Patients May Have a Right to Fall AND We Have a Duty to Minimize the Risk!

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Ok this may be another one of my ranting posts, but I do get irritated when a patient falls and someone says, “Patients have a right to fall”!  I’m not advocating for restraints to prevent falls, but I am advocating for enough staff to be available to patients when they are needed.  I know we can’t prevent all falls, yet don’t we have a duty to minimize? And shouldn’t we be careful to make sure we are not using this mantra to cover up for substandard care?

In my heart, I know that some of these falls were due to inadequate numbers of staff... Click To Tweet

Sometimes people are seriously hurt! Events involving Falls that resulted in death or permanent loss of function according to the Joint Commission Sentinel Event data (reporting is voluntary and statistics only include a small proportion of actual events) from 2004-2013:

  • 2004-31 falls
  • 2005-47
  • 2006-35
  • 2007-53
  • 2008-63
  • 2009-81
  • 2010-56
  • 2011-96
  • 2012-76
  • 2013-82
  • 2014-91
  • 2015-95
  • 2016-92
Seems like we could do better, right? Click To Tweet

I want to ask, did they fall because they wanted to and were exercising some freedom?  What else might explain their fall?

Were they in pain and tired of waiting in bed for the nurse?

Did they have to use the bathroom and the call light was on the floor?

Were they confused? Overmedicated?  Undermedicated?

Had they turned on the call light….15 minutes earlier.  (Time is funny, to the patient lying in bed trying not to soil themselves even one minute can seem like an eternity.  To the Nurse Assistant who is caring for ten patients, 15 min may only be long enough to give one patient a boost in bed.  (See my post on repositioning patients for more about that!).

In my heart, I know that some of these falls were due to inadequate numbers of staff or staff who had inadequate skills and familiarity with the unit and patients to the best extent possible.  And I’m willing to bet the costs of medical treatment and lawsuits were more than prevention would have been.

What do you think?

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23 Responses to Patients May Have a Right to Fall AND We Have a Duty to Minimize the Risk!

  1. Stefanie says:

    What are people’s thoughts about patients who are of sound mind asking to be in the bathroom with privacy? Should the nurse refuse them that right if they are a fall risk, yet can understand to use a call light when done in the bathroom?

    • Great question! No simple answer either. A judgment call that would involve factors like how privacy might impact this patient’s ability and need to void, mentation and willingness to cooperate w/ nursing staff for waiting for help and not standing once done, staffing so that the patient wouldn’t have to wait, and possibly other options like is there a family member who the patient would be ok have present. Then we’d have to consider a physician’s order to allow, and/or a form that could waive liability. Sounds like lots to discuss with nursing, patient advocates, docs, and legal reps!

  2. Anonymous says:

    My grandma is in a rehab facility right now with a broken foot on complete nonweight bearing orders. She was sitting in her chair after I had taken her to the bathroom and leaned over to pick something up and fell out of her chair. I guess to me that’s about as much as ‘the right to fall’ is acceptable. She was sent to a rehab facility since the doctor claimed she would need to be assisted by rehab for her every need since she could not do it herself and with her weighing over 200 pounds, I couldn’t lift her to help her completely.

    Of course the rehab has around 40 patients with two aides at any given time on the floor plus a nurse. She’s dementia so everything is trying for her. She has to roll in her bed to help the aides change her. But she isn’t allowed to have bed rails as they are a restraint. I’ve complained and requested and whined because she can’t even roll without having some sort of assistance to do so then they roll her over getting annoyed with her incompliance and meanwhile she’s yelling and hollaring, “I’m going to fall. I’m going to fall.” because when rolled over all she sees is the floor and of course the aide is busy working on her pants and depends not so worried about how she is feeling unsafe and scared out of her mind having no real thing to hold onto. I don’t see how a bed rail is a restraint. My grandma gets out of hers at home all the time while healthy and we use them constantly for helping her get into the bed and out of it safely. Rolling is much easier and safer to do with a bedrail to assist. I’d love to believe that even a healthy elderly person can have the help they need to stand and have a walker there to help them pivot properly but that’s not realistic so a bed rail assists them in reaching their bed side commode safely.

    I live with my grandma usually and have her on 24/7 care per the doctor’s request. I even use a camera with her at night so she can ask for help and she does. In a nursing home they answer to bells and cannot hear her call for help. She gets upset not being heard and tries to get up to ask for help. She has a bed alarm which works the same as a call button for her since she isn’t able to remember to use a call button when her yells aren’t working. She sits up on the edge of her bed with the alarm going off waiting for someone to come. Since the staff are aware of her using it as a call button, it is treated like one. Again its not a restraint but instead a safety tool used to have others know to help her.

    I just don’t understand the idea of a person who can’t remember their name having the right to fall. It is nuts as we protect our children, babies, spouses, etc from falling when they are sick, or hurt yet our elders and grandparents and loved ones are left without safety devices to fall stating, “oh they have the right to fall and injure themselves.” We buckle into cars by the law to protect us, we use straps on high chairs for children and we ourselves buckle into to rides at fairs. Yet an elderly patient can’t even have a buckle on a wheelchair that someone else is pushing. If I was in a wheelchair I’d buckle myself if someone was pushing me because you just never know when you might hit a bump or a rock and be thrown forward. I’d want bedrails on my bed protecting me from falling out if I was unable to move much and to help me get out of the bed safely if I was injured. They provide call bells so really how is a bed alarm any different. It alerts the nurse or aide to come check on that person. It really sounds to me like just this “Right to Fall” is something said to make the staff feeling better after having a fall happen on their watch.

    • I’m so sorry that your Grandma fell and broke her foot. Thank you for your heartfelt story. I’m not sure the staff really feel better when this happens, (I sure don’t), but suspect the leaders of the organization sleep better b/c they feel protected from legal ramifications. I’m not sure they are, but such a policy does seem to blame the victim. As you can tell, I hope, I do NOT support a ‘Right to Fall’ policy in most cases.

  3. Anonymous says:

    As a 30 year Nurse I have pretty much seen it all the ruling came while I was working I was appalled the right to fall I said? Some of these patients are like babies dependent on us for there every need , due to their regression in orientation , I said you wouldn’t place a three year old in and open second story window and walk away. I don’t particularly approve of medicinal restraints or physical restraints but I do believe in appropriate staffing ratio’s per patient , and as above bed checks Q 15 min and PRN, soft pads on either side of the beds and one side rail down and of course call light with in reach, and if the patient continues to fall and is still alive use of a bunker bed , sounds cold but they have the room to move around and if they fall it is usually a soft landing!

  4. Juliet says:

    A common fall situation I see is a patient is assisted to the bathroom and then refuses to let the nurse or aide keep the door open and stay with them in the bathroom to keep them safe. They want their privacy. The aide or nurse stays right outside the door, sometimes not even successful in keeping it ajar and then the person can fall inside the bathroom. On restraints, side rails are only considered restraints if all 4 of them are up basically keeping the patient inside the bed. ironically it is usually family that does that to their family member to ‘keep them safe’, and we have to ask if we can bring one down in the case we think a true restraint is not necessary (pretty much always)

  5. Gulzar Sara Panjwani says:

    Every action must be taken by every staff member to prevent falls. I agree preventing falls is much more cheaper than dealing with treatment and lawsuits post fall. Hourly rounding is a good and effective practice to prevent falls. If patients needs are addressed during the hourly rounds then falls will decrease. We have tried this practice at my previous job and it does work.

  6. Nikki says:

    The right to fall…. that statement infuriates me. I’m not advocating restraints as in tying someone down either, but where I work, I was told to even implement a simple pressure alarm to their wheelchair or bed, prior to a fall, on high risk, fall patients, was against their rights. That also infuriates me. An alarm, to help call attention to already super busy staff, to me, seems more like a rational intervention, than abuse of rights. I’ve been a nurse for 24 years, and although I know what I’m fixing to say, may sound horrible, it’s truly not meant to be, so please take it in context, and forgive me in advance. 20 years ago, even 15 years, it was acceptable AND legal to use soft restraints, or lap belts, to help keep patients/residents, from constantly trying to get up and walk when a fall or injury was imminent. We had way less falls, and injuries from falls in 2000 than we do today. It breaks my heart every day to see these falls/injuries, happening, knowing one simple alarm could have helped prevent them.

    • Stephanie Stewart says:

      Maya Angelou said when you know better, you do better. I think we know better now than we did 15-20 years ago. We now know that restraints don’t usually prevent falls and actually cause a whole host of other problems! And alarms . . . look at the research . . . they don’t usually prevent falls, instead they tell us that the person is on the floor. Additionally, depending on the patient an alarm could actually cause more problems including startling, behaviors, etc.

      • Juliet says:

        what research? can you provide a link? do you mean a bed alarm? our bed alarms go off very quickly, often too quickly. we run right in there, help the patient and reset the alarm.

      • Laura Moss says:

        Stephanie,
        I agree with you 100%. I have done a lot of staff education on mitigating
        fall risk while honoring resident self-determination in long term care. I too tell staff that chair & bed alarms merely let you know who to pick up from the floor. They do not address the root cause of falls.
        Example: a frail, elderly man has fallen twice between midnight and 3:00am attempting to get out of bed and stand to urinate in his urinal. A bed alarm will not resolve his desire to help himself or his reluctance to pee in front of an aide. An analysis of his situation could result in a plan to 1) check on him between 10 & 11 pm and supervise his use of the urinal before he settles into bed for the night so he doesn’t have to go after midnight. 2)place a quarter rail on his bed and a non-slip mat on the floor next to bus bed so he can grasp the rail and stand without slipping. 3) if standing for a prolonged period is not an option, a stationary bedside commode could be placed. The man could pivot to the commode, void when he needs to, and get back into bed. Staff could check the commode and empty on rounds.
        I agree with Beth that inadequate staffing correlates with increased falls, but not all types. If a resident/patient wants help, calls for help and no one comes, that may be attributed to inadequate staffing; although as someone else commented, anticipating patient needs can make a significant difference.
        Staffing has less impact on falls that occur as the result of patients who are motivated to care for themselves. They won’t ring the bell in the first place, so how can we help them to “get the job done” on their own while reducing the risk for injury? Planning in this way is harder than restraining patients, telling them repeatedly to “sit down”(we’ve all heard it) or placing an alarm, but it is better and more appropriate patient care.
        We don’t know better than patients what they want or need, and we will never eliminate falls entirely. In fact, the more independence you allow, the more falls you will have. Is the “safe” alternative- in which patients become depressed and immobile- a better one? Often times an increase in falls indicates that a person is nearing end-of-life. Do the falls cause their death, or are they signs that death is near? No one should die as the result of a painful, damaging fall with severe injury, but we can do more to prevent the incidence of such falls. On the other hand, in the last days of your life, would you rather fall trying to do something for yourself, or waste (safely) away?
        I know which option I will choose.

    • Beth_Boynton_RN_MS says:

      Infuriates me and breaks my heart too. Even knowing that we can’t prevent them all and never wanting to hurt or imprison someone with restraints. I think we could do better with more staff in some situations.

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  9. Jennifer says:

    I am an RN and I learned all about the “right to fall” when my Grandma was in the nursing home. A fall is what put her in the nursing home. After 3 falls in as many months I asked for a bed check. Grnadma didn’t want a bed check or anything else and that was her choice according to staff-because she was of “sound mind”. Yet she was medicated, and off the medication she was no where near with it. She died within two weeks of her last fall.
    The hospital I work for does a huddle after each patient fall. The huddle goes over what can be done to prevent falls. We have reduced the number of patient falls over the last two years-sorry I don’t have exact numbers.

    • Beth_Boynton_RN_MS says:

      Hi Jennifer. Sorry about your loss and your Grandma’s falls! Your hospitals “Huddle” routine s/p falls sounds very wise! I’m always one for having conversations to make improvements. Thanks for your comment. Beth

  10. Martine Ehrenclou says:

    Beth,
    Great post. You are so right–increase staffing to help prevent falls. Training staff to help minimize patient falls is key. Your possible reasons for falls are all spot on. Who wants their hospitalized loved on to fall?
    The right to fall? I don’t get that.

    • Beth_Boynton_RN_MS says:

      Thanks for your feedback, Martine. There is no realistic way to eliminate falls, but we do, I think have a responsibility to do what we can to minimize them.

What are your thoughts?