Post fall root cause analysis report...

Specialties Geriatric

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Anyone have any pointers on this? I have to fill one out on a fall from almost 2 weeks ago and I have never done one of these before!! It's a 5 whys analysis. The resident who fell is very confused and attempted to crawl out of bed. When asking him what he was doing and/or why his responses made no sense, he doesn't usually answer questions at all! You ask him what color the sky is and he'll respond with something like "well no he didn't go down to the coffee shop yesterday.." So finding out why he was crawling out of bed is next to impossible. I am able to get why#1 and why#2 and nothing more!! The resident is incontinent and his brief was dry. It was 0500 when it happened and he had been checked on a few minutes before the fall. Can anyone help me with this?!

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Specializes in kids.

Was he hungry? was he thirsty? whats meds is he on? were there external factors? (noise in the room, hallway, bells, another disruptive patient?) any s/s of a UTI or any other infection? just a few off the top of my head.

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Specializes in Gerontology, Med surg, Home Health.

What was his job? Was he always an early riser? I have a guy who kept standing up to walk...had many falls. He was dry, fed, no pain. He was a firefighter for 35 years. He heard the call bells, thought it was the alarm in the firehouse and if he didn't get up and get on the truck, someone would burn up.

It's not easy to figure it out but there usually is a reason for people getting out of bed.

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Specializes in retired LTC.

postural hypotension? obstructed floor? what kind of footwear?

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What was his job? Was he always an early riser? I have a guy who kept standing up to walk...had many falls. He was dry, fed, no pain. He was a firefighter for 35 years. He heard the call bells, thought it was the alarm in the firehouse and if he didn't get up and get on the truck, someone would burn up.

It's not easy to figure it out but there usually is a reason for people getting out of bed.

That is so cute though!

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The root cause analysis format that I was told to use was the "5 whys" I could only get to the 4th why... It looked like this

Problem: Resident found on hands and knees on the floor, next to his bed.

Why #1:Resident attempted to transfer himself out of bed.

Why #2: Resident does not use call light or ask for assistance.

Why #3: Resident is very confused and impulsive.

Why #4: Resident has a hx of a traumatic brain injury.

doesnt really give the root cause of why he fell per se... It's not possible to figure the cause out in this situation. We have no idea what he was trying to do or where he was trying to go. This guy is so confused, the first time I met him he was using a pen to tighten an imaginary screw on his call button. He thought the pen was a screw driver. He has a long history of falls... Our facility just recently went alarm free, he used to have an alarm. I kinda wish he still did...

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Why did he try to transfer himself? Where was he going? What was happening on the unit at the time? Why was his brief dry? Did he need to go to the bathroom, or did the aides just change him and he thought it was time to get up?

With dementia residents, it is usually pointless to include the call light since they don't know what to do with it. However, you still need to ask them questions. Even if they don't answer appropriately, you will still get information

With your root cause you listed here, you are headed in the wrong direction. The goal is to figure out why he was trying to get up.

There is always a reason why they fell. They heard a noise and was going to let the dog in, they were going to shut the front door, is time to make breakfast or go to work, etc.

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Specializes in Public Health.

These things are so frustrating. Sometimes you just can't prevent the falls. It's not practical to have a sitter for each confused pt. It sucks but what are you gonna do?

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Exactly Slinky! I don't agree with the thought that a cause can always be found for a fall. Nor will finding a cause prevent another fall in a resident who is this confused.i haven't gotten the analysis form back to redo so I'm guessing it's satisfactory enough for my DON

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You can't prevent falls, you can reduce the risk of injury from them.

There is always a cause to the fall, otherwise, they wouldn't fall.

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Specializes in LTC, assisted living, med-surg, psych.

Is there a pattern to the falls, e.g. does he tend to fall at a particular time of day? Is he on psychotropics or narcotics? Why does he get up in the first place (early riser, needs to use the toilet, confused as to place/time, heading to "work")? Is he wearing non-skid socks or shoes at all times? Is the furniture situated in such a way that he is stumbling over something? Might he have a UTI?

There are a million and one reasons why elderly people fall. There is always a reason for them, although we may not always be able to figure it out or stop the person from falling.

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Our employers told us you do not need all 5 whys filled out to come up with an answer. Another poster was correct, you sometimes will find no reason for the fall. I would have put after he is unable to use callight, it's because he has poor safety awareness and why that is because he has dementia then stop. This would only be used if no other problems could be found like if he could be helped by a scheduled tolieting program.

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