Found on the Floor on Warfarin
At 5:40 a.m. you find Mr. Pruitt, 80, lying on the floor beside his bed. He takes warfarin daily. The bed is in the low position, his call light is on the floor out of reach, and the floor mat is pushed against the wall. He says, “I’m fine, just help me up - I was only going to the bathroom.” He is holding his right hip and has a small scrape on his forehead. He is awake and talking, and he rates his pain 6 out of 10. The nurse is at the far end of the hall with another resident.
1. What do you do in the first two minutes, and what do you refuse to do?
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Do not move or lift him. He has hip pain, a head strike, and takes an anticoagulant. Lifting him could turn an undisplaced fracture into a displaced one, or worsen a spinal injury.
Do:
- Stay with him and keep him still and warm with a blanket, without rolling or pulling him.
- Call for help loudly, or use the call light or phone, so someone else brings the nurse. Do not leave him alone; if you truly must leave, say so out loud and go fast.
- Check responsiveness, breathing, bleeding, and where it hurts; ask what he remembers about falling.
- Keep him from trying to stand - “I know you want up; the nurse needs to look at you first.”
Do not give him food or drink, do not try a gait belt lift, and do not let a coworker talk you into a two-person lift before the nurse has assessed him. Follow the facility's post-fall protocol, which usually requires a mechanical lift.
2. Why does this particular resident need faster escalation than a routine fall, and what exactly do you report?
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Warfarin plus a head strike is a bleeding emergency until proven otherwise. He can be bleeding inside the skull with no visible wound, and a hip fracture can bleed substantially in an anticoagulated resident. Deterioration can be delayed by hours.
Report, immediately and in this order:
- That he fell and where and when you found him.
- That he takes warfarin.
- The forehead strike and the hip pain rated 6/10.
- Any change in alertness, speech, headache, nausea, or one-sided weakness - and keep rechecking these while you wait.
- The environmental findings: call light on the floor, mat pushed aside.
Framing matters: report the call light and mat as facts about the environment, not as an accusation against the previous shift. The nurse needs neuro checks and vital signs; the cause of the fall gets sorted out after he is safe.
3. Once he is safely back in bed, what changes prevent this from repeating tonight?
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He fell because he was trying to get to the bathroom on his own with an unreachable call light.
- Toilet him on a schedule - before sleep, at night rounds, and on waking - and offer a bedside commode or urinal within reach. He is not getting up to wander; he is getting up because he has to urinate.
- Call light clipped within reach and actually answered quickly; tell him you will come.
- Bed low, wheels locked, floor mat flat and in place, night light on, non-skid footwear, clear path.
- No restraints and no raised side rails as a substitute for supervision. He will climb over them and fall from a greater height.
- Report the fall, the cause, and the plan to the nurse so the care plan is updated; document what you changed.
The judgment point: the fix is matching the environment to the reason he got up, not simply telling him to call next time - he did intend to call, and could not reach it.