NSG 3039 Week 1 Discussion-Relying on Data

Falls are the leading cause of unintentional injury and death in the senior community. In the United States, non-fatal injuries due to a fall cost $19 billion annually (Mei, Marquard, Jacelon & DeFeo, 2013). As the nurse manager on call, I am responsible for assisting the floor nurses in updating our residents’ care plans immediately after a fall, with an intervention related to the cause of the fall to prevent further falls. One night at 3  a.m., I was awoken from my sleep by one of our floor nurses calling to say that one of his residents had a fall with no injury and wanted help creating an intervention. Not fully awake, I asked the most common questions: What did they say they were doing before they fell? Were they being assisted? Were they soiled? Etc….

NSG 3039 Week 1 Discussion-Relying on Data

The floor nurse stated that the resident tried to go to the bathroom alone, did not use his call light to ask for assistance, and had no injuries. I asked if he had completed orthostatic vitals due to a possible syncopal episode, and he stated yes and that the vitals showed that he was positive for orthostatic hypotension. I did not verify or ask for the exact blood pressure or heart rate the nurse used in his findings or documented in the resident’s chart. I stated that as an intervention, he would complete orthostatic vitals daily for three days, ask for a medication review by the physician, therapy to re-evaluate his transfer status due to the orthostatic hypotension and put red tape to his call light to enhance his use. I thanked the nurse for being thorough enough to complete the orthostatic vitals (most of the nurses forget), and I went back to sleep. The next morning, I gathered the fall report, the written progress note, and the documented vitals. When I noticed that the resident did not have orthostatic hypotension, although the nurse documented it in their progress note as such. There was a 20-point difference in the pressures, but the pressure did not decrease in orthostatic hypotension. The fall resulted in the resident rolling out of his bed. A better intervention would have been a winged-tipped mattress for perimeter awareness. I was grateful the resident didn’t roll out of bed again that night. I learned even though I am sleepy; I need to evaluate and assess all the data retrieved by the nurses myself. The American Nurse’s Association (ANA)  Principles for Nursing Documentation (2010) states, “Documentation that is incomplete, inaccurate, untimely, illegible or inaccessible, or that is false, and misleading can lead to several undesirable outcomes” (pg 6). In this case, the resident did not have another fall, but had it happened before we could change interventions, our facility could have been in a lot of trouble legally if he had fractured.

References

American Nurses Association. (2010). ANA’s Principles for Nursing Documentation. Retrieved from http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of- nursing-documentation.pdf

Mei, Y. Y., Marquard, J., Jacelon, C., & DeFeo, A. L. (2013). Designing and evaluating an electronic patient falls reporting system: Perspectives for implementing health information technology in long-term residential care facilities—International Journal of Medical Informatics, 82(11), e294-e306. doi:10.1016/j.ijmedinf.2011.03.008

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NSG 3039 Week 1 Discussion-Relying on Data

For data to be reliable, several conditions need to be met—accurate, timely, and complete. Share an example of when you had to make a decision using data that was not accurate, timely, or complete.