When reviewing a record it is more likely than not that a fall will occur shortly after admission, an illness, or a readmission because these mark changes in the routine.
It is common for patients who cannot to attempt to ambulate to be found a few times before they fall half off the bed, or sitting up, or even ambulating. Many times a bed alarm is ordered and that is the last time that the bed alarm is mentioned. The patient then falls and the note reads as below:
Nurse heard patient calling out. Nurse went to room and found patient on the floor. Patient unable to tell nurse how patient ended up on the floor. Pt. MAE. Pt assisted back to bed and physician notified. NNO at this time.
After this the incident report will frequently record that the patient had a bed alarm in place and it was functioning, but outside of the physicians order there will be no documentation of the bed alarm in place and functioning each shift. As you can see the date of the above fall the bed alarm was not in place and functioning.
Unfortunately without the assistance of a nurse it can be hard to see all the potential problems involved in a fall.
We will focus on falls for one additional week before we move on to pressure ulcers.
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