Patient fall...my first time.

[muscledriver]

Recently just experienced my first patient fall, and feel completely horrible about it. The patient is a TBI (appx 2 years ago, has no family) whom experiences seizures. She is mute and rarely gets out of bed, but when she does, she jolts out of bed and quickly springs up the hall only to return a minute or so later. After assessing the patient during the evening, prior to shift change, she was resting calmly in bed, staring straight up (baseline) and bed alarm was on (documented). About 10 minutes after leaving the room while writing my notes at the nursing stations, I hear this sort of "grumbling" and then a big hit on the floor. I sprang up from my seat and sprinted over to find her face down on the floor in her own blood. Assuming she had a seizure, I rolled her on her side, checked pulses and respirations - still alive. I yelled for RRT, and assistance, none of the other nurses on the floor responded. I yelled again for assistance, this time I got someone to come, I ran for the crash cart, placed oxygen on the woman, and began to suction. Finally, the troops arrived, we stabilized her, got her on a stretcher, and sent off for a ct. The part that kills me aside from initially having nearly no back up (which has happened 2-3x with recent RRT's), is the bed alarm. I cannot recall if it went off, and even if it had, would I have been able to have gotten there in time to prevent this from happening? It is known that her roommate tends to turn her alarm off because she hates the noise it makes, and I know that it was on when I assessed the patient just prior to the incident - so its possible she turned it off when I exited the room. I feel completely awful this person got hurt, and even though the managers all told me I did a good job, reacted correctly, these kinds of things happen and are unpredictable, etc - I don't know what kind of trouble will result due to this and as a new RN, I am quite nervous about it. Can anyone offer some advice regarding this situation? My stomach is in knots! Thank you for reading.

[PacoUSA, BSN, RN]

I had a patient fall when I was a new nurse (the patient ended up coding and passing away, can't get any worse than that). There was never any blame placed on me or my aides, but it did involve a risk management meeting to discuss how this could be prevented in the future. There seemed to be an issue with the bed alarm getting deactivated at some point and it probably was not on when the patient exited. You can only do so much.

My question is, why does the roommate know how to deactivate a bed alarm? Most patients don't know how to do it, especially on a Versacare bed. I always activate and deactivate out of a neighbors view to prevent such a thing ... unless of course the roommate is an employee anyway, but then again, don't they usually get a single room? I digress.

Sounds to me like you did everything right and within your abilities. Be confident in that.

Sent from my iPad using allnurses

[Anna Flaxis, BSN, RN]

Listen to me.

You did a good job. You reacted appropriately. These things happen and are unpredictable.

Now, about that bed alarm. This is a serious safety issue. Time to go into problem solving mode. Can you move the other resident, or put a lock on the bed alarm so it can only be inactivated with a code, or ??? I think some brainstorming with your colleagues would be in order.

[martymoose, BSN, RN]

since it was possible that the pt was having a seizure, there'es nothing that an alarm is going to help, except to let you know they are not on the bed. We have big mats on the floor available for those who get up faster that we can get there. Also low beds, not having all the rails up- just the 2 by the head( if they want out, they are getting out- at least they dont hang them selves over the rail). They have these hip pads to we can put on the pt- they look like a football player lol. Since this pt is seizures and tbi, maybe they should now wear a soft helmet?

Not sure what to do about room mate. I guess I would move them to another room. Cant take the chance.

Don't feel bad, sounds like you are very conscientious

[Raewynv]

As a student nurse who has also witnessed patients falling, one who was standing right next to me, you did the right thing. I am a bit shocked that the others took time to respond. I did a five week placement on a Older Adult ward and falls were common. Patients had alarms but some of them knew how to take them off and even hide each bit in different areas of the ward. What you did was what any nurse would do (from what I have seen). Do beat yourself up about it :)

[firstinfamily, RN]

Sometimes the bed alarms do not truly sound until the pt is completely out of bed. Perhaps an earlier alarm system is needed. We used clip alarms as well as bed alarms on our frequent fallers. They are a clip attached to an alarm box and placed on the upper side rails so that if the pt starts to get up it detaches and alarms before the bed alarm sounds. The idea of a floor mat alarm is also good. We also used the "hipsters" padded on the hip area type pants over the briefs for any pt who had a history of falls. Supposedly they help to prevent hip fractures. Falls happen, making frequent rounds and checking on pts and alarms is the only other thing to do. It sounds like you responded appropriately. Is there a safety committee or falls program at your facility??

[muscledriver]

Thank you for you replies! I really appreciate the support. Several close friends who are also RN's basically had the same response as you guys, and also said in actuality I probably played a large role in saving a life. I was also told by one co-worker that the patient has a history of doing this, and felt it was just a matter of time that something like this happened. Hopefully when I return to my unit tomorrow and speak to my manager, we can have a rational conversation about it.

[Raewynv]

I just realized my spelling mistake.....Suppose to be Don't beat yourself up about it