F
FAILURE TO PROVIDE INFORMATION
Occasionally, the nurse may encounter patients, their family members, or legal guardians who lack the capacity to provide accurate or complete information about their health history, current medications, or treatments. Most of the time, this is not a willful violation of sincere communication but, rather, a mental status concern. They may be uncooperative for various reasons. They may think that too many caregivers have asked the same questions too many times, they may not understand the significance of the information that is being requested in providing expert care on their behalf, or they may be fearful or disoriented. They may be suspicious of why such personal information needs to be divulged. Alternatively, they may have severe pain, a psychiatric problem, or a language barrier. In such situations, the nurse needs to obtain the information from other sources or forms.
Essential Documentation
The nurse needs to clearly document any trouble encountered in communicating with the patient. Patient responses should be recorded clearly in the patient’s own words. Essential documentation in an electronic health record (EHR) is somewhat different because the nurse must seek out a way to include a narrative description of the situation at hand. Checkboxes and filled-in numbers do not “capture” the nature of the situation in a way that others can be made to comprehend the nature of the patient’s or other’s lack of capacity to participate fully. The nurse’s interventions or explanations of the importance of this
information in order to provide the patient with the best possible care need to be included. The following also need to be done:
information in order to provide the patient with the best possible care need to be included. The following also need to be done:
Document the name of the health care provider notified about the patient’s lack of capacity to share information and the time of notification.
Write down other sources of information, such as family members or previous records.
Narrative notes are becoming scarce with the innovation of EHRs in many health care organizations at all levels of care. However, documenting the full scope of patients’ mental and emotional status protects everyone, including the patients, their families, their health care providers, and the care organization, from safety breakdowns. Copying and pasting old information from a previous chart entry is a violation not only of patient safety but also the integrity of the caregiver. This is not tolerated by the nursing profession (American Nurses Association [ANA], 2015).
Failure to Provide Information
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FALLS, PATIENT
Falls are a major cause of injury and death among older patients. In fact, the older the person, the more likely death will result due to a fall or its complications. In acute care hospitals, 85% of all inpatient incident reports are related to falls; of those who fall, 10% fall more than once, and 10% experience a fatal fall. In nursing homes, approximately 60% of residents fall every year, and about 40% of those residents experience more than one fall. If a patient falls, despite preventive measures, the nurse should:
Stay with the patient and do not move the patient until a head-to-toe assessment and vital signs check are performed, having assigned another person to notify the health care provider.
Provide any emergency measures necessary, such as securing an airway, controlling bleeding, or stabilizing a deformed limb.
Ask the patient or a witness what happened.
Ask the patient if he or she is in pain, lost consciousness, “saw stars,” or hit his or her head. If no problems are detected, return the patient to bed with the help of another person.
Notify the attending physician.
With the advent of EHRs, more and more organizations that treat people across the life span are including documentation of fall risk management in the initial patient assessment. However, there are many categories of patients who are not perceived to be at a higher fall risk than the general population, and that is a misperception that could create harm for lack of due care. Among those who appear not to be at risk, but may be, are the following: cardiac patients with syncopal (dizziness) episodes, patients with inner ear (vestibular) problems, pregnant women in early pregnancy (dizziness) and later pregnancy (lack of normal balance as the pregnancy progresses), newly walking toddlers due to their proportionately larger head sizes, and the neurologically impaired (patients with seizure disorders, evolving stroke, developing brain tumors, etc.). Such conditions should prompt a fall risk evaluation by the nurse. Including a short fall risk questionnaire for each patient would shed light on these unsuspected conditions. Notably, falls are common among young children without developmental disabilities, and they usually recover rapidly unless they are unattended or experience falls from greater heights than the ground beneath them.
Essential Documentation
If a patient falls despite precautions, the nurse should be sure to:
File an incident report and chart the event. (See “Incident report,” pages 200 to 202.)
Record how the patient was found and the time discovered.
Document an objective assessment, avoiding any judgments or opinions.
Assess the patient and record any bruises, lacerations, or abrasions.
Describe any pain or deformity in the extremities, particularly the hip, arm, leg, or lumbar spine.
Record vital signs, including orthostatic blood pressure.
Start with a head-to-toe assessment, observing for loss of consciousness and neurologic status first.
Document if the patient had a seizure or a suspected unobserved seizure.
Document whether the fall was witnessed by others, and if so, include their names.
Document the patient’s neurologic assessment. Include slurred speech, weakness in the extremities, or a change in mental status.
Record the name of the health care provider and other persons notified, such as family members, and the time of notification.
Include instructions or orders given.
Recommend admission or emergency department evaluation for any patient who sustained loss of consciousness, concussion, or head trauma.
Call the rescue squad if the individual who fell is not already in an inpatient or emergency department facility if indicated.
Also document any patient education.
Falls
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FALLS, PRECAUTIONS
Patient falls resulting from slips, slides, knees giving way, fainting, or tripping over equipment can lead to prolonged hospitalization, increased hospital costs, and liability problems. People of all ages fall, notably because they have risks that may not be perceived by direct observation. Among those people are newly walking toddlers, small children, pregnant women, and people with cardiac syncope (dizziness) or neurologic problems that are not visibly detectable (evolving strokes,
brain tumors, seizure disorders, etc.). Because falls cause so many problems, the facility may require assessment of each patient for his or her risk of falling and to take measures to prevent falls. (See Reducing the risk of falls, page 142.) If the facility requires a risk assessment form for patients, it should be completed and kept in the patient’s chart. (See Risk assessment for falls, page 143.) Those at risk require a care plan reflecting interventions to prevent falls. (See Reducing the nurse’s liability in patient falls, page 144.)
brain tumors, seizure disorders, etc.). Because falls cause so many problems, the facility may require assessment of each patient for his or her risk of falling and to take measures to prevent falls. (See Reducing the risk of falls, page 142.) If the facility requires a risk assessment form for patients, it should be completed and kept in the patient’s chart. (See Risk assessment for falls, page 143.) Those at risk require a care plan reflecting interventions to prevent falls. (See Reducing the nurse’s liability in patient falls, page 144.)
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