What would you do, and how would you document this situation...

"At x time Mr Jones was found on the floor by CNA Y. The fall was unwitnessed and not heard; he was last seen at x time, resting in bed/sitting in the chair...

"Mr Jones [account of fall if known - mechanical floor, legs gave way, confused and unable to recount]. He denied striking his head/reports striking is head/is unsure whether he struck his head. [Visible injuries, assessment].

"Returned to bed, neurological observation commenced - [results]; resident contacted, awaiting review/reviewed as above.

"[Treatment plan]

"[Pre-existing falls plan, if relevant; new strategies to reduce further falls.]"

"Nurse was told by pt's CNA that pt was found on the floor..."

Date & Time: "Pt found on the floor by CNA @ 2100. Pt. A & O X4 (whatever it may be). Initial VS T. 98.3 P. 98 R. 24 BP. 132/84 2/10 pain level (add location) 94% O2 Sat level. Interview the patient & document findings, then do a FULL BODY ASSESSMENT, and also document your findings. Doing it by body systems is the best way in my opinion, but you do it how you feel comfortable doing it.

PS. I like what another posted "The fall was unwitnessed & not heard" but I would take out the "fall" part because since it was unwitnessed, & not heard we really don't know if the patient really fell. If the pt. was ambulatory, they could have just sat on the floor. So I would put "Pt. lying on the floor, and how he got there was unwitnessed & not heard" We can't assume that the pt. fell, unless he specifically stated he did indeed fall.

Hope this helps, and good luck!

Thanks all who replied! This was really helpful! May GOD bless!

I have to agree with the previous poster about not including verbiage that indicates that the pt fell if it was not witnessed.

I document only what I witnessed, what was witnessed by other staff, by a pt, family member, etc. When including observations by others, I make sure to indicate that "pt's family member stated that..." or "pt stated that..."

Whenever there is a pt fall, always do a head-to-toe, complete VS including neuro check.

I'm finishing up NS and we are doing our last 2 week rotation in leadership at a sub-acute facility. Last Friday, a pt was found on the floor just before our shift started. She was sent to the ER - even though she said she was fine and there were no obvious injuries.