Question I
Assigning fault in this case is difficult because all the facts are not presented; there are so many details and questions that are left unanswered to make a justified decision as to who really is at fault in this case. That being said I would not place fault to anyone in this case, however everyone involved in this case has some shared responsibility to the patients care. During report Jane is told that the patient fell without injury around lunch time but has had an uneventful evening. At my current place of work VA Hospital there is a Fall Prevention Program with a Post Fall Management Protocol in place, these are measures that are to be implemented after a fall by nursing, and multidisciplinary team members they are; assess for injuries and determine level of injuries, assess vital signs, including sitting/standing blood pressure and pulse, If diabetic, check blood glucose, notify physician/medical provider, The provider of or on-call physician will assess patient within one hour, provide care, order any needed diagnostic tests, medications, etc., complete a Report of Fall Incident Note and document circumstances of fall in medical record, notify all team members of the patient’s fall, complete Fall Risk assessment and implement high risk fall interventions, if indicated. First 24 hours after the fall: obtain vital signs every 8 hours, observe for possible injuries not evident at the time of the fall (assess limb reflex, joint range of motion, weight bearing), Assess for mental status changes, Assess need for restrictions in mobility if warranted, If actual or suspected head trauma, perform neurological checks as ordered by physician. (VAMC 2007).
It is unsure what type of post fall assessments if any, were done after this patient fell, was the doctor notified were any orders placed for further diagnostic testing, or assessments, or if any