We're number one! We're number one! (For falls)

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i work in an adult medical inpatient setting. we have 35 beds, which is a small fraction of the approximately 1100 in our organization. for the month of september, we experienced ten falls. that is the most for any department in the organization. six of those ten falls were on the 11-7 shift.

during a typical 7-3 shift, there are 8-9 nurses and 3-4 techs. during a 3-11 shift, there are usually 8 nurses and 2-3 techs. on midnights, there are 6-7 nurses and no tech or one tech. like i said, this is typical. there are days that day shift only has two techs, or midnights has two techs. but from the numbers, one can see that there is a bit of a difference between day shift staff and night shift staff. (that makes sense, and i realize that's what usually happens. i have no problem with this, because i have no desire to work days no matter how much staff there is!) however, our manager has said time and again that staffing has nothing to do with falls, or with the disproportionate number of falls on midnights.

oh yeah, one other thing about staffing - september probably broke some records in regards to number of 1:1 sitter cases on our floor. we have a sitter pool in our organization, but those individuals seem to only be available during day and evening shifts. even then, with sometimes three sitter cases at one given time, we've often had to staff our own cases. (on midnights, the norm is to staff our own cases). yet when one looks at the staffing "grid," our techs are counted as techs even if they are sitting during that shift. so, on paper, staffing isn't really that much of an issue and therefore cannot be a factor in the falls (right?).

we were asked for feedback on what was contributing to the falls, and just about everyone blamed staffing. in fact, we were even called at home to be asked for our feedback. despite this feedback, management continues to insist that staffing has nothing to do with it.

instead, we have been given a new set of "strategies" to prevent falls, which include:

~ hanging a large laminated paper tree on the unit and putting up a numbered, laminated smiling leaf on the tree for each day without a fall

~ double documenting our rounding - once in the flow sheets as per now, and signing a paper in each room

~ changing assignments around on midnights so staff nurses have more patients and the charge nurse has less (sounds good, but this also means that staff nurses are going to be divided into more than one district)

~ and the one that gets my goat, boils my blood, shucks my corn....

we are going to be asked to sign a "focus on falls contract. this contract will state our recommitment to patient safety. the contract will have reminders regarding rounding, nursing code of ethics, documentation, and a general performance reminders as well as our recognition goals for fall free milestones" (direct quote from management).

to top it all off, our downtime on midnights is being scrutinized. we're not supposed to read, do school work, be on the computer, or socialize. i manage to complete my assessments, pass my meds (including prns), do flowsheets, chart checks, nursing profiles, care plans, write progress notes, stock my drawers, bathe completes, turn, toilet and do incontinence care every two hours, perform hourly rounding, do my own vital signs, answer my own call bells and add up my i's & o's. if all of this is finished and no one else needs (or others refuse) my help, what am i supposed to do? do they want me to hover over the patients as they sleep, moving from bed to bed like a ghoul or something?

i do my job, and i do it well. i advocate for my patients successfully, help out as much as i can, and i've perfected the science of the middle of the night admission! i clean up messes left for me by nurses who make errors (some dangerous) or neglect their duties. i've talked to management about this, but nothing is done to these nurses! yet my manager heard a rumor about my internet use and yelled at me for it. that's right, she's basing it on a rumor and admitted as much (her words "this is all hearsay.") now i have all of this falls-obsessed crap to deal with...

i know that was really long, and i won't be surprised if no one managed to make it to this point. i'm not even sure what i want from all of you. i know no job is perfect and each department has its issues, but...am i nuts, or are there other things that should be of some importance to management aside from falls? and doesn't one department each month have to be number one?

thanks,

naomi grace rn

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I'm sorry this is happenning to you. I totally know what you mean though, with management not getting it. Anytime you bring up an issue with management about a better way of solving an issue or the issue itself, all that happens is the nurses and nurse aides get more work! That is the solution to everything right? Just give them more work, when half the reason you have these problems is because they have too much work to begin with.

I'll give you an example. I used to work at a facility for adults with disabilities. I was a caregiver there. When I was working one night, there were 3 caregivers and one nurse there (relatively small patient population so it normally should have been okay).

What was not okay about this particular night? There were 3 patients needing 1:1 care. Which meant that all three caregivers were in three different rooms attending to their one patient all night. And the one nurse, poor thing, was running around doing everything for every other patient! All the turning, any bathroom calls, and anything else needed during the night. Not to mention that when I was there, I was 1:1 with this patient for 10 straight hours. Yes. 10. straight. hours. We all were....what else could have happenned? The poor nurse was running around doing everythign else, there was no time to be relieved for anything...to go to the bathroom, drink of water or anything.

Now normally on nights the caregivers (not the nurse) would do a fair bit of cleaning...it was in the job description. Now I have no problems with this. But this particular night, as mentioned, there was no staff left to clean.

And the facility wasn't like down right dirty or anything...cleaning happenned quite frequently (meaning no true harm was going to be done by not cleaning one night given the cirumstances. None.

So, we did not do it. The nurse left a note for management explaining the situation, stating that there was no way cleaning could occur and the patients could be taken care of and she made a judgement call and reserved it that way.

I was working 1 and a half shifts (worked midnight, then stayed till one p.m the next day. wouldn't advise it lol ) Management calls me in because i'm the only one remaining from night shift to discuss the situation. Manager calls me in, asks me why I didn't clean. I explained the situation. Manager says "well, you could have attempted SOME of the cleaning." Then I got angry, but was talking to my boss here. So I politely stated "well what was I supposed to do? The only way I could have cleaned is if I left my 1:1 patient." Manager states that I should have gotten someone else to relieve me. I again explained that this wasn't a possibility...if it was we would have done that, like we do every night! The manager then repeats herself saying "i should have done some of the cleaning."

A massive email is sent out to all night shifters explaining the importance of cleaning, and that not cleaning won't be acceptable.

The solution? day shifters are supposed to do a "morning cleaning routine" prior to a.m care, cutting into the first half hour of the shift that is overlapped with night shift. Normally this first half hour gives the day shifters time to get situated, get report on what happenned during the night, and read over the treatment guidelines on the computer that have changed since the last time they were there (very important because of the nature of the facility, there weren't charts so you had to remember what was going on with your patient!!!).

WTH? Yes, that is the solution. Make more work for other caregivers. That is the solution. Not adequetely staffing night shift in the first place right!!!!

People and their bright ideas.

I understand your pain. And I'm sorry you got chewed out. I agree...if all your patients are taken care of and everyone else's are, why can't you be on the computer???

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Specializes in Oncology.

Hourly rounding is silly. If your patient is sleeping (which they SHOULD be at 0300), it takes maybe 30 seconds to peak your head in and sign some sheet. That leaves 59 min 30 seconds per hour (presuming no one has any other reason to be in the room) that the patient can fall.

Has anyone figured perhaps people are falling at night because they're tired and it's dark? Shocker, I know.

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Specializes in cardiothoracic surgery.

Aren't there studies out there saying that staffing is related to falls? It makes sense to me. What are the reasons for the falls? (besides staffing) Medications, confusion? Management should be looking at the cause of the falls and addressing those as well. Pharmacy reviews medications for our high risk for falls patients to see if any of the medications could contribute to a fall. I have to somewhat disagree with you on one thing though. Addressing falls in the hospital is important, because people can get seriously hurt from a fall, and then here come the lawsuits! We have to do and document hourly checks on our fall risk patients. I know it is very frustrating and makes more work for everyone, but the reasoning behind it does make sense, patient safety. Now I am not stating I like all of the extra work, because I absolutely don't. It is all of those extra little things they require us to do that cause us more stress and in turn, higher stress increases the risk of patient harm. And I don't think management recognizes this. It has been driving me crazy lately so much, that I am almost ready to leave bedside nursing.

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Specializes in Management, Emergency, Psych, Med Surg.

We have new beds and they all have bed alarms. We place all patients who are fall risk as close to the nurses station as possible. If they are at great fall risk and there is no other option, they get a sitter and we try to place high risk pts in rooms together so the sitter can sit with both. We have MUCH better staffing than you have. On the 3-11 shift we have gone the last 90 days with no falls. 7-3 had no falls for 180 days and nights no falls for 90 days. The other thing we do sometimes is we take the patients that are really active and sit them in a wheelchair at the nurses station with us. We talk to them and pester them and make them stay awake. When they get tired, we put them to bed. Usually they are so tired by then that they sleep and don't try to climb out of bed. Our floor is 34 beds. Our nurse patient ratio is 4:1 or 5:1 with 2-3 CNA's on each shift. Most of our patients are elderly. General medicine, GI and orthopedics.

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Thanks for your input, everyone!

I actually don't think hourly rounding is silly; if nothing else, it's a reminder to check on your patients who aren't "ringers." And we do our rounding! Management claims our rounding is ineffective and we're too busy doing other things rather than spending time in rooms. (Another manager quote: "I know you're not doing your rounding because the rooms are a mess." Well, excuse me, sir, I know it's two AM but I decided your room needs to be cleaned! It's kinda ridiculous but midnight techs have been yelled at for not cleaning rooms!)

Bed exit alarms are great, and sitting patients at the nurses' desk in a geri-chair, or utilizing 1:1's as necessary...these are things we do. The thing is, the patients who are falling, at least lately, are not old, and do not require assistance. They're independent, alert and oriented. Why do they fall? I haven't had time to sit down and investigate (I wish I did) but I know I trip in my own home in broad daylight. I think the falls on midnights are because of staffing (as in, it might take longer for someone to answer the call bell and the patient decides to just get up and go for the commode or whatever), because it's dark, because the patients are tired, and because they don't know their surroundings as well as they think they might. I don't think medications have been a factor in any of the falls. Now our management has us put a bed exit alarm on every single patient. The alert and oriented, self care patients who have to wait for someone to walk them to the bathroom just LOVE that. In fact, a doctor ordered "do not place bed exit alarm on patient." One of our management team members called him and said we were refusing that order!

Here's an interesting tidbit. Last night, one of our techs (I don't know where she found the time, honestly...I was pulled to another floor last night) sat down with the falls data from the last thirteen months, and found that day shift has had the most falls, and night shift has actually had the least. In the previous year, night shift had ten falls, then we had six in September. Those twelve months included seven fall free months for midnights. When we've had falls, we tend to have a bunch together. These things tend to happen in droves.

I do understand where management is coming from in this, I really do. I know the higher ups are breathing down our managers' necks something fierce, and I think they're reacting for the sake of reacting. They have to do something, or it's their @$$es. I also know if it's not one thing, it's another. I just feel that there are more pressing issues at hand (like doctors' orders not being carried out appropriately and some kinda serious med errors) that are just put on the back burner while we deal with falls.

Thanks again for listening! You guys really do know what I'm experiencing!

Naomi Grace, RN

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Specializes in Neuroscience/Neuro-surgery/Med-Surgical/.

At our hospital, a patient gets sitter ONLY if they are suicidal or going thru alcohol withdrawl; even then, management wants one of our techs taken off the floor and used as a sitter!Leaving the burden to the RNs to take most their caseload as primary care. ;(

Rarely allowed to give the pt something to calm them down as its a neuro floor (neuro changes caused by med or did they stroke again?), bed and TABs alarms will get us running to the room, but won't prevent the fall. And yeah, the hourly rounding...what a joke! They still have 59 more minutes to crawl out of that bed.

So the solution.....we end up physically restraining the patients if pt's family/friends are not able to stay with them overnite. I think that's a shame to end up with that option. :cry:

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