Patient Falls Require Thorough Documentation

In the hospital, a patient fall must be carefully documented because the
patient may initially blame himself or herself, but later change the story
after talking with family members and/or a lawyer.

Patient death or serious disability associated with a fall while being cared
for in a health care facility is one of the 28 items on the National Quality
Forum’s list of ‘never events.’ This is a controversial ‘never event’ because
it involves whether or not patients are compliant with the instructions they
were given and whether or not patients understand their own limitations.
Fortunately, many falls do not involve death or serious disability, but they
could.

One example is that of a new mother. She has just given birth, has gone
through quite an experience, and feels that the worst is over. She has had an
epidural, and she wants to get back to her normal routine. Despite the fact
that she cannot feel her feet, she gets up to walk and experiences a fall.
Because these types of falls occur in young and healthy individuals, usually
there is not a serious injury, but the potential for a serious injury is
present.

Enormous amounts of research have been performed across the United States in
terms of preventing falls in general, preventing falls with serious injury,
and identifying individuals who are at risk for injury if they fall. We need
to accept that patients will fall in the hospital and that we need to try and
limit the frequency and severity of those falls. This requires good
communications with patients to explain to them that they are at risk for
falls and why they are at risk.

To better manage risks of falling or later litigation, the health care team
must perform an initial evaluation when the patient arrives to determine if
the patient is at risk for falls. This evaluation must be carefully
documented, instructions given to the patient must be carefully documented,
and any falls also must be carefully documented. Documentation helps the
health care team understand the level of care required by the patient, but it
also helps protect the facility if a legal claim is filed.

The situation that we are now seeing with increasing frequency is that the
patient falls and initially blames himself or herself. At this point, the
health care team should document the fall and use patient quotes in their
records. However, once the patient leaves the hospital with the broken arm or
leg resulting from their fall, they begin talking to the family and then they
talk to a lawyer. Suddenly, the patient’s story about the fall may change. The
hospital needs to have the original account of the fall carefully documented
in case the staff later needs to prove what happened.

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events:
Falls Occurring at the Health Care Facility – Part 1