitting and standing positions. Plus, 5 minutes after the incident, we are to take the vitals again in the supine, sitting, and standing positions. I did not know we had new incident forms to fill out, and I only took the vitals once, since it was the usual procedure in the past. Plus, none of us nurses were inserviced on these new forms. I was off from work today, so I don't know what will happen to me because I didn't do it (the resident was sent to the hospital), but I found it odd that vitals had to be taken so many times during an incident. Six times? Is this a common procedure at your LTCF for incidents? What if the resident cannot be put into the sitting or standing position due to an injury after an incident?

In addition, the new report is 10 pages long, and often asks the same questions on different pages, such as what time the incident occured (I think I answered that 6 times!) and what time I last saw the resident, for instance. Plus, it requires us to have a medication evaluation by the pharmacy for side effects that might contribute to a fall. For a document that is supposedly internal-only, it was very time-consuming and redundant. Is this what incident reports at your LTCFs are like?

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I don't know what is common in LTC's- I work ER, but have a few thoughts:

By taking six sets of vitals you mean doing orthostatics twice. Requiring two sets of orthostatics on every pt who has an incident is goofy.

Documenting the same thing multiple times is not only a waste of time, it is a liability problem. Far more likely you will make a mistake.

A 10 page incident report is really, really, stupid.

The process you describe will reduce patient safety at your facility. Wasting nurses' time with this sort of nonsense takes time away from patient care. It will also discourage the use of incident forms. Whoever decided this is a good idea is an idiot.

The pharmacy review of the med is not a bad idea.

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Specializes in Agency, ortho, tele, med surg, icu, er.

Whoever thought of this ingenius idea was not a nurse. I am a very honest and forthright nurse and I would be tempted not to report if this was the drama I had to go threw. You guys have like 40 patients on a nightshift. I can only imagine what it would be like if you had to do all that crap plus all the other documentation you had.

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Specializes in LTC, Ortho, Quality.

That seems to be alot of redundancy that will set you up for failure. I suspect, given the fact that it is 10 pages long, that this form was origianlly developed to cover any and all incident types, from falls (hence the ortho-stat bp's) to med errors to what ever else you need to report. But, along the way in your facility's development/approval process they tweeked it and removed the pieces that say "if incident is a fall then proceed to page 2....if incident is med error proceed to page 5....etc" I would call and talk with your clinical ed person, or who ever handles new forms education to get the situation straightened out quickly, and hopefully get the ball rolling on re-education on the use of the form facility wide! Good luck to you!

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Specializes in Gerontology, Med surg, Home Health.

Our basic incident report is one page. Add one page if it's a fall, add a different page if it's a bruise,,,then add pages for witness statements. We do vitals once...neuro checks on all unwitnessed falls and chart every shift for 72 hours.

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Wow, a one-page incident report?! I can only dream of such a thing.

The statement part of the report is different than before in that only the CNA assigned to the resident fills it out. It's mostly questions, such as: last time you saw, feed, or toilted the resident. It's not a blank statement form like previous witness statements that I filled out when I was a CNA. Oddly, there wasn't a form for someone who may have witnessed the incident, but wasn't the CNA assigned to the resident. In my incident, it just so happened that the CNA assigned to the resident saw the resident on the floor, but why wouldn't an incident report have a form for employees who may have seen the incident, but were not the CNA or nurse assigned to the resident? I'm told that we are going to be inserviced on the new forms, thank goodness. However, this should've happened before we were given these new forms.

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We do the same as Cape Code does in her facility but when there is a fall we do a post fall assessment after that. Update the Careplan, of course if it is a fall with injury requiring hospitalization our state has us call and tell on ourselve we just got a 15,000 fine for reporting ourselves lol. Any my beloved nurse aide class taking away. I am sad and disappointed but I did read we get to continue the current class going on. But our nurse aide turn over rate is bad and we are finally getting some good ones in there if this is stopped for 2 YEARS as they mandated --dang who is going to take care of our residents? I feel so bad because most that go to the local college take our class first and we utilize them for weekend work while they are in school hoping to retain them after they complete LVN training. I have been reading rules and regs half the night. Making Inservicing stuff for the DON on changes of condition -- which they hit us hard on that and Notification of Doctors. Folks you better beef up your pain careplans they go for the jugular on that one!! Yes I have also vamped up my resume and sent out some via job search engines. Those of you that pray do pray for our little small nonprofit facility. It is my home away from home most of the time.

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Specializes in LTC.

Yes, my friend, 1 pg incident reports do exist....we used to have it at my facility til 3 yrs ago when this new DON took over...its now 6 pgs front and back with the SAME?s on it repeatedly.....VS 6 x is crazy unless its a neurocheck. And to have the same thing on that many pgs is redundent charting...and like another poster said....leaves one open to liablity and error. What i have started doing on ours is for all that repeated junk I just write "see first page" or something to that effect that says 'LOOK ! ITS WROTE SOMEWHERE ELSE" without actually having to write that lol. I wish we had our old ones back....it takes even a swift nurse like me 45 plus minutes to do one incident report...and when I have to do more than one in a shift....is awful....and these things are for falls, skin tears, bruises,...you name it.

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