Understanding the Significance of Patient Documentation & Fall Risk Assessments

With the turbulent nature of today’s healthcare environments—staff changes with every new shift mixed with the constantly evolving needs of patients—having accurate and consistent documentation for handoff is key to delivering effective care throughout.

Unfortunately, when documentation is not consistent, errors can occur, ultimately impacting the outcome of the patient. To put this into perspective, let’s examine a case that involves an 89-year-old female patient who arrived at the emergency department with complaints of irregular heartbeat and shortness of breath.

Intake Assessment

After an initial examination was completed, she was admitted to telemetry for monitoring. The staff immediately noted her fall risk score as high with a prior history of falls documented in her admission records. With this in mind, bed alarms were put in place, as well as a red flag indicator on the patient’s door to signify her increased risk.

Shift Change Assessment

At shift change, however, the staff rated the patient’s fall risk assessment as moderate and—contrary to earlier assessment notes—she was noted to have no history of prior falls reported. Due to this inconsistency, the incoming night staff did not utilize the bed alarm during their shift.

Incident Occurs

Around 4:00 AM, the patient was found on the floor of the bathroom when she attempted to use the restroom without calling for assistance. Chart notes indicated a skin tear, and the patient was alert and assisted back to her bed. However, when the physician rounded on the patient later that day, there was no mention of the fall in his progress notes.

Patient Condition Deteriorates

The physician did document evidence of respiratory distress that he felt had not been reported or documented by the nursing staff. The following day the physician rounded again on the patient and found her in moderate respiratory distress with heightened confusion.

The patient quickly became unarousable during his exam. A CT was ordered, and a large right-sided subdural hematoma was revealed. At this point, the patient’s family implemented a DNR.

Assessment in the Aftermath

Following the CT scan, a late entry was charted by the nurse stating that the patient’s fall had been reported to the physician. However, the physician disputed that he had never been advised of the patient’s fall. After meeting with the nursing staff and reviewing the basis for the various fall risk assessments, it was determined that due to the conflicting testimony of nurses and the physician, a settlement should be offered before the claim proceeded to the PCF panel.

Unfortunately, it appears that the staff in this case did not accurately document the patient’s risk level or the fall event that resulted. From there, critical omissions in their documentation compounded, leading to the patient not receiving emergency care she needed.

Neurological assessment post-fall is critical when the fall is unwitnessed, and it is not known if the patient sustained head injuries. In this case, had a neurological assessment been done, the staff may have noticed the patient’s deteriorating condition in a timelier fashion and prevented the eventual outcome.

Key Takeaways from This Case

Patient falls in healthcare are among the most common adverse events. Strong processes and continuous staff education on those processes are essential for preventing patient falls.

Furthermore, organizations should have a process for post-fall management when a patient fall does occur. This should be included in the facility’s fall prevention policy or adverse event reporting policy. The next steps should always include notifying the physician of the event and documenting any orders. The policy should also detail expectations for follow-up assessment of the patient in the event the fall was either unwitnessed or if it is unknown if the patient may have hit their head.

1. Leverage Risk Management Notes

Consistency in chart notes is critical to help incoming staff continue risk management practices from one shift to the next. In our case, the lack of consistency in our patient’s notes contributed to fall mitigation steps not being taken in later shifts, leaving the patient vulnerable to falls and injury.

2. Establish a Fall Prevention Policy

Every organization should have a patient fall prevention policy in place. Patient fall prevention policies detail the types of prevention measures that staff should take according to the level of risk identified through the assessment. Best practice for patient fall prevention includes the use of an evidence-based fall risk assessment that staff should complete upon patient admission, at each shift change, and any change in the level of care and condition.

3. Utilize Risk Assessment Best Practices

Often, the risk assessment data in the medical record is not reflected in the patient’s care plan. This makes the findings of completed patient risk assessments critically important for clinicians.

Staff must include information from assessments in hand-off communication and relay it to the next caregiver to ensure continuity of care.

4. Document All Patient Care Events

Documentation is such an important function for patient care staff. All documentation should occur before the staff ends their shift. Understandably, staff members sometimes need to enter documentation late, but they should discuss notes entered the next day or beyond with the Risk Manager. Charting policies should be in place that direct staff in the proper way to enter a late note into the medical record.

Enhance Your Safety Process with LHA Trust Funds

Effective documentation and fall risk assessments are important elements of an overall safety plan for any healthcare facility. At LHA Trust Funds, our experts offer Onsite Risk Assessments focused on patient falls to identify gaps in safety and help your team implement proven best practices to produce the best outcomes possible for your patients.

Ready to enhance your safety infrastructure? Contact Vice President of Patient Safety & Risk, Stacie Jenkins, RN, MSN, at StacieJenkins@LHATrustFunds.com today.