Responding to a Patient Fall: Floor Assessment, Recovery, and Reporting

A fall can look minor and still be serious. A patient who says "I'm fine" may have a slow brain bleed. A broken hip can be made much worse by a kind person pulling them up. What you do in the first few minutes, and what you notice over the next few days, can change the outcome. You do not diagnose anything. You stay with the person, get the right help and give an accurate account. The nurse assesses and decides when and how the person moves. Facility, agency and state rules vary, and your employer's fall policy comes first. Anything you do on the floor with a lift needs hands-on training first.

What You Will Be Able to Do

• Respond in the right order when you find someone on the floor.
• Collect the facts the nurse needs.
• Recognize the signs that need emergency help.
• Choose a safe way up, once the nurse clears it.
• Watch for delayed signs of injury.
• Write a fall report that is factual.
• Help find out why the fall happened.

In the First Minute

You may see the fall, or you may just find the person on the floor. If you are there as they start to go down, do not try to catch them. Guide them to the floor while protecting their head, and move anything that could hurt them.

Once the person is down:

1. Stay with them. Do not leave to go and find help. Use the call light, your voice or a phone.
2. Tell them not to get up. "Stay still. I'm right here. Help is coming."
3. Look before you touch. Are they awake? Breathing? Bleeding?
4. Call the nurse, or use your facility's fall alert. In a home, follow your agency's plan, and call 911 if you see any danger sign.
5. Do not move them. Leave them where they are until a nurse or emergency crew has checked them, unless they are in immediate danger, such as from a fire.
6. Keep them warm and calm. Put a blanket over them. Wait for the nurse's OK before you put a pillow under the head, in case the neck is hurt.

If they do not respond and are not breathing normally, call for emergency help and start CPR if you are trained.

Warning: Do not lift the person, sit them up or help them to a chair just because they ask. Moving someone with a broken hip or a neck injury can make it much worse. Their "I'm fine" does not rule out an injury.

Who Decides What

If you work alone in a home, you may be the only person there. You can look for danger signs, but do not try to rule out injury yourself. If you cannot reach the nurse quickly and you are unsure, call 911.

What to Observe and Report

While you wait, gather what the nurse will ask. Do not press on anything or test the person's limbs.

A person with dementia may not be able to say what happened or that they are in pain, so watch the face and body. Do not trust "nothing hurts" from someone who cannot reliably tell you.

Danger Signs

Get emergency help through your facility's process, or call 911, for any of these:

• Loss of consciousness, even briefly.
• A hit to the head in a person on a blood thinner, such as warfarin, apixaban or rivaroxaban.
• Severe pain in the head, neck, back or hip.
• A leg that looks shortened and turned out, or any limb out of shape.
• Numbness, or being unable to move an arm or leg.
• New confusion, or more confusion than is normal for them.
• Heavy bleeding.
• Seizure, chest pain, trouble breathing or stroke signs.

An unwitnessed fall is one no one saw. Treat it as if the person might have hit their head, because you do not know that they did not.

Getting the Person Up

Once the nurse or emergency crew says it is safe, the question is how. A person should never be pulled up by the arms or lifted off the floor by staff with no equipment. Doing that risks a shoulder injury to the patient, a back injury to you, and a second fall for both of you.

Using a Lift From the Floor

1. Check that the lift can reach the floor, and that it is rated for the person. Not all lifts reach that low.
2. Roll the person and place the sling. A slide sheet can help. Keep their head supported.
3. Bring the lift in as the manual says. Some models have different brake rules for floor lifts, so read yours before you need it. Practice this in training.
4. Attach the straps, and do a small test lift. Go slowly.
5. Lift only as high as needed, and lower them onto the bed or chair.
6. Keep a hand on the person, and have one staff member watch their head.

An air-assisted lifting device is a set of air cushions. You slide or roll it under the person, then it inflates to raise them to sitting or stretcher height. Some models can support very heavy patients. Follow your training.

Rising With a Chair

This works only for someone who is alert and uninjured, who is strong enough, and who has the nurse's OK. Bring a sturdy chair close, and help them roll to their side, then onto hands and knees. They put their hands on the seat, bring their stronger leg forward with the foot flat, push up, then turn and sit. You guide and coach. You do not lift. If they cannot do it, stop and use a lift.

Do not rush any of this. Take time at each stage, and ask about dizziness and pain. Stop if either one appears.

After They Are Up

Most serious problems after a fall show up in the hours that follow.

1. Nurse's assessment. The nurse checks vital signs and looks for injury. You may be asked to take vital signs.
2. Neuro checks. A neurological check looks at alertness, pupils, speech, and strength. Facility policies set the schedule, and many keep this up for as long as 72 hours after an unwitnessed fall. The nurse decides who does each check.
3. Keep watching. You are with the person more than anyone else. Report changes right away.

Watch for these delayed signs, which can follow a head injury or a fracture:

• A headache that gets worse.
• Repeated vomiting or nausea.
• Slurred speech, weakness or numbness.
• One pupil larger than the other.
• Getting more confused, restless or sleepy, or being hard to wake.
• A seizure.
• New pain on standing or walking, or refusing to put weight on a leg.
• Bruising that spreads.
• A person who has stopped eating, or is just "not themselves."

CDC warns that older adults have a higher risk of bleeding in the brain after a head injury, and that blood thinners raise this concern. A bleed can develop slowly. A person who seems fine on Monday may be sleepy and confused on Wednesday. Your report may be the first clue.

Warning: If a person who fell in the last few days becomes more sleepy, confused, or complains of a worsening headache, treat it as urgent. Call the nurse right away.

Reporting the Fall

Report every fall, even if no one was hurt and the person asks you not to. Report near-falls too, such as when someone slid to the floor with help, or was caught by a coworker. Those are warnings.

Write facts: what you saw, heard and did. If you did not see the fall, do not write that the person fell. Write what you found.

Example note. "06:40. Found Mrs. Lin sitting on floor on left side of bed. Call light in reach, bed in low position. Floor dry. Wearing socks, no shoes. Resident states, 'I had to go to the bathroom.' Awake, answers questions as usual. Rubbing left hip, rates pain 4 out of 10. No bleeding seen. Stayed with resident. RN Patel notified 06:41 and arrived 06:43. Moved to bed with mechanical lift at 07:05 after RN assessment, 2 staff."

Do not assign blame in your note. Fill out the incident report as well, because that form feeds the facility's safety work. Many employers ask you not to mention the incident report in the chart, so follow your policy. The nurse usually calls the family and provider, so check before you talk to the family about what happened.

Why Did It Happen?

Many facilities hold a short post-fall huddle soon after a fall. Staff who were there talk through what happened while the details are fresh. Your view is valuable, because you know the person's routines.

Think through these questions:

• What were they trying to do? Going to the toilet is a very common reason.
• What changed? A new medicine, a new room, an illness, less sleep?
• Was there a pattern? Same time of day, same spot, same activity?
• Was the plan followed? Call light in reach, walker close, bed low, right footwear?
• Was anything in the room a hazard? A wet floor, poor light, clutter, a loose cord?

Worked example. Mr. Reyes fell at about 5 a.m. on Tuesday and nearly fell at 5:15 a.m. on Friday, both on the way to the bathroom. He started a water pill last week. You report this at the huddle. The nurse asks the provider about the timing of his medicine, and the team adds a toilet trip at 4:45 a.m. and a night light. He does not fall again that month.

Falls are often a sign of something else. A new pattern of falling can point to infection, a medicine problem or weakness, so tell the nurse.

Common Mistakes

Check Your Understanding

1. You find Mrs. Green on her bathroom floor. She says, "Help me up, I'm embarrassed." What do you do?

Reassure her and stay with her. Do not lift her. Call the nurse, and observe her for injury. Keep her warm until she is assessed.

2. Mr. Ford was found on the floor. He takes apixaban and has a small bump on his forehead. He says he feels fine. What do you do?

Treat it as an emergency. A head strike on a blood thinner needs urgent evaluation, even if he feels well. Get the nurse right away or call 911 as your setting directs. Do not move him.

3. Two days after a fall, a resident who is usually chatty is sleepy and did not touch her breakfast. What do you do?

Report it to the nurse right away, and mention the fall. New sleepiness in the days after a fall can mean bleeding in the brain.

4. After a fall with no injury, the nurse says to get the resident up. He cannot stand and is too weak to use a chair. How do you get him up?

Use a lift rated for floor use, with at least two trained staff. Do not lift him by hand.

5. You did not see the fall. A coworker says to write that he "tripped on his walker." What do you write?

Write only what you saw and what he told you, in his words. Do not guess the cause.

Key Takeaways

• Stay with the person, keep them still and get the nurse. "I'm fine" does not mean they are fine.
• Treat any fall no one saw as a possible head injury.
• A head strike on a blood thinner is an emergency.
• Nobody gets lifted off the floor by hand. Use a rated lift, or call for help.
• Watch closely for days, because a brain bleed can show up late.
• Write what you saw, report every fall and near-fall, and help find out why it happened.