Just when I think we’re making progress, something happens that shows me we’ve got more work to do. I came back to work after the weekend and reviewed the 24 hour reports. I saw that on Friday night Hattie had another fall. Fortunately, she doesn’t have an injury. When I went to the health record to learn more, I saw that the night nurse put a tab alarm on Hattie and it’s been on ever since. Since Hattie broke her hip the last time she had a fall, I suppose the nurse put the alarm on because she is worried about another fall. However, I am not sure if that’s her reasoning because the documentation about what happened isn’t clear. I can’t find a root cause analysis form following the fall, and I don’t see any clear follow-up for Hattie based on this fall. I thought our systems were better than this! I guess I’m going to have to follow up to figure out what happened.
We review all falls at our Wednesday IDT meeting for this neighborhood. It looks like we have a lot of systems issues. How do I begin to sort out what to do next?