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Falling Down

Anyone who has read “The House of God” knows Fat Man’s Second Law:  Gomers Go to Ground.  It’s harshly worded and blunt beyond our politically correct society can accept, but it is true.  People, especially the elderly, fall.

And why not?  The elder with dementia that doesn’t understand their own limitations, the folks we pump full of beta blockers, diuretics, narcotics and anti-psychotics, and the TBIs and CHIs that can’t grasp their clumsiness are all part of the hospital (and in greater society) milieu.  They fall.  For multiple reasons.  If you do a quick search of the literature, I’m beyond positive that you will find hundreds, if not thousands of pieces of information of falls, causes, risks, sequelae, outcomes and the like.  And the chorus is the same:  falls are bad.  Falls that result in injury are bad.  Elder folks falling is bad.  Our friends of the Borg, er, The Joint (smoking) Commission have decreed that, Falls Shall Never Happen! Oh, and by the way, if they do pipes up CMS, we ain’t going to pay for the care costs related to the fall.  Go to ground and break your hip?  Hospital eats it as no one (even private insurers are starting to follow this trend), is going to pay for your care.

This fear of non-payment has created a flurry of activity.  Fall programs, rounding programs to ensure falls don’t happen by addressing all the things that cause folks to fall (pain, potty, position…), new special booties that both identify the wearer as a high fall risk and provide excellent grip and with all of this loads upon truck loads of new paperwork and charting.  So where does this leave us?  Stuck charting and paperworking instead of providing patient care.

OK, now what do we do about it?  Simple:  accept the fact that people fall.  Don’t point fingers in a blame game or penalize institutions when it happens, accept the simple fact that this will happen.  Then start operating under the assumption that everyone is a fall risk in the hospital.  Actually reduce the paperwork and charting so we can be present and available to prevent falls.  But always know that it will happen.

It’s not an easy fix as say preventing BSIs or CA-UTIs where checklists and proper technique will prevent many if not all infections.  Falls are too dynamic to be placed on a rigid checklist.  For example, a certain patient on my floor was incredibly unsteady, but was strong enough to be “mobile”.  Even though we rounded on them, they were close to the desk, minimized meds that could alter their mentation (worse than it was), they could have fallen in an instant.  Many times, even though they were mere feet away from my typical charting spot, they were up and in the bathroom before I could get to the room after the bed alarm sounded.  There was the patient that threw themselves over the bedrails opposite of their hemiparesis, of the one who suffered cardiac arrest while up walking.  These things happen.  We can never stop them all.

I know why we do all the excessive charting and paper trails besides the whole, “Look we’re doing something about it!”  It’s a way of (hopefully) reducing our liability in court.  So we can say, “Look at all the things we did.  We should be paid (or not have to pay)  Aren’t we good?  Forms in triplicate and fall assessments every 4 hours!  We did everything!”  If we had the assumption that people were going to fall and the rational expectations of this, none of that would be necessary.  But there is no such thing as rational expectations in health care anymore so we all suffer.

The best thing though is when asked where you were while the patient fell would be to reply, “I was charting their fall assessment!”

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  1. August 5, 2010 at 6:15 pm | #1

    I think one of the top three reasons I came back to Canada after practising in the U.S. was JCAHO. It’s a horrid and nurse-hostile at heart. And the response to falls is typical —- throwing paper at a problem never fixed a damn thing!

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