Post-Fall Assessment and Reporting
You are a nursing assistant on a 30-bed unit. At 2:00 PM, you hear a thud from room 204. You find Mr. Johnson, an 82-year-old with dementia, on the floor next to his bed. He is conscious but confused, and complains of pain in his right hip. He is wearing non-skid socks. His call light is on the floor, out of reach. The bed is in the low position, but the side rails are down. You are alone and have not yet notified the nurse.
1. What are your immediate priorities in the first 2 minutes after finding Mr. Johnson? List at least four actions and explain why each is critical.
Read the worked answer
- Do not move him – Suspected hip fracture; movement could worsen injury.
- Assess responsiveness and breathing – Ensure airway, breathing, circulation.
- Call for help – Use call bell or yell; do not leave him alone.
- Check for bleeding or other injuries – Observe skin, head, limbs.
- Stay with him and reassure – Reduce anxiety and prevent further harm.
- Notify the nurse immediately – RN must assess and decide on further action.
2. After the nurse arrives and assesses Mr. Johnson, what should be documented about the fall? Include at least five specific details.
Read the worked answer
Document: time found, location, position, witnessed/unwitnessed, patient's complaints (right hip pain), vital signs, neurological checks, skin integrity, bed height and side rail status, call light location, footwear, immediate interventions (e.g., not moving patient), who was notified, and physician notification. Also note any contributing factors (dementia, call light out of reach).