Safe and Quality Care includes Holism

Holism | AdlerPedia

Written by Professor Kirby

My Director of Nursing (DON) accepted Mr. W. as a scheduled admission to our skilled nursing facility on a Friday evening. She did not inform the nursing staff he was a high risk for falling or allocate additional staff to monitor this patient. When the nursing staff did receive reports from the hospital, they discovered he was a high fall risk. However, it was too late to discuss the plan of care for this potential admission or if he was an appropriate admission for our setting because the DON left for the day. Unfortunately, this patient was admitted on Friday and fell five times over the weekend.

Although, none of the falls resulted in an injury but the weekend staff was overwhelmed. They made multiple phone calls to the DON in reference to their inability to safely care for Mr. W. The DON informed the staff that she needed to fill the empty beds and as a result, she had to accept this high-risk admission. Then, she instructed the nursing supervisor not to document the resident’s incidents as falls, but a purposeful change in the plane. The nursing supervisor felt this was the wrong thing to do because the resident’s cognition was intact, and he had the ability to ambulate. Her assessment was that the patient clearly fell as a result of his hallucinations. However, she followed through as instructed.

This resident’s cognition was intact, and he had the ability to ambulate.  When the management team returned on Monday, we met with Mr. W. to discuss his plan of care.  He explained he knew when he was hallucinating.  He recognized some of his ideas were not the best choice, but he would proceed with them.  He continued to fall multiple times after the first weekend, and every morning management discussed his care or lack thereof because our staff patterns did not allow for one on one nursing staff to monitor Mr. W. and we’re a restraint free facility.  Therefore, Mr. W. was placed on every 15-minute checks ongoing daily.  Also, a new policy was implemented to perform checks every fifteen minutes on every new resident for the first week on night shift only.  These two interventions produced a safer environment for Mr. W. and future new admissions.


What could we have done differently to promote a safer environment at this skilled nursing home? Or better yet, how could holistic care been implemented? First, the DON view of the patient was number or census driven admission and not person driven admission. If the DON and the nursing team, seen Mr. W. as a person and considered his needs as a whole being fall prevention would have been a priority. They DON was not mindful of the patient’s needs. According to Philbrick (2015), mindfulness is purposefully focusing on or giving your attention to a specific person or thing. Mindfulness was not implemented initially for Mr. W. during the admission process. But, later, mindfulness became a routine part of everyone’s daily routine care to ensure Mr. W’s safety. Consequently, holistic values such as standards were not instinctively initiated by nursing. Dossey and Keegan (2016) defines holistic nursing as person-centered care which involves purposeful and attentive care which aligns with both the American Nurses Association and Relationship Based Care principals, as well. Initially we failed to establish a meaningful relationship with Mr. W., and he was a number on our census. Patient-centered and relationship-based care was developed much later. Unfortunately, it was a forced relationship due to the numerous incidents of falls. However, holistic nurses recognize the physical ailment of the disease as only one aspect of the human need and therefore, the nurse strives to meet both the seen and unseen needs of the patient. The art of caring for the whole person produces hope and gives a better an outlook on life.

References
Dossey, B. M., & Keegan, L. (2016). Holistic Nursing: A handbook for practice. (7th edition ed.). Burlington, MA: Jones and Bartlett Learning.

Philbrick, G. (2015). Using mindfulness to enhance nursing practice. Kai Tiaki Nursing New Zealand, 21(5), 32-33.

84 thoughts on “Safe and Quality Care includes Holism

  1. I have not experienced any problem like this but this was a horrible experience for the client. I feel very sad that he hve to go through this.

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  2. Wow! That was really awful . Although, none of the falls resulted into an injury but it should’ve been indicated on the resident’s medical records. They should have kept their integrity. This is really sad! hope other healthcare workers see this and make the difference.

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    • Weyatta, Thanks for your feedback. This was a trying time for the nurses and the patient (Mr. W.). The facility staff learned the hard way but my hope is every future hero in our class learn the easy way…..from this nursing staff’s mistakes 🙂 Mrs. Kirby

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  3. l think after finally receiving Mr W ‘s record from the hospital the nurse should have applied her critical thinking,plan and implement a wayor goal to prevent or minimise the falls,l also believe this was an unfortunate situation for Mr W as well as the nurse but l strongly feel she must have documented everything regardless.

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  4. I have experienced a similar kind of situation. In my opinion, the clients admitted to the facility regardless of medical record the nurses has to closely observe every 15mins to better know about the client and may have prevented the number of risks of falls.

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  5. In my opinion,after admission of new patients/clients besides following the careplan from their hospital medical records, every client/patient must be kept under observation that need to check every 15mins for few days in order to know better about the patients condition and thus can avoid risk of falls.

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  6. After getting all the reports and documents nurse should had plans to put the resident under monitoring for her shift, and should had document all the falls.

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    • True… but the staffing was inadequate to monitor the patient. Nevertheless, every 15-minute checks could have been implemented. However, neither the DON nor the nursing supervisor thought of this idea in the heat of the moment. A policy on frequent falls would have helped the nursing staff meet Mr.W’s needs and prevent falls. Absolutely, document, document, document…..”if it’s not documented, it was not done.”

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  7. Good Evening Professor Kirby, I have a question. What the DON did by ignoring the obvious fact that Mr.W needed extra help, and by asking the nursing supervisor not to document the falls, Does that pose an issue on ethics in the nursing profession? Also, would it be a factual statement to say that these sorts of things happen a lot of skilled nursing facilities?

    From the moment we start nursing school, it is stressed upon us the importance of documentation, for the continuity of care. A patient’s physical and mental wellbeing is placed in the hands of medical professionals who are supposed to protect him. I think it was unfortunate that Mr. W had to go through such an experience. It was unfortunate that the DON had to put a quota over the wellbeing of a patient and I think it was unfortunate that the Supervising nurse was put in such a situation.

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    • Miriam, Great Insight! Several things should have been done differently. Yes, admitting a patient without the proper tools to meet their needs is considered maleficence which is an ethical term that means harmful. Also, asking the nursing supervisor not to properly document the event is unprofessional, illegal, and unethical. Now, I am not in the business of making generalizations in regards to any setting, person, place, or entity. Occurrences of this nature may happen in any setting, it is my job to help the few future nurses entrusted to me but not make the same mistakes. Thanks for the great dialogue! Mrs. Kirby

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  8. This was a terrible incidence and should have never happened. For the DON to say “don’t document that” is completely wrong and totally unprofessional. It is wrong for Mr. W. To have fallen once, let alone five times! Thankfully he was not hurt but as a facility that is caring for patients , it is there job to ensure the safety and the well- being of that person. They should have implemented his plan of care as soon as he came to that facility and not be looked as a number. So sad!

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    • Caitlin,
      Thanks for your feedback. This situation was a frustrating one. As part apart of the management team, I heard both sides of the story. The staff complaints and administrations stress to keep heads in the bed. Nevertheless, I believe if the patient was the focus (or center) each side could have experienced less frustration.
      Mrs. Kirby

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  9. Personally, I’ve experienced many situations like this in my workplace. Specifically with getting a troublesome admission Friday night and feeling overwhelmed all weekend. I think that the staff should’ve implemented the Q15 checks with the patient sooner because that could’ve kept the patient safer and could have possibly stopped some falls. Secondly, they implemented some holistic care by talking about why he was doing what he was doing and trying to better understand it. Sometimes by sitting down and understand why the patient does what they do better allows us to implement holistic care.

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    • Bryanna,
      Thanks for your feedback. It is disheartening to hear this situation is a common practice for some facilities. It’s not good for staff morale and/or patient care. You are right! A few moments to find out more from the patient would have allowed the staff the opportunity to provide safe, individualized, holistic nursing care (like the q15 min checks).
      Mrs. Kirby

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  10. Hi Ms. Kirby. I find it a little shocking while reading this article that the DON was perfectly fine with allowing this patient to remain in a place that he was not going to be properly cared for based on his needs. I think it also poses a pretty significant issue that the nurse listened to the DON’s orders to not document properly. I have never experienced a scenario like this, but I would hope that it is not a common occurrence. Filling beds over providing the proper care for a client says volumes about the facility and its employees.

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    • Hi Annie,
      I will say it is more common in some facilities than others. The DON’s leadership was questionable and it a bad reflection on the facility. However, nurse should have spoken up and expressed her discomfort with falsifying records. This facility was a pretty nice place to work and was an isolated incident.
      Mrs. Kirby

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  11. Wow, I feel terrible this patient had to go through this. The DON even though has many responsibilities should have looked at the patient with a heart beat, and not just a number for her census. It is a shame that she did not give the staff proper information to perform the all around care he needed. Also, to change his care plan to cover her name is morally wrong, not to mention having the supervisor do it.

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    • Jaclyn, You brought up some great points! Ethics plays a huge part here. The DON’s cover-up and did the staff do the right thing (deontology) by listening to her. Also, why did no one anonymously report this to the state? Some ethical dilemmas are noted here.
      Great Catch!
      Mrs. Kirby

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  12. Unfortunately this is something that is done more often than anyone would like. People have to stop being looked at as a number or a bed to fill. More focus needs to be on whether a facility can properly care for the client and taking all of their needs into consideration when they are admitted so a proper plan of care can be made.

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    • Hello Deana,
      Spoken like a true nurse! I believe if our focus remains on patient-centered care, the patients will come and the beds will be filled. However, sometimes people have a hard time stepping back and seeing the big picture. They get preoccupied with the task which is one issue when there is a global issue to address. Like, why the census is low in the first place?

      Mrs. Kirby

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  13. Thankfully no injury on Mr.W . Documentation is key and cannot be left undone , how much of intentionally concealing it .Such an unprofessional, and unethical act from a leader ( DON) .Surprisingly , it didnt occur to her that she/the facility could face a huge issue with Mr.W family or state if it is discovered that such fall was undocumented.
    I was relieved to read that plan was put in after all, to monitor him .He really needed on-on -one monitoring ..
    Did the facility ever got him a therapy session with a psychologist?How was the unprofessional act from the DON addressed? Sadly , we might have the likes of this DON who would let “Quality care,Safety and Holism ” fly out of the window in a bid to fill up empty beds of residents we lost to COVID19 .
    I would love to read more from you .You have interesting blogs , Prof. Kirby .Kudos!!!

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    • Hi Chinwe,
      Thanks for your response. You have great insight. The DON was not reprimanded for this because the state (DOH) did not find out and the administrator was supporting her efforts to fill the bed. No documenting the falls was her way of making sure the state and family did not find out. His mental health was addressed by both a psychiatrist and a psychologist. They were able to stabilize the patient but nursing still needed to keep a close eye on him. Ultimately, the DON was covering her behind. This could be an ethical issue too. Should I or other staff members report this to DOH?
      Mrs. Kirby

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      • No need this run across to DOH yet , not until this issue has been brought up be /addressed at Weekly Nursing Dept/care meeting because concealing and not documenting will be seen as a fraudulent act .

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  14. Holistic care could have been implemented by nurse staff working with the Mr. W
    and agreeing to a care plan that lead to his recovery.
    Nursing staff should follow a fall prevention protocol to ensure the safety and well being of the client.
    The DON could have communicated better with the nurse staff about Mr W fall risk.

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    • Hi Tamara,
      Thanks for your response. You are correct there are a number of things that should have been done differently to have a better outcome for the patient and staff. However, because a holistic patient-centered care plan was implemented this situation occurred.
      Mrs. Kirby

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  15. For starters, I thought this was just a made up scenario. This makes me very sad to learn otherwise. This is a failure all around at the cost of the patient. He may not have been physically hurt but fall after fall, especially to an older patient, can definitely bruise the ego and have lasting effects. I’ll be honest, if my DON told me to do something that I knew was wrong, I might have done it as well. It’s hard to go against what your supervisor is telling you to do!

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    • Jenel, Thanks for your honesty, and at the end of the day personalities vary. Therefore, responses will vary, too. Easy after the fact to say I would have done better in this situation, but who really knows what they would have done as the nurse. I can imagine she was tired, frustrated, and now, concerned if she defies a directive she may be punished by the DON. Yes, sadly this is a true story and I have many others, too.

      Mrs. Kirby

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  16. This was unfortunate situation for Mr. W. One I have seen at the facility I work at. The people who are not direct care workers don’t understand that we talking about people and their safety not numbers or dollar signs. As for the nurse who was told by her DON, not to document Mr. W. falling. All I can do is shake my head. I would like to think that if I was in that situation I would do something about this situation. It is just unacceptable. They are very lucky that Mr.W. was not severely injured during one his falls.

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    • Hi Ilyse,
      Thanks for your feedback. You are correct sometimes administration is not fully aware of the day to day needs of the staff and residents. However, know this is not everywhere. There are many great leaders and healthcare systems that value both their patients and staff.
      Mrs. Kirby

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  17. The director of nursing should have notified them that he was an at risk fall patient. The way the nursing staff acted was unethical and they should always be documenting falls even if there was not injury.

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  18. Hi Mrs. Kirby,
    I cannot believe how negligent the DON was with accepting the admission with no initial communication whatsoever to the nursing team. Though there was no injury, the DON has failed the patient and in my opinion is partly to blame for the patient’s falls. Furthermore, the DON is setting the nursing team up for failure by instructing them not to document the patient’s falls. I feel that this could have all been prevented with proper communication from all members of the team, starting with the DON.

    Caitlin

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  19. Mr. W had very unfortunate circumstances. It all started with the director of nursing (who you would think would be on top of things like this) did not put in his documentation as a high risk for a fall. That’s very dangerous and this happens in real life as well – because of that charting mistake, he has fallen 5 times since then over the weekend. Also, deciding not to document the falls even though it did not result in any injuries, is against the law and the facility could be sewed or shut down because of this. holistic care emphasizes the partnership between nurse and patient and the negotiation of healthcare needs that lead to recovery. None of this was happening for Mr. W and they were more concerned about leaving things out of documenting so they would not get in trouble. Fall prevention for Mr. W would have been a priority to the nurses if they did their job correctly. Later on is when they applied these steps to secure Mr.W’s safety because of the past incidents. To promote safer ways for patients like Mr.W in the future they need to document everything correctly when admitting the patient to the facility.

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    • Hi Breiana, this is a true story. You make some great points! Instead of focusing energy on covering their track the DON and nursing staff focus should have been on Mr. W. and providing patient-centered care. The energy exerted would have been more productively used by developing a holistic plan, and treating his hallucinations. Mrs. Kirby

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  20. I thought this was a fake article at first, because this is a very sad and unfortunate situation for anyone to go through let alone for Mr. W. I hope that this hospital has gotten better with dealing with such situations, if not they should definitely get repercussions, because what Mr. W went through is unacceptable in the healthcare field.

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  21. This is a good example of showing failed patient care and poorly management in health care facility. Management putting their attention on fill empty beds instead of focus on provide holistic care to patients. I think Mr.W (the victim) should take legal action immediately. DON who is mentioned in this article should get fired right away and receive penalty by completely neglect patients safety. In this case it also showing me the Swiss cheese effect i think a way of closing holes is communication and action. When the nurse reached out to DON and realized things are done wrong she should approach to the management team so they could make a difference.When we talk about a Holism – or a Holistic approach to health- this is referencing the idea that our physical, mental and spiritual systems are viewed as wholes, It emphasizes the entire individual. its so sad to see things like that keep happening. I hope all of us when we out there as nurses make a positive impact in Health care.

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    • Hi Dian, You rule with an iron rod! But, I agreed there should have been some consequences to the neglectful action of the DON. Holistic nursing was an afterthought for this patient when it should have been a primary thought. I love our optimistic outlook to make a difference as a future hero!

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  22. Unfortunately, I have dealt with similar situations where poor communication and a lack of knowledge result in a lack of preparedness by the nursing team when it comes to new admissions. Sometimes that means that the tools and interventions just aren’t in place for clients and that puts both the clients and the staff in danger, depending on the situation. Luckily in this situation Mr. W. did not get seriously injured but that could have happened very easily and the whole situation could have been avoided if the DON hadn’t just seen another bed filled and instead had looked at him as a person with his own unique needs.

    I feel disgusted by the DON’s actions in regard to viewing the client simply as a number, and unfortunately I know these types of people are out there, but also in the way that they dismissed the concerns of the nursing staff and ordered them to cover up what was actually happening. I feel like the supervisor should have stuck with her original assessment. While that may put her job at risk with this DON doing otherwise puts her license at risk and the client at risk with partial or inaccurate information documented.

    By communicating with Mr. W., getting to know him, and working with him a solution arose to help mitigate the risk of him falling. This intervention also sounds like it is one that has benefited other clients and changed how the nursing team looked at things.

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    • Hi Danielle, You are correct the policy that was implemented prevented this situation from reoccurring. However, the DON acted irresponsibly and jeopardized the safety of the patient. A few extra moments with the patient would have revealed his compromised mental state and prompted a closer watch. Mrs. Kirby

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  23. I have worked at a facility in Jersey just like this facility in the article and It was horrible. First off I want to say the communication within this facility is poor. The DON knew the patient was a fall risk and did not inform the nursing staff members about the patients information. I also think not documenting Mr.W falls was also not right because that’s one of the first things you learn in Nursing school is to document everything or it did not happen. Thank god Mr.W was not severely injured because that would have made the situation even worst. The nursing staff should have implemented a care plan based upon Mr.W as a whole and unfortunately they failed to do so.
    Deanna Glover

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  24. I kept thinking to myself why didn’t the DON tell her fellow nurses that he was high risk for falling. She needs to communicate with her team. It was poor on her part to not communicate to her team, it just goes to show that she does not care about the safety of her patients.

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    • Hi Taylor, I don’t know if she did not care about her patients or if she was overwhelmed herself. Not to make any excuses for her behavior but sometimes people do not want to face the issues. It’s easy to ignore problems, and harder to face them.
      Mrs. Kirby

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  25. It is sad when someone like this DON, who’s is suppose to make sure all clients receive quality care starts to clients more like a quota to fill. She has failed on so many levels. She didn’t tell her staff about the high risk for the new patient. Leaving staff who were not adequately prepared or able to care for him, but to not provide the quality of care he deserves. For her to tell the charge nurse not to document his falls is negligent on her part and also on the charge nurse for following. This leaves staff overwhelmed, the new patient not receiving the care he needs and other patients also receiving less than adequate care as well. I feel very blessed to not have ever experienced this, and saddened to know this can happen.

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  26. While no injury occurred, integrity is what we are known for as nurses. We are held at a high standard to always be honest no matter what. I think the DON sets a tone for the entire staff and it creates a very unsafe work environment for clients and employees. Documentation must be done no matter what happens because that is what is expected. Trying to brush something under the rug because you were just trying to keep a high census is not the right thing to do. Maybe that is why the facilities census is low in the first place… the care is not of good quality?

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  27. Hello Mrs. Kirby, this was an extremely frustrating situation to read about. This patient deserved better care and to have a plan of care set in place from the beginning. I believe that the DON was one hundred percent in the wrong for covering up what happened. Also, the staff played a big part in the cover up and should have never went along with the DON. I understand it’s a hard situation considering the DON is their superior but I would like to think that if i were in the staff I would stand up and say something.

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  28. Hi Mrs. Kirby! This situation is awful, my jaw dropped when I read the DON told the staff not to document falls, that’s so unprofessional and even though his falls didn’t cause injury, they very well could have. I’m really glad the new policy was implemented for 15-minute checks on new admissions.

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  29. This blog post highlighted how important patient-centered care truly is. When Mr. W was just another number on the census, the nursing facility failed to enact policies that would not only help Mr. W, but future patients as well. Once they gave Mr. W his identity back and focused on holistic values, they were able to focus on his immediate needs.

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  30. I think it is wrong that the Director of Nursing, informed her nursing staff to NOT document the clients fall. I believe this is absolutely wrong and the DON should be reported and punished. It is our job to report everything to ensure the present and future safety of all clients and that was taken away from this client. The DON is supposed to lead by example correctly, and she let her self and her staff down.

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  31. I’m sad to read this, but unfortunately not surprised. In recent months I have had to write up two individuals for dereliction of duty, which includes not only an unsafe environment for the clients, but lack of performance. Mr. W was never treated as a whole person. I understand the ethical dilemma of the woman who she asked not to document. It is easy to say that we as individuals would never make that decision. However, until it is encountered. For myself, I had deliberated when the lack of completing tasks was the only issue at work. Once safety became the issue, it was no longer a dilemma.
    The DON treated this situation as a business rather than a person-centered. Unfortunately no consequences will be had as nothing was reported so this may wind up not being the only time this ever happens. I do hope that is not the case.

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  32. Its a shame they accepted him as a patient because it seems like they clearly didn’t have the right care for him at first and to me it seems like they did it to just fill the bed and I took that as basically doing it for the money. One question I do have is what is a purposeful change in plane mean? And I agree with the nursing supervisor that it was wrong not to document the incidents as falls.

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    • Hi Natalie, Thanks for your post. I forgot your name on the list. However, thank you for your diligence. Great question no one asked about this term and I am certain others did not know this term. Change in-plane is a term used in healthcare to indicate purposeful movement from a higher surface to a lower surface. For example, some people like to sleep on the floor and may have always sleep on the floor. However, in a facility, we must give them a bed. This patient may move from the bed to the floor purposefully out of habit and preference. This must be a care plan for this preference.

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  33. First the DON should have had an internal meeting with the staff and let them know the census was very low and they may need to take in more high risk clients.
    Than the DON should have let the staff know about the incoming high fall risk patient before she left for the day. She should have made sure sh had the proper staff lined up or at least more assistive devices ready incase the high fall risk patient needed it.
    Once the staff got report they should have made the proper adjustments to staffing schedule to provide more assistive staff to help monitor the patient.
    After the patient fell the nurse should have documented it and try to put in preventative measure like a fall mat make sure his bed is in the lowest position at all times, make sure call bed, remote and phone is within reach and do 15 min rounding!

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  34. Reading this makes me wonder if people get into the nursing field for money instead of patient care. Yes, he wasn’t the nurse on shift taking care of Mr. W but he should have seen/ been on call and listen to what the nurses were saying. Mr. W was clearly miss treated and that’s unfair to him. he should have had had the right precautions placed right away, or because the DON had left there should have been some type of care in place that he should have been helped while he needed to get up. nurses I know have a lot on their plate, but when it comes to falls Mr. W could have hit his head on the fall or broken bones. He should have gotten extra attention even though yes, the plate is full already but maybe a CNA could have been there to monitor. every 15 minute checks seems like okay yeah it could help but what if he decided to get up 5 minutes after his check and he falls and gets hurt. who’s fault is it? filling beds shouldn’t be priority its patients care who comes first and his needs. I’m sad that things like this happens. for the DON to have the nerve to say “Don’t document that” blows my mind. that is not okay. I hope they got fired.
    Thank you for the Blog. its an eye opener

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    • Thank you Miranda for your passionate response. She did not get fired (sad to say). And, yes I agree she had some audacity to make such a request of her nurses. I would never ask someone to break the law. This is immoral and definitely an eye-opener.
      Mrs. Kirby

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  35. My jaw dropped when I read that Mr. W fell numerous times while under care. The nursing supervisor shouldn’t have followed through on orders she knew were completely wrong. This instance of obedience reminds me of a movie I recently watched called “Experimenter” where a psychologist conducted a series of behavior experiments that tested ordinary humans’ willingness to obey authority even if it involved hurting another person. This psychologist found that 65% of participants willingly proceeded to cause “harm” just because they had been commanded to do so by an authority figure.

    I’m glad Mr. W did not have any injury at that time but I’m concerned if Mr. W would have future complications resulting from these falls that could’ve been prevented. The nursing staff should’ve assessed Mr. W’s condition and set in place the 15 minute checks as soon as he arrived at the facility; if available a TeleSitter could’ve been implemented for Mr. W to aide in preventing falls alerting the nursing staff before Mr. W’s attempts to get out of bed.

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  36. After reading this article about the way Mr. W was treated, i felt really bad. As a head of a facility, it is your job to make sure that every resident that comes to your place be safe from any harm or danger. Since the DON knew about the resident being a fall at risk and he didn’t put any kind of safety rule down so that the nurses can prevent the resident from falling, he should be fire immediately. From the comment he made about trying to fill all the empty bed was not professional. The DON even when far by telling the nurses to not document the fall but make in a way so that it can be change in condition. I believe in karma, so what goes around will definitely comes back around. It’s sad to see how some of these residents are treated and some of their family members don’t even care as well so facilities just do whatever to them when it comes to their well being. There should always be a plan for residents who are at high risk for fall or anything related to patient safety.

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  37. Thank you for sharing this story, it is very helpful for my future experience as a medical worker. This story is really sad because each fall could have deplorable end.
    It is understandable that everything can happen, people are not robots that can function without system failure. In this case “plan A” was failed – DON forget to inform weekend nursing team about “patient high risk falling”, so “plan B” had to be in effect. It could include: facility regulations, temporarily followed previous hospital plan of care, or simply use critical thinking.
    But i wouldn’t put all responsibility on weekend staff. DON had to pick up phone on urgent calls. All high rank hospital, or health care facilities employees have urgent lines that have to be answered promptly

    Liubov Popelnytska

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  38. I feel the situation is very awful ! I work in this type of setting. I think coming from the hospital the nurse should’ve got a complete assessment on Mr.W and for staff to monitor him every 15 minutes to assure his safety. Its wrong for the DON to not document and for her to just want to fill the beds for census purposes.

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  39. The staff should have found out Mr. W was a fall risk sooner and checked up on the patient more often. The nurse should have documented the patients falls, and they should have also checked up on the patients physiological needs, which is apart of Maslow’s Hierarchy of needs.

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  40. I am so grateful that I have not witness this or know anyone in my personal life that has. But, with that being said this is a terrible to put a patient through. The violations that this facility went against were a disgrace. The thought of all the caregivers Mr.W came in contact with that went along with it is sad. I wish the company had a better understanding and help with staff for the high risk patient to help them with a better care setting at all times.

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  41. I don’t know if its my place to say but I believe the D.O.N of Nursing should have adequately prepared his staff for the admission of Mr.W. Although Mr. W did not sustain any injury’s from his falls he still was neglected by the nursing staff to an extent. When the DON of nurse told her staff to not report the falls as falls but as “purposeful change in the plane” I believe that was unethical. She should have ordered her nurses to record the correct thing instead of changing it up. I also believe that after the patient sustained the initial 5 falls at the facility an immediate nursing intervention should have been made. Its situations like these that could potentially grow into a law suit. I must say though I am happy that Mr.W turned out okay and I hope incidents like these do not occur any more at this facility.

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  42. Wow. I have never been in this situation, there should have been observation of this new patient every 15 min. This also should have been documented.

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