Found on the Floor at 0615: An Unwitnessed Fall in a Resident on Warfarin
Mrs. R is 82 and has left-sided weakness from a stroke. She takes warfarin daily, uses a walker, and her care plan says 'assist of one with transfers; call light within reach.' At 0615 you answer her light and find her sitting on the floor beside the bed, glasses off, in a small amount of urine. She says, 'I didn't want to bother anybody, I just had to go.' She is awake and talking, her skin is dry, there is no bleeding, deformity, or bruise, and nothing in the room is broken. She denies hitting her head but cannot say how she got down. The other aide is in the shower room and the charge nurse is at the medication cart down the hall.
1. List, in order, what you do in the first five minutes, and explain why each step sits where it does in that order.
Read the worked answer
1. Stay with her and call for help from where you are. Use the call light, the emergency pull cord, or your voice. Never leave a resident who has fallen alone - you do not yet know whether she is injured, and she may try to get up and fall again.
2. Do not move or lift her. This is the step new aides most often skip. The fall was unwitnessed, so the mechanism is unknown, and she is on warfarin. Lifting or 'just helping her up' can turn a stable injury into a fractured hip that displaces, or mask a head injury that is about to declare itself.
3. Assess what you can while you wait. Is she alert and oriented? Breathing normally? Any pain, especially in the hip, back, or head? Any deformity, shortening or rotation of a leg, or new weakness? Compare her left side to her right. Ask what happened and what she remembers.
4. Keep her warm and covered. She is sitting in urine on a hard floor; a towel or blanket protects her dignity and her skin.
5. When the nurse arrives, hand off clearly. Report that it was unwitnessed, that she takes warfarin, and exactly what she said. The nurse - not you - decides whether she can be moved and how, and will start neurological checks because of the anticoagulant.
6. Transfer only on the nurse's direction, using a mechanical lift and two staff if indicated.
Why order matters: airway and safety first, then 'do no harm' by not moving her, then information gathering, then hand-off. Everything else (changing her, cleaning the floor, documenting) comes after she is safe.
2. Her daughter arrives 20 minutes later and demands to know 'who dropped her.' How do you respond?
Read the worked answer
- Acknowledge the fear first. 'I understand - if it were my mother I'd want answers too.' Anger here is fear.
- State only facts you personally know: 'I found her sitting on the floor beside her bed at 6:15. She was awake and talking. The nurse has assessed her and is checking on her.'
- Say what you do not know: 'I don't know how she got down. It wasn't witnessed.' Do not guess, and do not invent a cause to fill the silence.
- Do not blame the resident, the previous shift, or the facility. Do not say 'she shouldn't have gotten up' - that is blame, and the care plan, not the resident, is what failed.
- Do not promise outcomes ('she's totally fine') and do not give clinical opinions about injury or treatment.
- Hand the clinical questions to the nurse: 'The nurse can talk with you about her condition and what happens next - let me get her.'
- Keep your own feelings out of the chart and out of the hallway. Do not discuss it with other residents, visitors, or staff who do not need to know.
Ten minutes later, if you are asked again, you give the same short factual answer. Consistency and honesty are what defuse these conversations; speculation is what inflames them.
3. Later the nurse says, 'Just note in the chart that the incident report is done.' What do you say, and what do you actually document?
Read the worked answer
What you say: 'I'll fill out my incident report with what I saw. I can't chart about the report in her progress notes, and I can't chart anything I didn't see - if you did something, you'd need to document that yourself.'
Why:
- The incident report is a risk-management document, completed by the person who found or witnessed the event, and it does not belong in the medical record. Writing 'incident report filed' in the chart is a common error that can expose the facility and you.
- You may only document what you personally observed, did, and were told - never another person's actions or an interpretation such as 'resident fell due to negligence.'
What goes in the resident's care record (objective, timed):
- '0615 - Answered call light. Found resident seated on floor beside bed, glasses off, clothing damp with urine. Resident alert, speaking in full sentences, denies hitting head. No bleeding, deformity, or bruising noted. Stayed with resident; call light used to summon help.'
- '0618 - Charge nurse in room; resident on warfarin reported to nurse. Resident assisted to bed with mechanical lift per nurse direction at 0635.'
What does NOT go in: opinions ('she should have called'), blame ('non-compliant with call light'), guesses about injury, or mention of the incident report.