Advanced Professional Roles and Values Wgu

4119 Words Jan 21st, 2015 17 Pages
Advance Professional Roles and Values Project
Falls

Keri Cochran
October 20, 2014
Western Governor’s University

The problem and explanation: The hospital I am employed at is currently having an issues with patient falls. The hospital is a “no restraint facility” and strongly discourages the use of any form of restraint including leather, soft, posey vests, or chemical. Currently the line of defense is using staff sitters, moving the patient to a visible room when available and or family members are encouraged to come and stay with their loved ones who are at high risk of falls. This does not always rectify the issues secondary to staffing issues and family participation.
The facility has had two critical falls this year, one
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As a facility, we have adopted the slogan “No one potties alone” thus meaning staff have to be present at all times when a patient is on the toilet. You can imagine how this has been perceived. Patients refuse to have staff standing waiting while they use the toilet, patient and staff are very uncomfortable with this facility wide decision. Simply stated it is not working well. We have continued to have falls and or “near misses” and patient satisfaction has declined. Our patient surveys seem to have a common theme, patient’s need and want their privacy while in the restroom.

On our unit, 4 Tower, I brought up the issues of falls secondary to our manager stating this is a hot topic. I introduced discussion at the unit based council meeting that we have an issues and we need to address the issue and do something because this plan of “no one potties alone” is not working. Hence, this project has come to life.

The investigation and analysis: The issue is patient falls in the acute care setting. In looking at this issue, I researched all the falls that had occurred on my unit and pulled patient charts and researched RN and CNA documentation, procedures, medication records etc. to be able to start seeing correlations / similarities between the falls. I pulled NOEs (notice of events) our facility internal method of tracking falls. In reading documentation most falls were during the
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