Question

When responding to the call bell, the nurse finds the client lying on the floor. After a thorough assessment and appropriate care, the nurse completes an incident report. What information should be included?

A. The client fell out of bed.
B. The client climbed over the side rails.
C. The client was found lying on the floor.
D. The client was restless and got out of bed.

Answer 1

An incident report after a patient fall should include specific information such as the time and location of the fall, client condition when found, potential reasons for the fall, medical care provided, and notifications made. It should be factual and concisely detail the event and the nursing team's response.

Step-by-step explanation:

When completing an incident report after a client has fallen, it is critical to include specific, factual information about the circumstances and aftermath of the incident. The report should detail the events leading up to the fall, how the client was found, the time of the incident, the actions taken by the nursing staff in response, any injuries sustained by the client, and interventions put in place to prevent future incidents.

An effective incident report might include something like:

• The time and location the client was found on the floor.
• Observations about the client's condition at the time, such as any visible injuries or level of consciousness.
• Statements or evidence suggesting how the fall might have occurred, like whether the client attempted to climb over the bed rails, or whether they were restless and might have attempted to get out of bed.
• Any immediate medical care provided to the client.
• How and when the healthcare team was notified, including documentation and communication with the client's family and healthcare providers.

The goal in writing the incident report is to ensure a clear record that can be used to prevent future falls, and improve client safety protocols.