The reason for the unwitnessed fall and seizure is the nurse's fault because the nurse did not get the medication to the patient or let anyone else know the medication was not available. To measure the outcome of a fall, many facilities classify falls using a standardized system. He was awake and able to answer questions in regard to the fall, I took vitals, gave him a full body assessment, and FOUND out that he was just trying to get up out of bed and his legs gave out. 2 0 obj 1. I was TOLD DONT EVER EVER write the word FOUND.I was written up for thatout of all the facilities I have worked in since I graduated this facility was the only one that said that was wrong. It is estimated that fall death rates in the U.S. have increased 30% from 2007 to 2016. No head injury nothing like that. Choosing a specialty can be a daunting task and we made it easier. she suffered an unwitnessed fall: a. How do we do it, you wonder? %PDF-1.5 3. After the patient returns to bed, perform frequent neurologic and vital sign checks, including orthostatic vital signs. unwitnessed falls) are all at risk. Call for assistance. Depending on cause of fall restraint might be instituted such as a lap belt on wheelchair , or 4 side rails up on bed. Before moving the patient, ask him what he thinks caused the fall and assess any associated symptoms. Call is placed to doctor who is then informed of incident, informed on what steps have been taken so far. This study guide will help you focus your time on what's most important. . Analysis. If staff fear negative responses from their supervisors, they will not be willing to report near misses or clues that might reflect a staff error. I spied with my little eye..Sounds like they are kooky. 0000000833 00000 n [NICE's clinical knowledge summary on falls risk assessment], checks by healthcare professionals for signs or symptoms of fracture and potential for spinal injury before the patient is moved, safe manual handling methods for patients with signs or symptoms of fracture or potential for spinal injury (community hospitals and mental health units without the necessary equipment or staff expertise may be able to achieve this in collaboration with emergency services), frequency and duration of neurological observations for all patients where head injury has occurred or cannot be excluded (for example, unwitnessed falls) based on the NICE guideline on head injury. 25 March 2015 Be aware of the following warning signs: numbness or tingling in the extremities, back pain, rib pain, or an externally rotated or shortened leg. Reference to the fall should be clearly documented in the nurse's note. Be sure to note the patient's thoughts about the cause of the fall and associated symptoms, and whether the patient lost consciousness. A written full description of all external fall circumstances at the time of the incident is critical. Program Goal and Background. %PDF-1.5 The unwitnessed ratio increased during the night. Provide analgesia if required and not contraindicated. 5600 Fishers Lane Notify the treating medical provider at the time of the incident, and schedule an interdisciplinary review of the patient's care. 2 0 obj Arrange further tests as indicated, such as blood sugar levels, x rays, ECG, and CT scan. Patient is either placed into bed or in wheelchair. Patient found sitting on floor near left side of bed when this nurse entered room. Develop plan of care. An immediate response should help to reduce fall risk until more comprehensive care planning occurs. Specializes in LTC/Rehab, Med Surg, Home Care. * Check the central nervous system for sensation and movement in the lower extremities. Notice of Privacy Practices Nurse managers should be non-blaming and skilled in problem-solving with frontline staff. In the FMP, these factors are part of the Living Space Inspection. AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. What are you waiting for?, Follow us onFacebook or Share this article. 4 Articles; % The distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred. Resident #1 (R1) sustained a right orbital fracture from an unwitnessed fall. Microsoft Word - Post-Fall Algorithm 2014 Author: gwp0 Created Date: 9/3/2014 11:09:21 AM . (Figure 1). AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. We inform the DON, fill out a state incident report, and an internal incident report. Assess immediate danger to all involved. Simulation video: unwitnessed fall 1) What are signs and symptoms that place patients on fall precautions and what made this patient have them ordered. Abstract Objectives: To assess the agreement between falls as recorded in the Minimum Data Set (MDS) and fall events abstracted from chart documentation of elderly nursing home (NH) residents. Level 3 Fall Select Unwitnessed fall in section Fall Details Also select Dementia/cognitive impairment in Risk factors for falls - behaviour/mental state/cognition 8 Consumer who is cognitively intact and IS a reliable historian, is found sitting on floor. The number of falls that occurred every 3 h decreased between 15.01 hours and 18.00 hours and increased around 0.00 hours. . <> Monitor staff compliance and resident response. * Note any pain and points of tenderness. * Check the skin for pallor, trauma, circulation, abrasion, bruising, and sensation. Failure to complete a thorough assessment can lead to missed . The form should next be checked by the Falls Nurse Coordinator or director of nursing and any missing information such as emergency room visits, hospital admissions, x-ray results or additional medical tests added at a later time. A practical scale. Step two: notification and communication. Who cares what word you use? Step one: assessment. Just as a heads up. * Assess the current level of consciousness and determine whether the patient has had a loss of consciousness. (\JGk w&EC dE*9`iXAuz.y0$@fw '\PsJ4\CBQdn.`}4EP$"G$mJb_tc?JM|rIhKm5cRt-! Record circumstances, resident outcome and staff response. He eased himself easily onto the floor when he knew he couldnt support his own weight. Revolutionise patient and elderly care with AI. Physiotherapy post fall documentation proforma 29 Forms and Training Materials (Appendix Contents), Appendix C. Case Study and Program Examples, U.S. Department of Health & Human Services. Automatic faxes are used to communicate with the resident's physician, nurse practitioner or physician's assistant. <>>> Specializes in NICU, PICU, Transport, L&D, Hospice. Physiotherapy post fall documentation proforma 29 Nurses Notes: Guidelines On What Not To Chart, Baby Boomers and Hepatitis C: High-Risk Group with Low Rate of Testing, How the patient was discovered and all known. Environment and Equipment Safety, Appendix A. References and Equipment Sources, Appendix B. This includes creating monthly incident reports to ensure quality governance. Post Fall Assessment for a Head Injury Here's what should be done by a nurse in the assessment of a patient who has fallen, hit her head or had an unwitnessed fall. Activate appropriate emergency response team if required. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> | Specializes in psych. Receive occasional news, product announcements and notification from SmartPeep. Specializes in Gerontology, Med surg, Home Health. Facilities have different policies regarding falls, incidents, etc and how its to be documented and who is to be notified. Moreover, caregivers cant monitor residents at all times to accurately depict how each fall happened. Last updated: All this was documented but the REAL COMPLAINT on my note was the word "FOUND" so being the State was coming in soon, this kind of twisted their gonads a bit and they were super upset. When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. Usually, the resident is charted on at least once a shift for 72 hours, noting if the resident is having any continuing problems r/t the fall, pain, pain control measures, wounds, etc. 0000013935 00000 n g" r Protective clothing (helmets, wrist guards, hip protectors). Program Standard: Agency will have a fall program in place that includes: Incident Reporting and Documentation Policy A validated fall risk assessment Identification and stratification (Identify patient-centered goals . Content last reviewed January 2013. Or better yet, what happens if an elderly is unable to accurately explain the causes of their fall due to diseases such as dementia? Then conduct a comprehensive assessment, including the following: * Check the vital signs and the apical and radial pulses. I don't remember the common protocols anymore. 402-559-4000|Contact Us, 2021 University of Nebraska Medical Center, University Computer Use Policy After a fall in the hospital. unwitnessed fall documentation example. allnurses is a Nursing Career & Support site for Nurses and Students. Record neurologic observations, including Glasgow Coma Scale. Was that the issue here for the reprimand? The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake. endobj Implement immediate intervention within first 24 hours. Wake the resident up to Has 12 years experience. Thus, this also means that unwitnessed falls will no longer go undocumented and care staff wont have to crosscheck with each caregiver to find out the cause of the falls, saving up to 80% of caregivers time in performing an incident investigation. Which fall prevention practices do you want to use? Initially, vitals are taken, and if it's suspected (or confirmed) that the pt. And decided to do it for himself. Agency for Healthcare Research and Quality, Rockville, MD. Sit back, let us do the work for you, and allow your residential care facility to become the leading care provider of the nation. unwitnessed incidents. Everyone sees an accident differently. endobj I also chart any observable cues (or clues) that could explain the situation. % Whether it's written on the patient's chart or entered in the hospital's electronic medical record, documentation for a fall should include. Data source: Local data collection. Safe footwear is an example of an intervention often found on a care plan. B]exh}43yGTzBi.taSO+T$ # D w>yy#GO3z(,Vm$[aBFj5!M_TMPf(.>nT['as:&U)#[\z0ZW74{_,JG:wVR!` *J92XfU,h} | As per Australias National Aged Care Mandatory Quality Indicator Program layout, all fall incidents must be recorded. (a) Level of harm caused by falls in hospital in people aged 65 and over. Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Immediate evaluation by the nurse after a resident falls should include a review of the resident systems and description of injuries. When a fall happens, we fill out a form (computerized), notify the family of the resident and the resident's doctor. Specializes in Geriatric/Sub Acute, Home Care. More information on step 6 appears in Chapter 4. Observe for signs indicating stroke, change in consciousness, headache, amnesia, or vomiting. endobj We have the charge RN do an assessment, if head injury is suspected we do neuro checks (usually q15min x 1 hour, q 30 min x 2 hours, q 1 hour x 2 hours, q 2 hours x 4, q 4 hours x 4, q 8 hours x 4), we chart on the pt q shift x 3 days. unwitnessed fall documentationlist of alberta feedlots. At handover, inform all clinical team members about the incident, any changes to the care plan, and possible investigation process. If it was that big of a deal, they should have had you rewrite the note or better yet, you should have been informed during your orientation. In addition, there may be late manifestations of head injury after 24 hours. Assist patient to move using safe handling practices. They didn't think it was such a big deal.the word FOUND, was fine, so is the word, OBSERVED. An 80 year-old male was transported by ambulance to the emergency department (ED) for evaluation after experiencing an unwitnessed fall in a local nursing home. Be certain to inform all staff in the patient's area or unit. These Medical Lawyers seem to picky on word play and instill more things into a already exploding basket of proper legal terms that dont SOUND like this happened or that happening. When a resident falls who has already been entered into the FMP, the nurse should send a FAX Alert to the primary care provider. Rolled or fell out of low bed onto mat or floor. First notify charge nurse, assessment for injury is done on the patient. Most facilities also require that an incident report be completed for quality improvement, risk management, and peer review. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. 0000014676 00000 n the incident report and your nsg notes. Each shift, the nurse should record in the medical record a review of systems, noting any worsening or improvement of symptoms as well as the treatment provided. Documentation in the chart should clearly state: Incident reports are generated but are never part of the patient's chart and mention is never made in the nursing documentation in the chart that an incident report was made. Checks for injury should be included in a post-fall protocol that is followed for all older people who fall during a hospital stay. Get baseline vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and hydration). Early signs of deterioration are fluctuating behaviours (increased agitation, . Increased assistance targeted for specific high-risk times. (Full citation: Jevon P. Neurological assessment part 4Glasgow Coma Scale 2. 2023 Wolters Kluwer Health, Inc. and/or its subsidiaries. Postural blood pressure and apical heart rate. The Fall Interventions Plan should include this level of detail. This is basic standard operating procedure in all LTC facilities I know. To sign up for updates or to access your subscriberpreferences, please enter your email address below. w !1AQaq"2B #3Rbr Thus, this also means that unwitnessed falls will no longer go undocumented and care staff won't have to crosscheck with each caregiver to find out the cause of the falls, saving up to 80% of caregivers' time in performing an incident investigation. Developing the FMP team. A copy of this 3-page fax is in Appendix B. 0000105028 00000 n 5600 Fishers Lane Has 40 years experience. They are "found on the floor"lol. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html. Now, that I was interviewed for another nursing job recently, I ASKED them what word is proper documentation when writing on a fall. } !1AQa"q2#BR$3br MD and family updated? Even when a resident is found on the floor after an unwitnessed fall, direct care staff can use their experience and knowledge of the resident to make educated guesses based on the evidence. Increased monitoring using sensor devices or alarms. These symptoms suggest spinal cord injury, leg or pelvic fracture, or head injury. Section A includes basic resident information, methods for documentation in the medical record and notification of the primary care provider and family. Equipment in rooms and hallways that gets in the way. A program's success or failure can only be determined if staff actually implement the recommended interventions. Has 8 years experience. All of this might sound confusing, but fret not, were here to guide you through it! %PDF-1.7 % 199 0 obj <> endobj xref 199 22 0000000016 00000 n . Data Collection and Analysis Using TRIPS, Chapter 5. | https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/postfall-assessment.html. Fall Response. A history of falls. Specializes in Geriatric/Sub Acute, Home Care. You follow your facility's P&P for falls, with all the ballyhoo assessments, notifications & paperwork, incl. Content last reviewed December 2017. with variable performance around neurological assessments after an unwitnessed fall or a fall where the patient's head was struck. This video is one in a series of nursing simulation scenarios created to educate nursing students and refresh new practicing nurses about situations they cou. Any orders that were given have been carried out and patient's response to them. Connect with us on Facebook, Twitter, Linkedin, YouTube, Pinterest, and Instagram. Continue observations at least every 4 hours for 24 hours, then as required. trailer<<0c87cf0cbbf7ae766c1a82591f1e61f4>] >> startxref 0 %%EOF 200 0 obj <> endobj 220 0 obj <. 3. . - Documentation was not sufficient; the post fall documentation was missing from the health record and there was no . The one thing I try most intensely to include any explanatory statement by the pt, verbatim, if poss. Commissioners (clinical commissioning groups and NHS England) ensure that they commission services from providers that have a post-fall protocol that includes undertaking checks for signs or symptoms of fracture and potential for spinal injury before moving an older person who has fallen. I was just giving the quickie answer with my first post :). Any one of your starting entries seem basically OK with me, but soooo much, much, much more documentation is necessary. Typical fall documentation at a nursing home in my area (Central OK): Nurse assesses fallen resident for injury and provides appropriate care. One-third of the witnessed falls were observed between 12.01 hours and 15.00 hours. Specializes in Med nurse in med-surg., float, HH, and PDN. Any injuries? After talking with the involved direct care staff, the nurse is asked to use his/her experience and knowledge of the resident to piece together clues so that "unknown" is used sparingly, if at all. I am an RPN and I assess for injury, fill out an incident report, let the family know and do a focus note on the computer and report sheet for the next shift. If head trauma is known or suspected, neuro checks are done and documented per the facility's protocol (usually q15min x 1 hour, q 30 min x 2 hours, q 1 hour x 2 hours, q 2 hours x 4, q 4 hours x 4, q 8 hours x 4. I would also put in a notice to therapy to screen them for safety or positioning devices. LTC responsewe do all of the above mentioned, but also with all of our incident reports we make a copy and give it to therapy, don, adm, social service and dietary. the incident report and your nsg notes. Agency for Healthcare Research and Quality, Rockville, MD. . rehab nursing, float pool. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 792 612] /Contents 5 0 R/Group<>/Tabs/S>> 2,043 Posts. Source guidance. Next, the caregiver should call for help. A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other . Continue observations at least every 4 hours for 24 hours or as required. More information on step 7 appears in Chapter 4. Before moving the patient, ask him what he thinks caused the fall and assess any associated symptoms. The post-fall assessment documentation audit reviews whether staff are appropriately documenting and compliant with post-fall assessment requirements. As far as notifications.family must be called. 0000104683 00000 n Immediate follow-up will help identify the cause and enable staff to initiate preventative measures. The interventions listed on this form are grouped in the same five risk areas used for the Falls Assessment. Thought it was very strange. Sign in, November 2007, Volume :107 Number 11 , page - [Free], Join NursingCenter to get uninterrupted access to this Article. Proportion of falls by older people during a hospital stay where the person is checked for signs or symptoms of fracture and potential for spinal injury before they are moved. Investigate fall circumstances. Past history of a fall is the single best predictor of future falls. Published: Then, notification of the patient's family and nursing managers. stream Therefore, the percentage of elderlies who have experienced falling once or more, and the percentage of senior residents who have suffered from major injuries due to their falls must be recorded and submitted into the My Aged Care provider portal. ?W+]\WWNCgaXV}}gUrcSE&=t&+sP? When investigation of the fall circumstances is thorough, it is usually clear what immediate action is necessary. molar enthalpy of combustion of methanol. Being weak from illness or surgery. US Department of Veterans Affairs Post-Fall Procedures/Management: The VA National Center for Patient Safety Falls Toolkit policy document offers an example Post-Fall Management protocol (see Section VII and Attachment 3) and differentiates follow-up for patients with and without head trauma. Implement immediate intervention within first 24 hours. In section B there are questions related to 1) circumstances, 2) staff response and 3) resident and care outcomes. 0000104446 00000 n Resident response must also be monitored to determine if an intervention is successful. More information on step 8 appears in Chapter 4. Such communication is essential to preventing a second fall. The Fall Interventions Plan should be used by the Falls Nurse Coordinator as a worksheet and to record the final interventions selected for the resident. 4 0 obj <> [Adapted from the National Patient Safety Agency's rapid response report on essential care after an inpatient fall, recommendations 1 and 2, and expert consensus], Quality statement 1: Identifying people at risk of falling, Quality statement 2: Multifactorial risk assessment for older people at risk of falling, Quality statement 3: Multifactorial intervention, Quality statement 4: Checks for injury after an inpatient fall, Quality statement 5: Safe manual handling after an inpatient fall, Quality statement 6: Medical examination after an inpatient fall, Quality statement 7: Multifactorial risk assessment for older people presenting for medical attention, Quality statement 8: Strength and balance training, Quality statement 9: Home hazard assessment and interventions, What the quality statement means for different audiences, Definitions of terms used in this quality statement, Royal College of Physicians (2012) Report of the 2011 inpatient falls pilot audit, National Patient Safety Agency. Appendix 1: WA Post Fall Guidelines: Definitions and explanatory notes 21 Appendix 2.1: Occupational therapy supporting information 23 Appendix 2.2: Occupational therapy sticker for patient's health care record 27 Appendix 3.1: Physiotherapy post fall guidelines cue card 28 Appendix 3.2. We do a 3-day fall follow up, which includes pain assessment and vitals each shift. Quality standard [QS86] endobj Has 2 years experience. 0000001288 00000 n After reviewing the "Unwitnessed Fall' video respond to the following questions with a minimum of 200 words but no more than 300. Reference: Adapted from the South Australia Health Fall Prevention Toolkit. Follow your facility's policy. ' .)10. Arrange further tests as indicated, such as blood sugar levels and x rays. (have to graduate first!). This study guide will help you focus your time on what's most important. While the falls care plan may include potentially effective interventions, it is staff compliance that will reduce fall risk. 3 0 obj <> He has been told repeatly to use the call bell( and you know the elderly they want to remain independent or dont want to wait as most of us wouldnt. Specializes in Med nurse in med-surg., float, HH, and PDN. R1 stated that the morning shift staff observed R1 with blood on their face, and immediately rendered medical aid and dialed 9-1-1. Is the fall considered accidental (extrinsic), anticipated physiologic (intrinsic), or unanticipated physiologic (unpredictable)? Communication and documentation: Following a fall, the patients care plan will need to be reviewed. ETA: We also follow a protocol. An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall. This includes physical hands-on assistance to lower someone to a surface who is in the act of falling. 0000014699 00000 n Internet Citation: Tool 3N: Postfall Assessment, Clinical Review. * Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain. Already a member? That would be a write-up IMO. HOW do you start your Nursing note.PATIENT FOUND ON FLOOR WHEN THIS NURSE ENTERED ROOM,, PATIENT OBSERVED ON FLOOR WHEN ENTERING ROOM, PATIENT SITTING OR LYING ON FLOOR WHEN THIS NURSE ENTERED ROOM? Background: This protocol explains how to assess and follow injury risk in a patient who has fallen. I am from Canada so my answer may differ but here the RPN does a range of motion assessment, head injury assessment, pain assessment, vitals, notifies the RN in the building who writes an incident report. ANY, ANY, ANY time, way, or how a pt is on the floor, it's treated as a fall incident, even if unwitnessed. Nursing Simulation Scenario: Unwitnessed Fall Intake and Output Nursing Calculation Practice Problems NCLEX Review (CNA, LPN, RN) I and O | 1-612-816-8773. Create well-written care plans that meets your patient's health goals. You seemed to start out OK in your notes (pretty much like #1 poster), but you need a whole lot more to it. All Rights Reserved. (b) Injuries resulting from falls in hospital in people aged 65 and over. Design: Secondary analysis of data from a longitudinal panel study. I am a first year nursing student and I have a learning issue that I need to get some information on. Information and Training for Staff, Primary Care Providers, and Residents and their Families, Chapter 6. This will help to inform decisions about safe handling and ensure that any injuries are treated in a timely manner. Create well-written care plans that meets your patient's health goals. Contributing factors to the fall included the following: - The fall risk assessment was not completed on admission as per policy. unwitnessed falls) based on the NICE guideline on head injury. If a resident rolled off a bed or mattress that was close to the floor, this is a fall. Notify treating medical provider immediately if any change in observations. By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. Results of the Falls Assessment, along with any orders and recommendations, should be used by the interdisciplinary team to develop a comprehensive falls care plan within 1-7 days after the fall. This report should include. Specializes in Acute Care, Rehab, Palliative. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input. Has 30 years experience. $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ? National Patient Safety Agency. Evidence of local arrangements to ensure that hospitals have a post-fall protocol that includes checks for signs or symptoms of fracture and potential for spinal injury before the older person is moved. 4. North East Kingdom's Best Variety pizza strips rhode island; spartanburg obituary 2020; 9 days novena to st anthony of padua pdf; shark tank cast net worth australia; marvel characters starting with e. churchill hospital jobs in oxford; I'm a first year nursing student and I have a learning issue that I need to get some information on. This level of detail only comes with frontline staff involvement to individualize the care plan. "I went to answer the doorbell for the pizzaman" or "I'm looking for my pen under the bed" or "didn't I tie the rope into a pretty bow (the call bell !)?". I'm trying to find out what your employers policy on documenting falls are and who gets notified. The exact time and cause of traumatic falls among senior residents might not be easy to document without error if they were unwitnessed. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. 2017-2020 SmartPeep. The FAX Back Orders sheet and the Falls Assessment should be placed on the medical record once completed. In the medical record, document the incident, outcome, and initial and ongoing observations, and update fall risk assessment and care plan. I am in Canada as well. Because the Falls Assessment will include referrals for further workup by the primary care provider or other health care professionals, contact with the appropriate persons should be made quickly. By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. Introduction and Program Overview, Chapter 3. On or about May 6, 2022, did one or more of the following with regards to client JH after she suffered an unwitnessed fall: a. The following measures can be used to assess the quality of care or service provision specified in the statement. Review current care plan and implement additional fall prevention strategies. How do you sustain an effective fall prevention program? We also have a sticker system placed on the door for high risk fallers. hit their head, then we do neuro checks for 24 hours. Often the primary care plan does not include specific enough detail to effectively reduce fall risk. Note: There is increased risk of intracranial hemorrhage in patients with advanced age; on anticoagulant and/or antiplatelet therapy; and known coagulopathy, including those with alcoholism. 1 0 obj If someone falls, and doesn't need anything more than first aid, we: 2) Enter the incident into the risk management software, detailing where the pt fell, were they on fall precautions, seizure precautions, psych history, blind, dementia, sundowner -- anything that could explain why the person took a header.