#7132
Xiyu
Member

I remember one day during my night shift one resident had a fall. He was lying on the floor beside his bed with a pillow under his head and covered himself with a blanked. It was an unwitness fall. I took his vitals and did a head to toe assessment. Although he denied any injury, I put him on head injury routine. Since it was his third fall in this month, he was supposed to be sent to hospital according to the facility policy. Resident strongly refused to be send to hospital , although I explained again the importance for him to be examed in hosptial. I checked the hight of his bed (It should be the lowest postition. ) and the siderails(one siderails up according to her care plan). I put a floor mat on the side of bed that without a side rail up and I delegated a PSW to go to his room to check him every half an hour. I checked his vitals very 15 minutes later. His vitals were stable and there was no injures according my assessment. I decided to continue to monitor. I thought I would call 911 at once if there was any sign to indicate his condition was not stable. The paramedics would assess him and made a final decision. Fortunately, his status was stable and he slept quietly and comfortably on the bed. The next morning I reported this to the morning nurse and she check his status with me. He already waked and alert and oriented and seemed in a good mood. I think in this case, I collected the clinical data, did my implementation and made decision that led to a best practice.