Q: We are struggling with what to document and who to notify when a resident falls. Any suggestions?
A: Falls are becoming one of the most cited deficiencies, and require some of the most documentation.
First, it might sound obvious, but look at your regulations and facility policy to ensure you are following all requirements. Regulations and policies exist for a reason and usually take a while to develop — so it behooves all of us to take them seriously.
Not following your own policies is one of the worst things you can do. It opens you up to all kinds of potential penalties and lawsuits, risk management experts and attorneys have repeatedly warned.
Consider starting a fall huddle focused on how to handle accidents like these. A group of staff involved with a resident who fell or candidates for falls should be assembled in order to take an educated approach to whatever happened, or could happen. The huddle can be a quick stand-up meeting in the resident’s room.
Act like you are writing for McKnight’s Long-Term Care News and answer all of the journalist’s typical W’s. Those would include who is the resident, what did you see and how (an honorary member of the “w” club) you became aware of the suspected fall. Also, expect to identify where the resident was, and when they were found (time of incident), as well as what they were doing at the time, and what you did for the resident.
Document all the notifications, such as those for family and providers. Update the care plan, and also ask: Did the incident cause any changes to what should be newly included in the MDS? Also, don’t forget to document in the chart everything necessary per your policy.
Many facilities chart every shift for 72 hours, so see your policy and what the regulation is for your state. If you did not witness the fall, but the resident is on the floor, treat the event as a fall and document it!
Sherrie Dornberger, RN, CDONA, FACDONA, is executive director of NADONA. Please send her your resident care-related questions at [email protected].
From the December 2022 Issue of McKnight's Long-Term Care News
