Ensuring Patient Safety and Documentation in a Nursing Home Setting

QUESTION

C.S. is a 78-year-old PT admitted to the nursing home unit with a diagnosis of dehydration. C.S. has increased her fluid intake as suggested, but now needs to use the restroom.

Please answer the following questions:

1. What safety assessments should be completed on the patient prior to assisting with ambulation to the restroom?
2. What Risk factors does the patient have for falls?
3. List 2 interventions and provide rationales on how to prevent falls for C.S.

After doing the safety assessment of the patient, C.S. is escorted to the restroom by the nurse. Although safety protocols were in place, C.S. slipped on a small amount of urine that was previously left on the bathroom floor. The nurse immediately recognizes that a safety event has just occurred.

Please answer the following questions:

1. What are priority assessments of this patient?
2. If the patient is safe to move, what safety equipment can be utilized?

C.S. is back in bed and comfortable. A little shaken up from the fall, but there are no physical injuries noted. The nurse knows that this would be a good time to complete documentation of the event.

A. Formulate a NOTE to include in the patients’ electronic medical record:

B. What should be documented in the Safety Event Report for this patient?

ANSWER

Ensuring Patient Safety and Documentation in a Nursing Home Setting

Introduction

In a nursing home setting, patient safety is of utmost importance to prevent adverse events such as falls. This essay addresses the safety assessments to be completed before assisting a patient with ambulation, identifies risk factors for falls, proposes interventions to prevent falls, and discusses the priority assessments and safety equipment to utilize after a safety event. Additionally, guidance is provided on documenting the event in the patient’s electronic medical record and safety event report.

Safety Assessments prior to Assisting with Ambulation

Before assisting C.S. with ambulation to the restroom, the following safety assessments should be completed:
Fall Risk Assessment: Assess C.S.’s fall risk using a validated fall risk assessment tool such as the Morse Fall Scale or the Hendrich II Fall Risk Model. This assessment evaluates factors such as history of falls, gait and balance impairments, use of assistive devices, and cognitive status.
Environmental Assessment: Evaluate the immediate environment, including the restroom, for potential hazards such as wet floors, loose rugs, clutter, inadequate lighting, or uneven surfaces.
Physical Assessment: Assess C.S.’s physical condition, including muscle strength, range of motion, and ability to bear weight to determine if any physical assistance or assistive devices are necessary.

Risk Factors for Falls in C.S.

C.S. has several risk factors that predispose her to falls, including:
Age: Being 78 years old places C.S. at a higher risk of falls due to age-related changes in balance, vision, and musculoskeletal function.
Dehydration: Dehydration can lead to weakness, dizziness, and orthostatic hypotension, increasing the risk of falls.
Mobility Issues: C.S. may have mobility impairments such as muscle weakness or joint pain, which can affect her balance and increase fall risk.
Environmental Factors: Factors such as wet floors, inadequate lighting, or hazards in the environment contribute to fall risk.

Interventions to Prevent Falls for C.S.

To prevent falls in C.S., the following interventions should be implemented:
Regular Rounds and Supervision: Increase staff presence and perform regular rounds to monitor and assist C.S. in her activities of daily living, including ambulation to the restroom.
Rationale: Increased staff presence and supervision reduce the likelihood of C.S. attempting to ambulate alone, decreasing the risk of falls.

Environmental Modifications: Ensure a safe environment by promptly cleaning up spills, removing tripping hazards, providing adequate lighting, and using nonslip mats or flooring in the restroom.
Rationale: Modifying the environment minimizes potential hazards, reducing the risk of slips, trips, and falls.

Priority Assessments after the Safety Event

After the slip and fall incident, the following priority assessments should be conducted:
Physical Assessment: Assess C.S. for any physical injuries, pain, or discomfort resulting from the fall, paying particular attention to the head, neck, spine, and extremities.
Neurological Assessment: Evaluate C.S.’s level of consciousness, cognitive function, and neurological status to detect any signs of trauma or concussion.
Vital Signs: Monitor vital signs, including blood pressure, heart rate, and oxygen saturation, to identify any changes that may indicate complications related to the fall.

Safety Equipment for Safe Patient Movement

If C.S. is safe to move, the following safety equipment can be utilized:
Transfer Belt: Use a transfer belt around C.S.’s waist to provide stability and assist in safe ambulation.
Non-Slip Socks or Footwear: Ensure C.S. wears non-slip socks or appropriate footwear with good traction to reduce the risk of slipping.
Bedside Commode or Urinal: If C.S. has difficulty ambulating to the restroom, provide a bedside commode or urinal for easier access to toileting.

Formulated Note for the Patient’s Electronic Medical Record

Date and Time: [Insert Date and Time]
Event: Patient experienced a slip and fall incident in the restroom due to a small amount of urine on the floor.
Description: Patient, C.S., slipped on the wet surface and fell, but there were no physical injuries observed. Vital signs were monitored, and the patient was assessed for any signs of trauma or neurological changes. No immediate complications were noted. Patient is currently resting comfortably in bed.

Documentation in the Safety Event Report

Date, time, and location of the event
Description of the event, including how it occurred and any contributing factors
Actions taken immediately after the event, including assessments and interventions provided
Any communication with the healthcare team, patient, or family members
Recommendations for preventive measures or environmental modifications to prevent future incidents

Conclusion

Ensuring patient safety in a nursing home setting requires comprehensive safety assessments, interventions to address risk factors for falls, and prompt action in response to safety events. By conducting appropriate safety assessments, implementing preventive strategies, utilizing safety equipment, and accurately documenting safety events, healthcare providers can mitigate the risk of falls and promote a safe environment for patients like C.S.