What exactly is the procedure for resident falls?

[Sensoria17]

I had an interview today and the DON asked me what the procedure is for resident falls. I launched into an answer regarding all the documentation. I did say to first check if the resident was hurt or not but then she asked how you check this. I did not know how other than to ask him or her:doh:. So for all you working LVNs, what's the drill?

[NurseCubanitaRN2b, BSN, RN]

LOC I believe is what she was looking for. You check to see if their pupils are constricted/dilated. Have your aide check their vitals (there's usually protocol on how long etc). Check and see if pt is showing any s/sx of shock. Check for any bruises, skin tears etc. Depending on your facility policy you might need PT to come over and assess to see if it's safe to get the resident up. When you document, NEVER PUT IT IN THE CHART. If you put it in the patients nurses notes, it can open up a whole can of worms if something were to arise from it. File an incident report instead, and don't forget to notify the family and physician. I'm sure there is more, so if I left anything out, someone please add on.

[sasha2lady]

at my facility we do document it in the chart...you only chart the facts "resident noted to be sitting in upright position on the floor in front of her w/c. Resident stated she was trying to get her shoes off. moves all extremeties without difficulty. denies any pain at this time. O injuries noted. assisted resident to w/c, br, and back to w/c without difficulty. cb in reach. reoriented resident to cb. RP Jane Doe notiified. Will cont to monitor and chart changes. VS wnl ( and put what the vs were of course).... XXX Lpn.....and include the time and date. You never chart that you filled out an incident report in your notes. that is something completely separate. and we have to notify the RP...and if there is no major injury I just put it in our md book for him to see as an fyi...now if there is a big injury like a possible fx or what not....or a lac that needs stitches.....I call the doc and send them out to the er to get fixed or xrays. ...then for 3 days each shift this person is supposed to be charted on...and whether or not thats a policy at a place...Id do that anyway just to cover myself. if they hit their head we start neurochecks and do them for 3 days each shift too.....plus any additional charting. I look over their skin for tears and bruises also. I look for any shortened limbs and i make them move each limb if this is applicable....and look for a change in it. You never know....if you dont chart that someone was in the floor...in 3 days they could start c/o hip pain or leg pain and end up w/ a fx that is of "unknown" origin according to the nn....your nn are what saves you. If a fall occurred 3 days ago and now a new c/o pain is coming about.....you have a starting point to go with when you tel the doc and the family wont be as ****** when moma has a fx'd hip that came from a fall that she wasnt told about...thats when you open a can of worms and open yourself up to a lawsuit and a highly ****** off RP....we notify families of skin tears and bruises also. ....cuz its not pretty when they come in for a visit and moma has a dsg on her leg that they know wasnt there yesterday. ...then they start to grill you wanting to know why it happened..when, where and why nobody told them about it. Be safe. In my state ...the state surveyors cannot look at incident reports unless they specifically ask for it.......they go only in that chart. another good idea is ....if you have a fall in the pm.....go back before you leave your shift and just chart how they are doing post fall....any new complaints? any more attempts to get up without assist? have they used their cb? any mental changes like inc confusion etc.? .....and if this same pt falls again ....id put them down on the book or whatever to be checked for a uti...which is sometimes the culprit of falls....or look at any new meds like ambien....its known to cause hallucinations and falls in the elderly. if they got a skin tear....write down the blood thinning meds they take...are they on aricept? coumadin? lovenox? asa? nsaids? heparin? we have a packet to fill out that includes all this stuff with our incident reports. if you dont have one ....you might want to suggest it to your DON ...b/c believe me ...it will protect you. if you have any type of skin assessments ....if they get a s/t or a bruise...go put it on that skin grid and chart about it too....i had a resident last year who wore a metal stretchy banded watch..it pinched her skin and made a big bruise on her wrist....I found it....charted it, filled out the report, put it on a skin grid, notified her RP and put it on the MD book and boom.....how about her daughter even though I told her where it came from...called state on us..they came in reviewed her chart and asked for the report and thank god....I had put everything where it was supposed to go and they found her complaint unfounded and left. CYA!

[NurseCubanitaRN2b, BSN, RN]

Oh I'm sorry I forgot to add that you always want to do your ABC's first. Patent airway.

Regarding documentating falls in the patient charts, here in our facility and other places they don't do that They fill out an incident report. It can be a local thing or a state thing. I'm unsure, but here we don't report it in the chart.

But I like the way sasha charts in detail, and its pertinant.

[Sensoria17]

A lot of good info here for me to keep in mind during the next interview. Thank you!