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Scenario #3 – FallPatient presented to ED with c/o generalized weakness, abdominal pain, and two day history of nausea and vomiting. History of cancer in left lower extremity with probable brain metastasis. Patient admitted to medical floor and treated for hypokalemia, hypercalcemia, UTI and lethargy. Condition – guarded. Patient hypertensive but noted multiple allergy or previous adverse reactions to many anti-hypertensive medications. CT of head in ED showed multiple lytic lesions consistent with myeloma. Patient received consults to oncology/hematology, neurology, critical care and nephrology. In ED patient given Dilaudid and Haldol for pain and agitation. Patient assessed upon admission and with each shift as fall risk with standard fall risk preventions implemented. Timeline of Events 4-days post-admission:Day shift: Patient had been requiring assistance of two people to get out of bed. 0400 - Patient suddenly rallied and was up walking around. Patient confused; he pulled foley out. Patient returned to bed, foley reinserted and patient given Ativan. 0520 - patient again got out of bed, got walker and tripped, tumbling to the floor. He was assessed by the RN to have no injury. The primary MD and family notified of fall. Post-fall patient was provided a sitter 1:1. 1030 - Neurology examined the patient and noted mental status changes, seizure-like activity, hypertension and decrease in O2 sats. Patient given Labetolol and transferred to ICU. The ICU RN noted a bump on the patient’s head and advised primary MD who ordered repeat CT of the head, which demonstrated a subdural hematoma. DVT prophylactic meds were halted and sequential cuffs placed. EEG showed sharp waves consistent with cortical irritability and tendency for seizures emanating from left hemisphere. 2030 - Patient’s prognosis was poor and the family opted for comfort measures and hospice. Patient expired a few days later. Issues:Day shift nurses did not communicate that patient had been up walking during the day shift.Documentation of post-fall assessment by Medical floor nurse could not be located. Was entered as a late entry 2 weeks after patient’s death.New bedside medication verification process was being rolled out on the unit for the first time, causing additional stress. Had normal staffing, but did not allow for additional stress of new process.Sedating patient due to agitation increased risk of fall and this was not taken into consideration. Policy indicated Ativan is not to be used for sedation without sitter present.Had foley in patient to keep him in bed and to get strict I&Os – foley increased agitation but due to illness was necessaryMultiple bed alarms not working on the unit, so staff believed that alarm on patient’s bed was not working. Nurse did not set alarm since they rarely worked any way.Plant Operations unaware of malfunctioning bed alarms. No low beds in hospital; no floor mats available around beds for high risk patientsStaff comfortable bringing forth safety issues, but feel that issues are not always heard. It takes longer than it should to get things fixed. ................
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