When an individual is admitted to the Hospital, it is assumed, both legally and morally that the individual needs help. He is being admitted to the hospital because he is not capable of looking after himself or that the procedures needed are of a highly technical nature which require him to stay in the hospital. Both these reasons transfer responsibility for this safety and wellbeing to the medical and nursing staff.
Upon admission, the nurse must do the patients vital signs, document the patient’s history and do a nursing evaluation of the patient. This information will be filed as a baseline and will used to formulate care, evaluate progress and plan for discharge. Similarly, medical staff do the admission note and formulate the medical diagnosis.
All medical problems will be attended to by the treatment team. Nursing problems relating to safety and care will be attended to by all nurses caring for the patient. As a matter of routine, all patients must be assessed for fall risks and the appropriate forms completed. Elderly patients and immobile patients must be assessed for pressure sore risk. This is done by completing the Waterlow Pressure Risk Assessment Form. Some facilities use the modified version of this form. Irrespective of which form is used, it is important that the assessment is done thoroughly. The form is only a tool.
It is a good practice to keep the bed at the lowest level possible so that patient injury is minimised, if he should fall out of bed. If a patient does fall out of bed he should be checked out and treated, by medical and nursing staff immediately. Most institutions have a policy which will outline exactly what is to be done and by whom.
After attending to the comfort and emergency needs an incident report will need to be completed. This is usually for the benefit for the institution’s Risk Management Department. Some institutions clearly state that this report is not to be mentioned in the patients notes for legal purposes. (This practice is most common in the United States because of litigation and compensation issues. It is in the institution’s interest to minimise payments to a “fall victim”.
The Doctor must be notified of the fall and he must come and access the patient and document his findings. It may be necessary to complete an x-ray form and to get an x-ray of the pelvis and all other injured parts of the body. If one is employed in an aged care facility without x-ray facility, then the patient will need to be transported to a hospital.
It is important that the documentation is completed by the person who found the patient on the floor. If the patient was found by another patient then the documentation is to be completed by the PCA or Registered Nurse who first saw the patient.
All documentation should be completed as soon as possible after attending to the immediate needs of the patient. It is not good practice to delay completing the report because we all forget many things with the passage of time.
All incident reports must be completed honestly and must contain the following information:
- Time and date of incident.
- Name (s) and addresses of witnesses.
- Names and addresses of staff on duty.
- Location of incident and contributing factors. Identify amount of light, slippery/wet/dry floor.
- Name and address of patient. Condition of patient before and after the fall.
- Medical report of patient condition after the fall.
- Signature of person completing report.
- List of injuries sustained by the patient.
- Corrective action(s) taken by nursing medical staff.
- Note if the equipment was faulty.
Documenting these will allow for corrective actions to be taken and prevent future falls. The interventions are aimed at reducing your legal liability by minimising the patient’s losses.
When your patient falls and injures himself/herself you will end up paying because you are responsible for the patients care.
In patient fall litigation, it may be noted, both lawyers win. The lawyer representing the plaintiff wins a big settlement. The lawyer representing the defendant also wins a big settlement. All other parties are the losers.
