What to do when a patient falls?


Being a new nurse of just 2 months, I have been working in the LTC and have had 1 patient fall on my shift and another fall on my shift but was the other nurse's patient (although I was first to respond to her patient although she was closer but the latest 2 minute gossip was more important). The first patient I was told was lowered to the floor by the aid. Since I had only been working as a nurse for about 14 days, the other day nurses came to assist me. I guess I want to get more comfortable with what signs to look for and when do I leave them on the floor and not move and when to assist them up.

Obviously if they are in pain or obvious fx, I leave them on the floor and do not move them and call 911. But what do I do for someone who fell and says they don't have any pain? I know I do visual assessment and vital signs. Do I do range of motion and see if they have bilateral, equal grips? What do I do if they fall and are in an uncomfortable position and want and are trying to move? How do I know they don't have an injury that they shouldn't be moved? What other types of assessment do I do before assisting them up to make sure I am not going to harm them more by assisting them up? I am trying to get answers and research situations that I am uncomfortable with so if they happen again (and in LTC I am told they will) I can be more prepared.

diane227, LPN, RN

1,941 Posts

Specializes in Management, Emergency, Psych, Med Surg. Has 32 years experience.

When we have a patient who falls, my follow up always depends on the situation. I do an exam of the patient to assess for injury. The mechanism of the fall is key. Where they lowered to the floor or did they fall from a standing position. In any case, I notify the physcian, document an occurance reprort and implement any safety measures that have not be established to help prevent further falls.

Specializes in M/S Short Stay/TCU.

I just started SNF and have been their 2 weeks. I know at my facility we are suppose to do Neuro checks on the patient. The supervisor is notified and if during your assessment the patient says ouch, or is in severe pain, or can't move, Call 911. Neuro checks is extremely important...... I am no expert; but I hope this helps you.... I am a new RN too.

You should have a protocol in your facility.

If they hit their head, neuro checks.

CT Pixie, BSN, RN

3,723 Posts

Has 10 years experience.

Not sure if you are an LPN or RN, but our facility does not allow we LPN's to move a resident until the RN on duty assesses the patient, so we do everything we can to make sure the patient does not move from where they are. If they are uncomfortable, we do all we can to make it more bearable, blankets, pillow behind the head, etc. We (the LPN) stays with the patient and does not leave until the RN arrives.

Until the RN is "on scene" I do vital signs, look for any obvious bleeding, cuts, scratches, any hematomas that might be starting to swell, look for any deformity to the limbs, check for any swelling or discoloration to the skin, do neuro checks, do a quick head to toe to see if there are any painful areas. Check LOC.

Our facility policy is any unwitnessed fall, then neuro checks are done for 3 days.

After the "all clear" I proceed to update the doc, call the family/person in charge of resident, do the 45231 pages of paper work for the fall, come up with interventions to try to stop another fall and update the CNA care plan, sent out a memo about the fall.

Specializes in Long Term Care.

Thank you all so much for the info. We have a protocol at the facility to call doc, notify family, etc. and use judgement to call 911 if doc. not responding in timely manner. I guess I was just unsure of when not to pick up the patient. I am an LPN and we are expected to do all the work. on the 3-11 shift many nights there are only LPNs in bldg. As far as the first lady, she fell when I worked on the 7-3 shift, the Unit mgr. was informed and never went in to assess herself. the facility caught it and i had to write a statement I informed her. Thank goodness I had 2 wonderful other nurses that helped me with the process. Being on 3-11 with less nursing staff, and without supervisor I am just trying to prepare so I can feel more comfortable and all the info helps. thanks a bunch!!

CapeCodMermaid, RN

6,090 Posts

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

Assess any resident who has fallen. Do they have full ROM to all extremities (if, of course, they did before the fall)? Are they in pain? Any alteration in consciousness? Anything not quite right? If you're questioning a serious injury, call rescue and get them out. I worked in a place where the doc told the nurses never to send anyone to the hospital if they fell in the middle of the night because the hospital didn't like it!!! Touch touchas as we say. If you think they are injured, send them out. Better someone come back with all negative xrays or ct scans then to wait and find an injury later. You might get told you are too quick to send someone out but better to explain your reasoning for sending to your boss then to TRY to explain a delay in treatment to a DPH surveyor or irate family member.

teeniebert, LPN

563 Posts

Here's what happens at my facility:

Take vitals, check for obvious injuries, do neuro checks, and if possible assess ROM before helping them up off the floor. If anything more serious than a skin tear or bruise, call 911 and ship to the hospital. If no serious injury, vitals q 15 minutes x4, q 30 minutes x4, q 60 minutes x4, then q shift until 72 hours post-fall. If they hit their head, or the fall was unwitnessed, neuro checks on the same schedule as vitals. Notify the MD, DON, and resident's family. Write an order for therapy screen and initiate Red Star (fall precautions) program. Fill out incident report with a brief description of what happened, where and when, was there any injury, who was contacted, was first aid provided, etc. Fill out post-fall assessment (facility document only seen by the fall review committee), including when resident was last observed 'safe', when resident was last toileted, what footwear they had on, if an appliance was used (walker, w/c, gait belt), whether necessary items were in reach (water, tissues, call bell, tv remote), if the floor was wet or dry, if there were any objects on the floor, lighting in the room at the time, resident's description of the fall if they can provide one, where the aid caring for the resident was at the time, where the nurse caring for the resident was at the time, was the resident on Red Star, were bed and/or chair alarms sounding, did the resident disable alarms...oh, and make sure the other 35 residents on the hall are getting the care they need at the same time.

If you do fall assessment and they are considered a fall risk then you should order a low boy bed with mats and give em a bracelet to wear. That way you cover ur butt and theirs. I would think that the patient who was lowered to the floor by the NA wouldn't be considered a fall as she was merely lowered to the ground. As long as the correct safety precautions for falls are taken before they happen then all is well...from a legal standpoint anyway. With the outphasing of sitters and the frowning upon restraints there isn't much we can do else we can do, as a solitary nurse with many patients, to stop someone who is determined and/or confused.

Specializes in Long Term Care.

Again, thanks for all the information. I entered it into my palm for when the situation arises. I wish I had more confidence, but I guess that will come with experience. :)

Specializes in Long Term Care.

Ok, so tonight must be full moon because every resident that is normally in bed was trying to get out tonight and guess what. I had a patient fall off the toilet onto the floor with the cna present. Thanks to the many suggestions I didn't feel panicked and did head to toe, pain, rom and nuero checks (hit head on trash can on way down). Then when she was assisted up and I started my charting i went back to the suggestions posted on here and i actually had done all of them.. So, I am glad I posted my question here to feel more prepared. I was calm and collected and went through my checks, the aid that was with her felt horrible and started to cry. I had her do a witness statement and contacted md, family and the don. Thank you for giving me the suggestions to boost my confidence up!!!!

Specializes in Geriatrics, MR/DD, Clinic.

Good job!

I try to keep it simple, check out the room, do VS (neuro checks if they hit their head), check ROM, look for "oddities", access LOC, ask about pain/discomfort, and check for any obvious bruising or fractures. This can easily be done within a few minutes.

Then we get them off the floor and I do VS again and start neuro checks if needed. We do neuro checks if there are any questions of them hititng their head also. Call family, notify doctor (via fax if no injuries or send out if there is), and start the never ending beginning of paperwork. Always remember to update the care plan, this is something a lot forget to do.