Without going into detail, I have had to document one personally, and heard of one anecdotal, about having to document an issue as a fall when they clearly weren't. I still struggle with "assisting to the floor" as a fall. Now there are instances where a "loss of balance" is considered a fall. Even when pt is no where near floor.
This is from an excellent article in the Journal of Legal Nurse Consulting, July 2014.
Hill E, Fauerbach LA (2014). Falls and fall prevention in older adults. JLNC 25:2, 24-29
Defining Fall
The definition of fall varies, depending upon the agency or regulating body. For patients in long-term care, the definition is in the assessment section of the long-term care minimum dataset (LTCMDS), Minimum Data Set (MDS) 3.0, section J 1400 of the 3.0 Resident Assessment Instrument Manual (RAI). This defines a fall as:
An unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair or bedside mat). The fall may be witnessed, reported by a resident or an observer, or identified when the resident is found on the ground. Falls include any fall whether it occurred at home, out in the community, in an acute hospital, or in a nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if he or she had not caught him or herself, or had not been intercepted by another person—this is still considered a fall (CMS, 2010).
The American Nursing Association's National Database of Nursing Quality Indicators (ANA-NDNQI) is recognized by leading researchers for comprehensiveness. According to the ANA-NDNQI a fall is, an unplanned descent to the floor, or extension of the floor, (e.g., trash can or other equipment), with or without injury†(p. 26).
Sometimes a fall is recognized and defined according to its cause. However, incident reports or other instruments may classify a fall according to the level of harm to a resident. The International Classification of Diseases 9 Clinical Modifications (ICD-9-CM) uses broadly defined codes to categorize falls including: accidentally bumping against a moving object caused by a crowd with subsequent fall, falling from one level to another, and falling on the same level from slipping, tripping, or stumbling (Curry, 2008). For the purpose of this paper, a fall is defined as coming to rest on the ground, floor, or other lower level regardless of whether injury occurs.
Refs from above:
American Nursing Association's National Database of Nursing Quality Indicators (ANA-NDNQI, 2014)
Curry, L. (2008). Fall and Injury Prevention. Chapter 10, In Hughes, R.G. Inpatient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality, Rockville, AHRQ Publication No. 08-0043.
mmc51264, BSN, MSN, RN
3,319 Posts
update-the one that I had to chart was not deemed a fall.