If the fall is witnessed, gather as much information as possible about the possible causes of the fall – was the patient attempting to toilet, reach their phone, their water, etc. Is the resident confused? Was another hazard present and responsible for the fall? If the fall was unwitnessed, gather as much information as possible
· If you are the witness or first on the scene, stay with the resident and send someone to secure assistance
· Administer basic first aid that can be administered without moving the resident
· Then conduct a comprehensive assessment, including the following:
o Check the vital signs and the apical and radial pulses.
o Check the cranial nerve.
o Check the skin for pallor, trauma, circulation, abrasion, bruising, and sensation.
o Check the central nervous system for sensation and movement in the lower extremities.
o Assess the current level of consciousness and determine whether the patient has had a loss of consciousness.
o Look for subtle cognitive changes.
o Check the pupils and orientation.
o Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain.
o Note any pain and points of tenderness.
Be aware of the following warning signs: numbness or tingling in the extremities, back pain, rib pain, or an externally rotated or shortened leg. These symptoms suggest spinal cord injury, leg or pelvic fracture, or head injury.
· Notify the physician, Director of Nursing and next of kin. Follow your facility’s policy and procedure on reporting falls/accidents utilizing your internal systems of incident reporting.
· Be certain to inform all staff in the patient's area or unit. Such communication is essential to preventing a second fall.
· Each facility has its own policy regarding post fall assessment protocol. Be sure to look at yours to be sure you follow it. In most cases, if fracture or more serious injury is suspected or any trauma to the head occurred, the patient would be sent to the emergency room for clearance. Bruises should be documented and monitored for size and shape over the next few days. Many facilities conduct neuro checks for the next 72 hours. Follow your facility’s procedure by looking it up.
· In addition, follow your facility's policies and procedures for documenting a fall. Thorough documentation helps ensure that appropriate nursing care, fall prevention measures and medical attention are given and that the care plan is appropriately updated. Documentation for a fall should include:
o All observations. as described above
o Patient statements regarding the incident
o Assessments immediately following
o Notifications of all parties as described above
o Interventions instituted to prevent a recurrent fall
o Evaluation of the measures instituted
(Be sure to note the patient's thoughts about the cause of the fall and associated symptoms, and whether the patient lost consciousness.)
Most facilities also require that an incident report be completed for quality improvement and risk management. Utilize your facility’s preferred report however the documentation should include:
· Patient history
· How, where and when the fall occurred
· Assessments of the area, hazards, the resident condition when found, etc.
· Diagnoses, with particular emphasis on those that may have contributed to the fall
· Interventions implemented post fall such as placing the patient on fall risk precautions
· Usually within a few days the outcome of the interventions or injuries would be added to the incident report.
Identification of any causes underlying the fall may help to prevent future falls. Was this accidental and there is no identified cause? Did the patient have an unmet physical need which we can address more timely such as toileting? Does the resident have a diagnosis that leads to more frequent falls such as balance issues, diabetic neuropathy in the feet, etc.? Follow up by the nursing team on these issues will help the staff create an appropriate plan of care utilizing preventive measures