“Fall precautions in place.” What gets asked about it after a fall, and what to chart instead
Exhibit 12 a high fall risk patient
Fall precautions in place.
Which precautions, and when did you check them? A fall policy is a list: bed low, rails, call light, alarm, room near the station. The label says the list was done without showing which items were on when the patient got up.
What they ask about it
A trial court, quoted by the appeals court, on a fall note with gaps
Nurse Starkey’s chart note offers a breadth of speculative permutations relative to the circumstances surrounding Mr. McIlvain’s fall. … How quickly did Mr. McIlvain fall after Starkey first spotted him: was it instantaneous, or did Mr. McIlvain only fall after an appreciable moment or more?
An appeals court, summing up the expert evidence about a resident who fell four times
Robinson’s staff charted that Brakebill fell four times in a two-week span in December. It was unknown if additional care was not charted or simply not done.
The same expert, on which precautions were actually on
the bedrails were not consistently in place, the bed alarm was not consistently in operation, and fall-resistant wing-mattress bedding was not always in place.
Each nurse charted the measures themselves, not a label: bed low, upper rails up, items within reach, told to use the call button, plus her own check of how alert the patient was. The patient fell anyway. The court affirmed the judgment for the hospital because causation was not proven.
Nurse Cothern charted that Scruggs's bed was in a low position with the upper side rails raised, that her items were within her reach, and that Scruggs had been instructed to use her call button for assistance.
The hospital's fall policy was a list of five things. The only note about the fall said the patient "was asked if he needed any help", not that anyone helped him. The plaintiff's expert built her opinion on that gap. Summary judgment for the hospital was affirmed, on causation.
Per hospital fall prevention policy, this required the use of various preventative measures including assigning a patient a room near the nurse’s station, leaving the door open, instructing a patient to call for assistance, providing assistance with transfers and ambulation, and considering the use of a bed alarm.
The appeal was decided on the statute of limitations, so it is not a ruling on the nursing care. The court's summary of the evidence still shows the question: the chart recorded four falls in two weeks, and nobody could tell whether the care between them was done and not charted, or not done.
The physician expert opined that Robinson should have implemented greater fall- avoidance interventions.
Write instead
0210 Rounded. Pt asleep, resp even. Bed lowest position, wheels locked, 3 of 4 rails up (lower R down for bathroom access per unit standard). Call light clipped to rail at L hand. Urinal on L rail. Floor clear.
Nurse Cothern charted that Scruggs's bed was in a low position with the upper side rails raised, that her items were within her reach, and that Scruggs had been instructed to use her call button for assistance.
Every change shows. The record keeps the time of each entry and each deletion.
Correct your charting errors in accordance with your organization’s policies and procedures, ensuring that it is clearly marked as a late entry. Remember: electronic healthcare records automatically date and time each entry and identify electronic deletions, so any attempt to alter the patient healthcare information record is discoverable.
Not to protect yourself. A note added after an incident to cover the gap reads as guilt.
Don’t chart defensively after an incident has occurred. This is a red flag to lawyers later on. Defensive charting is not necessarily going to stand up in court as actual evidence of negligence, but it does telegraph the message that you believe you were at fault, and that’s the red flag the lawyers will be looking for.
Got a subpoena or a deposition notice? Call your liability insurer and your risk manager before anything else.
The first action nursing professionals should take is to inform their professional liability insurance provider and employer’s risk manager or legal counsel of the deposition notice.
The hospital's lawyer is not your lawyer. They represent your employer.
Keep in mind that this attorney is not your attorney, but is your employer’s attorney; therefore, you may wish to retain a board certified healthcare attorney or a litigation attorney to be “on your side” for the deposition.
You can describe your routine. What you always do is evidence too, but it is weaker than the note.
You can speak about your custom and practice in general at deposition, but there is no substitute for a well-written note and initialed treatment boxes.
Not legal advice. Your facility policy, your state and your
own attorney are what bind you. Every question and every quote here links to
where it was published; read the source, not us. Written by a med-surg RN,
ten years, day shift. Why there is no name on it.