Handling Refusals
True or False. The first step in handling a complaint is to listen by sitting down at their level
True! The patient wants to be heard first. A lot of control is taken away from patients in the hospital, so just listening to them can make a big difference.
True or False: You only need to chart post fall documentation if it was an unassisted/unwitnessed fall.
False. All falls must be documented even if they are witnessed and assisted.
What are the three levels of fall risk for the ROI module?
Universal Fall Risk (Purple)
Elevated Risk (Yellow)
Highest Risk (Red)
True or False: You do not need to use a gait belt on an elevated or highest risk fall patient if they say "The last person didn't put it on, so I don't need it"
False. Gait belts keep both parties safe. It will allow us to not hurt ourselves or the patient if they fall. Validate their concerns, align to a common interest, commit to safety, and respectfully explain refusal is not allowed.
True or False. There are three different risk levels of declining cares, and each level has a different escalation pathway.
True! These include low risk (like oral cares, bathing, linen changes), high risk (like labs, imaging, repositioning, CAUTI and CLABSI bundles), and highest risk (like tele, VS, O2, stat orders).
True or False. You only need to document an RL post fall if there was injury.
False. An RL is needed for each fall regardless of injury or not.
What fall risk level is everyone automatically under in the first 12 hours (for adult patients)?
Universal. However, the nurse can change it if they determine it is not appropriate.
Ture or false. Your tracker will automatically turn off and on the bed/chair alarms at all UCH hospitals.
False. Not all hospitals have that system setup. Make sure you know if your unit has the ability to know if you need to arm/disarm the alarms.
True or False. You only need to chart a declination of care if the care they are declining is under the high or highest risk level.
False. For each declination of care, you must chart what they declined, patient's reason for declining, escalated actions, and notification of patient declining this care. Include any comments you feel are important. A significant event note/nursing note will auto generate.
True or False: Falls are the leading cause of injury among older adults age 65 and older.
True. For hospitalized patients, 30-51% of in hospital falls result in injury
True or False. If we are utilizing a lap belt on a patient and the patient suddenly becomes confused and cannot show to how to self-release, we must remove the lap belt.
True. Then we need to chart that we are no longer utilizing the lap belt because the patient is unable to self-release.
True or false: The Hillrom system has a Hillrom Status Board that allows us to quickly see who has their bed alarms on and how many siderails are up.
True. It will tell you how many bed rails are up (and which ones), if their bed exit is on/off, if the bed is in the lowest position, if the breaks are on, and what the HOB is at.
True or False. If a patient declines cares, it is required to have immediate escalation no matter the risk level.
False. For a low risk level, a provider does not need to be notified until it is the 3rd time they are refusing that care either via verbal or sticky note communication (patient is refusing IS participation or patient is refusing oral care).
Name a medication that can contribute to falls risk
Diuretics, antihypertensives, beta blockers, nitrates, vasodilators, tricyclic antidepressants, antipsychotics, benzos, antihistamines, opioids, hypnotics, antidiabetics drugs...
How often do we need to chart ROI?
Chart Q12 hours or as needed for changes in condition (increased confusion, procedures, etc)
Bed in low position, call light within reach, bed/chair alarm on (if appropriate), no clutter on floor of room, remind the patient to use call light for assistance, ensure that all four bedrails are not up, move tray table with frequently needed items within arm's reach....
True or False. Whenever you chart a declination of care, it will automatically generate a nursing or significant event note.
True! Each individual declination of care while generate a note, saving you time.
If the fall was accidental AND the patient demonstrated no pattern of repeated accidental falls AND the precipitating factor(s) that led to the fall are no longer present.
What fall assessment tool do we use for ages 1-17?
Humpty Dumpty
If a patient is scoring elevated risk or highest risk of injury, we should keep what distance from them while they are ambulating or toileting?
Stay within arms' reach