Recently had the misfortune of having a patient fall under my watch. It was the first time I've had such an event in my career and I have been very upset with myself over it. Fall was unwitnessed. I had been in another room caring for a patient. As soon as I finished and as I was heading into said patient's room I was notified they had just come off the monitor. I rushed into the room to find the patient laying on the ground on her side. Pt had shown some signs of delirium prior but had been A&Ox3-4, following commands, and cooperative for the most part. And there had been no prior incidences of patient trying to get up out of bed before. Patient thought they heard something on the other side of the room and was trying to see what it was.
To sum up, patient did not suffer any serious injury or harm, no bleeds /breaks/ or bruises thankfully. Incident report was filed and family was notified. Have to fill out another more detailed report now. Although many safety measures had been in place, I'm afraid the bed exit alarm may not been reset from the last time we were in the patient room. Secretary said that the bed alarm did not go off. And when I had gone to check the bed, it was not on at the time. This report specifically asks if the bed alarm was on.
My question is, how honest should I be with this report and indicating the status of the bed alarm. I believe honesty is the best policy, but I also want to make sure I protect myself as well. I always been vigilant about bed alarms, its something I do all the time. But the one time I didn't, patient unfortunately got up and fell.
I want to be honest but I don't want to implicate myself either. I don't know what the consequences could be if I am too honest. I'm not sure what the best way to approach this situation. Any advice would be appreciated.
Specializes in Gerontology, Med surg, Home Health.
Alarms do NOT prevent falls. We have residents with bed alarms, chair alarms, motion detectors....the better intervention is one that mitigates injury from a fall...floor mats, low beds....
Are you a new nurse? Quit beating yourself up. **** happens, no matter how well you do your job. Way back when I was in nursing school, my patient was in full Posey restraints, and they were tied literally under the bed. There is no way that patient should have been able to get out of them. We went into her room and the patient was sitting in a chair with the restraints hanging off the bed. We could find no way she should have been able to get out of them. We asked the sweet old lady how she got out. She replied "Jesus let me out." It was as good an answer as any we could think of. Fill out your report and move on. :)
CMS, other agencies and government have taken events that inevitably will happen and can't be proven to be 100% preventable and have turned then into never events or SREs (serious reportable events). A fall will happen unless you have 24/7 staff monitoring all patients everywhere.
Bed alarms are archaic and unreliable IMO. By the time they are off the bed/chair, the patient/resident/client is down. I prefer lasers.
Since the facility will be zonked for having a fall they must 'BLAME" someone. I don't care if the patient is a member of Mensa and totally with it...a fall can happen. They're called accidents.
We have come a long way but we can't say that all falls are preventable. What meds is she on, did she turn off the alarm (the cognizant ones do it more than you could imagine), etc...
Just the facts ma'am...seriously: do not put any conjecture. If you tell the truth than you don't have to remember any white lies. You say she was with it but you had her on a bed alarm...I know she was acting off now and then. Did she fill out a fall contract...this is very important.
You will get through this but they will make you feel as if it's all your fault. Or, hopefully you work at a facility that doesn't have a gun at your back.
It seems each year that passes the regulations get crazier and crazier. I sometimes think if we didn't have a rule for every little thing, so many things wouldn't go wrong.
Specializes in Psych, Addictions, SOL (Student of Life).
I agree with all the advice you have been given. Later if you have a chance outside the investigative process to advocate for you patients you might mention that evidenced based research shows that bed alarms do not prevent falls and in fact facilities who rely on them have a higher incidence of falls. The best way to prevent falls is a comprehensive fall prevention program such as the Falling Star program.
I will pull up my research but am away from my home computer right now.
Should I explain the objective facts or just leave them alone...for example "lights had been dimmed" vs. "lights had been dimmed to aid with sleep" or pt was on "x medication" vs " "pt was on x medication to manage agitation/ delirium".
Specializes in Psych, Addictions, SOL (Student of Life).
Should I explain the objective facts or just leave them alone...for example "lights had been dimmed" vs. "lights had been dimmed to aid with sleep" or pt was on "x medication" vs " "pt was on x medication to manage agitation/ delirium".
You are over thinking it. do not put in reasons treat it like a deposition just the facts no subjective information. A good rule of thumb is to think about how you should answer questions in a malpractice deposition where the answer to every question is Yes, No or I don't recall.
Should i add that it may have been forgotton to be reset, because it had been on but when we turned her in bed we must have forgotton to reset it.
No. Just state that it was found in the Off position. Why do you want to speculate in a way that puts blame on yourself or others? Nurses are so darned ready to punish themselves, sometimes rightly and sometimes not, as in this case.
In fact, you really do not know who turned it off. As you stated yourself, the pt might have turned it off. Do not speculate on that either. Just say NO or "It was found in the Off position".
If asked if you turned it on or off, or if someone else did, state honestly that "I do not have a clear recollection regarding that". That is the truth, right?
Also - how can someone be both delirious and oriented? Don't say "delirious". That's a medical diagnosis. Just say she was oriented to person, place, time, whatever.
The secretary might not want to admit that she missed the alarm possibly.
Staffing levels are important to note, too, although someone will get mad at you if you indicate that they were lower than they were supposed to be or that someone was at lunch or in the restroom or tied up with another patient, like you were, and reasonably so.
Say as little as possible, do not conjecture, do not blame yourself. People do fall. Even people who have sitters 1:1 with them fall. They shouldn't but it's been known to happen.
Again, say as little as possible, do not speculate. And you will actually be telling the truth.
As has been said, just state the facts. The forms I have had to use ask for how you found them, what they say happened and ask for other things such as bed alarms, medications, vitals,neuro checks, etc. Some meds can contribute to falls. Also, as has been said, you can have all the precautions in place and the patient will fall. Maybe even right after you exit the room. Many times, when you hear the alarm, it is already too late by the time you reach the room.
Don't beat yourself up over this. Go over everything n your mind and then you will be more conscious of checking and double checking alarms when leaving the room.
Paws2people
495 Posts
The patient could of fallen even if the bed alarm WAS on.
Admit no fault. You don't even know if it was you who forgot to reset it.