Investigating Falls/ Accidents

[CoffeeRTC, BSN, RN]

How much of this falls on to you?

Fall occurs. Nurse completes an event/ incident report. What do your forms include?

We have a one page event report that nurse completes. Then we have witness statements. Everyone that had contact with that resident should complete one. The nurse and CNA assigned and those that responded to the event.

That is all we do. It gets shipped off to the DON then the risk manager.

The event should go on our 24 hr report and alert charting should be done for 3 days. Neuro checks are hit or miss and so is the charting. No one seems to be doing any immediate corrective action or critical thinking.

A lot of this just seems like common sense to me, but we are having a hard time with this.

I'm tying to come up with some type of reminder check off list for the nurses to do along with the event report to cue immediate intervention. I want to keep it simple.

Anyone have suggestions? or can you point me to a webiste etc?

Before anyone mentions increase staffing and assign sitters or voices a complaint about adding another form to fill out, I just want to mention that I'm still working in the trench and most of my duties include hands on care. I get that no one wants another form to complete, trust me.

[CapeCodMermaid, RN]

Forms won't help. Most nurses don't bother to complete a falls investigation. I have nurses who always add "Remind resident to use call ball" even if the patient is too demented...and they always add another alarm. It's an uphill battle. We bring the reports to morning meeting. The team reviews them, the documentation and any care plan updates. If none were done we do them right there.

[CoffeeRTC, BSN, RN]

You are probably right. I am doing an in-service this week. It is just so sad and frustrating. Most of our nurses have plenty of experience in nursing and at our facility but still, cant seem to complete an event report correctly or even critical think on how to provide and immediate intervention to precvent further occurance. They do nothing. A resident falls, they might or might not complete an event report and place the info on report. No follow up, nothing.

[DebZee]

Where I work all falls are investigated. Neuro checks should be done on any unwitnessed fall or if the resident hits their head. The 'root cause' of the fall should be determined. Was the resident incontnent? Do they have pain? Maybe they need a toileting plan or a pain med..maybe a wider bed..maybe bed bolsters? Maybe they are ill..could have an infection and need lab work..if staff isn't completing forms do they need to be educated or reprimanded? We can't prevent all falls but we need to try to prevent injuries from occurring.

[downsouthlaff, LPN]

At my facility us floor nurses are required to complete the Accident report, identify the cause of incident, address any injuries prudently, ex dress a skin tear, do neuros for head involvement etc, we then must initiate a corrective action for the incident. The DON or Weekend RN does reassessment and follow ups.

[HyzenthlayLPN]

When I was in LTC, our incident report had a section for an Immediate Intervention. I always explained it to my nurses as "What did you do to make sure this resident did not fall again on your shift?"

Each weekday, the DON, Quality Manager(s), Unit Manager(s) and the MDS nurses met to go over all inicidents, review the current plan of care and discuss interventions. The care plan was then updated and the changes implemented.

[CoffeeRTC, BSN, RN]

I detest our Event reports and would love to redo them. They are way too basic and really don't tell me much but instead, they rely on the witness statement forms that no one fills out. I remember complaining about a three page incident report our old company had us complete. I would love to got back to them and get rid of the current form and process. For most events i get a general location, check off for a fall and then that is it. The witness statements do not inlude much. Ask a CNA to fill it out and I get "found Mary on floor and called for nurse. Nurse looked at Mary and then we picked her up and got her to bed" yep....that's about it.