The nurse enters a client’s room and finds him lying on the floor. The client says to the nurse, “I fell because I was trying to go to the bathroom and no one answered my call light.” Which of the following actions by the nurse are correct?

  • assist the client back to bed
  • complete an incident report
  • notify the health care provider
  • assess the client for any injuries
  • document in the medical record that the client fell
Numbers 1, 2, 3, and 4 are correct.
When a client is found in the floor, the nurse should first assess the client for any injuries and then obtain help to assist the client back to the bed. The health care provider should be notified immediately, as the client may need an X-ray or CT to assess for fractures or internal injuries, especially if he hit his head. An incident report must be completed to comply with Joint Commission safety standards; client falls are monitored and facilities use this information to prevent similar incidents in the future. The nurse should not state in the medical record that the client fell, even if the client reports this, because the nurse did not witness the fall. The nurse would instead note that the client was found lying on the floor, followed by a narrative documenting the nurse’s interventions. Many falls can be prevented by ensuring that call lights are within reach and answered promptly, and that personal effects are close by. Confused clients may require a family member or sitter. All clients should be assessed for fall risk upon admission and wear a special “fall risk” bracelet to alert staff.