Found on the Bathroom Floor: A Resident on Warfarin Who Wants to Get Up
At 06:15 you answer a call light and find Mr. L, 78, sitting on the bathroom floor beside the toilet. He says, "I slipped. I'm fine, just help me up before the nurse sees." He takes warfarin daily for atrial fibrillation. He is awake and talking, his left hip is "a little sore," and you see no blood and no obvious deformity. He admits he "may have" hit the back of his head on the door frame. He is in a private room at the end of a long hall and no other staff are visible. The wall-mounted emergency pull cord hangs within his reach; the call-light cord is on the floor across the room. He is already trying to push himself up using the toilet-paper dispenser.
1. What are your first actions, and what must you not do?
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Do not help him up. Lifting a resident who has fallen can turn an undisplaced hip fracture into a displaced one, and can convert a stable spine injury into a cord injury.
- Tell him to stay still and put your hand gently on his shoulder to steady him.
- Get help without leaving him. Have him pull the emergency cord, or shout for the aide on the next hall; never leave a fallen resident alone.
- Assess: is he alert and oriented? Where does it hurt? Can he move both legs? Any head strike, bleeding, or new weakness? Did he lose consciousness?
- Head strike plus warfarin is an emergency flag - report it even though he looks fine. Anticoagulated residents can bleed intracranially with no external sign.
- Keep him warm and wait for the nurse's assessment before anyone moves him.
His embarrassment is not a reason to skip the assessment.
2. The nurse assesses him, finds no fracture, and clears him to be assisted up. What monitoring does he still need, and why?
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A fall is not over when the resident is back in bed. On warfarin, delayed bleeding is the main worry, so post-fall monitoring matters more than usual.
- Vital signs and neurological checks per facility protocol - typically more frequently for the first 24 to 48 hours.
- Watch for change in level of consciousness, new confusion, unequal pupils, vomiting, or a worsening headache, and report any of these immediately.
- Recheck the hip and head for swelling, bruising, or new pain with movement.
- Ask about pain at rest and with movement, and watch how he walks - a new limp or guarding may show up hours later.
- Toileting schedule and call-light placement: his call light was across the floor, which is likely part of why this happened. Put it in reach and check on him more often.
The fall was a system failure as much as a slip. Fix the reachable call light, non-skid footwear, and lighting.
3. What belongs in the incident report versus the chart?
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Both documents need facts, and they are not the same document.
Incident report: time found, position and location, exactly what the resident said, what you observed, who was notified and when, and objective contributing factors (call light on the floor, unlit bathroom). Facts only - no opinions about blame, no speculation that he "shouldn't have" gotten up, and no judgment about staffing.
Chart: the objective clinical facts - found on floor at 06:15, statements, injuries observed, vital signs, nurse notified at 06:20, monitoring begun. Often the chart notes that an incident report was completed per policy; follow your facility's rule on that.
Do not write the incident report inside the chart, do not let another aide write it for you, and do not alter either document later. If you are asked to describe what happened to a family member or an investigator, describe what you saw, not what you concluded.