Reporting a Fall???

CoffeeRTC, BSN, RN · Mar 1, 2012

If you didn't see them fall, don't chart that. If you have a witness that saw them fall..you can chart that. It goes on the incident report at our facility.

Res found on floor in a sitting postion in front of the wheelchair. Chair noted to be unlocked, res not wearing shoes. Per resident " I stood up and just fell, lost my balance"

psu_213, BSN, RN · Mar 1, 2012

I would think you could possibly LOSE (sorry, pet peeve) you license if you charted "resident fell" when it was not observed. If it was an observed fall either put in their word for word what the person who observed the fall said. For example: Per Jane Doe, CNA, "she got up out of her chair, lost her balance and fell sideways. She didn't hit her head." (P.S. I love quotation marks! :heartbeat :smokin: ) If you were acutally the one to obeserve it, I can't see why it would be wrong to use the word "fall" if they indeed do that.

agldragonRN · Mar 2, 2012

i was told not use the word "incident" in my charting because when lawyer sees that word, they likely would investigate it further.

i use the word fall/fell all the time if appropriate. if it was an observed fall, i chart it. if it was an unwitnessed fall, i chart "patient was found sitting up on the floor..." and not use the word fall because i did not really know if the patient "fell". i had a patient once who would do sit-ups on the floor for exercise so obviously that was not a fall.

however, if the patient stated to me she fell. i chart "patient stated she was trying to go to the bathroom when she lost her balance and fell on her buttock"

rndebracoll · Mar 2, 2012

hi,

this is from the rai users manual for long term care, and reflects federal regulations:

when a resident is found on the floor, the most logical conclusion is that a fall has occurred.

the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again.

more from that:

an intercepted fall is still a fall.

an episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall.

a fall without injury is still a fall.

the presence or absence of a resultant injury is not a factor in the definition of a fall.

the distance to the next lower surface is not a factor in determining whether or not a fall occurred.

if a resident rolled off a bed or mattress that was close to the floor, this is a fall.

i was told to never chart that a client/patient fell. but to write that they were found lying or sitting on the floor. ok i can understand this, if no one saw it! (even though that's most likely what happened) however, you're not even suppose to chart it, even if it was witnessed. this seems dishonest to me. can i loose my licence if i go along with this? i'm temped not to say anything and then just chart the truth when it happens.

what do you think? i'm still in orientation. my first part-time job in ltc.

SuesquatchRN, BSN, RN · Mar 2, 2012

You won't lose your license over charting or not charting a fall. You will lose your job if you defy the boss.

Don't mention any internal paperwork that is not part of the medical record in your notes.

mazy · Mar 2, 2012

Why on earth would you lose your license?

Sparrowhawk · Mar 4, 2012

If you didn't see it..and you chart that they fell...the state/court will say "Why weren't you observing them so they wouldn't fall" if you're there and they fall you say "lowered" simply because they'll have a hey dey with You let them fal??? Oh you bad nurse!

Chart observed on floor..chart what your boss tells you, nothing illegal going on here...Never chart you filled out an incident report, that's no one's business but the facility... the facts are the facts no matter how you word it.

wildflower53 · Mar 4, 2012

Get used to the wonderful world of healthcare, girl. Take it from me, whose big mouth and honesty has got her into trouble for 30+ years as an RN...do what they tell you. Nursing homes are a business, and they are run like one; documented falls reflect on their record with HHS. Just write found sitting/lying on floor, blah, blah blah.

One Flew Over · Mar 4, 2012

You document what you saw, it's not your job to document what you assume happened. Like a previous poster said, I've had residents in LTC that sit themselves on the floor, crawl, slide.. etc.. so not every patient you find on the floor has necessarily fallen. Of course you still fill out the incident reports, update careplans.. etc.. but don't document something unless you witnesses it and know it to be true, it's not any different from documenting on anything else.

gymrat33, LPN · Mar 14, 2012

i was told not use the word "incident" in my charting because when lawyer sees that word, they likely would investigate it further.
i use the word fall/fell all the time if appropriate. if it was an observed fall, i chart it. if it was an unwitnessed fall, i chart "patient was found sitting up on the floor..." and not use the word fall because i did not really know if the patient "fell". i had a patient once who would do sit-ups on the floor for exercise so obviously that was not a fall.
however, if the patient stated to me she fell. i chart "patient stated she was trying to go to the bathroom when she lost her balance and fell on her buttock"

ours is the same but now if it is unwitnessed, we start a 3 day neurochecks per facility policy no matter if the pt is alert and said she/he didn't hit their head.

joanna73, BSN, RN · Mar 21, 2012

We have falls all the time. If my NA tells me they found a resident on the floor, I chart it that way, but it's still treated as a fall. We follow the protocol: vitals for 3 days, incident report, family and doctor notified.