Negligence Found. The day before she fell and fractured her right tibia and fibula the fifty-seven year-old patient was involuntarily admitted to the hospital’s psychiatric unit for suicidal ideation. She had been in the same hospital several times over the previous few months for the same reason. Her Psychiatric Admission revealed, No Fall-Risk Nursing Assessment The fall-risk portion of the admission nursing assessment form was crossed out with the letters “N.A.” signifying that the nurse believed that risk assessment and fall precautions are not included in psychiatric care. The same nurse’s admitting progress notes pointed to unsteady gait, muscle weakness, confused mental state and poor judgment. The patient reportedly awoke, rang for help to the restroom, got no response and got up on her own. The jury in the Supreme Court, Richmond County, New York awarded her $598,000. The progress notes admittedly acknowledge the patient was at risk, yet where were the interventions? When you document the symptoms, you had better make mention what you did about them.

A frequent omission in nursing documentation is what has been provided to prevent a fall. In addition, there is an inadequate post fall assessment.  Nursing assessments tend to say no complaints voiced, awake alert and confused. What kind of assessment is that?  That is an observation, not an assessment. If you want to prevent litigation, then nurses need to document the actual strategies in place that prevent a fall and a post fall assessment. This is a critical element most forgotten. Following a patient's fall the nurse needs to document an assessment of vital signs, level of consciousness, neurological checks, and functional status pre and post fall. If significant changes in patient's condition occurs, consider further diagnostic tests such as plain film x-rays, CT scan of the head/spine/extremity, neurological consultation, and /or transfer to a higher level of care for further evaluation, that is the minimum standard of nursing care. If the patient is anti-coagulated, there should be a hospital wide standard algorithm for post falls that mandates CT. Due diligence speaks volumes and may avoid a litigiousness stream of cases.

An incident report, calling the doctor and family, along with scooping the patient back to bed are not to be considered fall prevention or post procedure assessment. To say you have a fall program in place, you will need a complete fall assessment, plan, intervention, evaluation and a post fall procedure algorithm for nurses.  A post fall procedure program will identify injuries and save lives.

Resources for LTC

Fall prevention in nursing homes continues to be among the most challenging aspects of geriatric nursing, not only because of the high frequency of falls but also because of the significant impact on residents, families, staff, and administration. Several programs specifically designed to reduce falls in nursing home residents are available on www.medqic.org these include comprehensive multidimensional programs, bed safety, and restraint reduction strategies. The resources on Medqic have been peer reviewed by national experts and are downloadable at no cost.

The use of hip protectors as a means of preventing hip fractures in adults who fall is being widely implemented as more and more health-care providers are becoming aware of the serious consequences associated with falls. Hip protectors are constructed and worn by an individual as an undergarment. Each garment has either sewn-in or removable hip shields. There are many different types of hip protectors (soft shelled and hard shelled), which are manufactured by different companies. Depending on the health-care insurance coverage that an individual has, the hip protector cost may be covered by their insurance. One of the biggest challenges in using hip protectors is to ensure that the individual feels comfortable when wearing them. Because they are not always comfortable or seem impractical to the user, wear compliance may be an issue.

Parker, Gillespie and Gillespie (2004) state that there is some evidence that “for those living in institutional care with a high background incidence of hip fracture, a programme of providing hip protectors appears to reduce the incidence of hip fractures.”

Parker, M., Gillespie, L., & Gillespie, W. (2005). Hip protectors for preventing hip fractures in the elderly. The Cochrane Database of Systematic Reviews, 
The VA National Center for Patient Safety (NCPS) worked with the Patient Safety Center of Inquiry in Tampa, Florida, and others to develop the NCPS Falls Toolkit. The toolkit is designed to aid facilities in developing a comprehensive falls prevention program. You may download the entire program free at http://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.html#notebook.

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