Unwitnessed fall found at 03:20, resident on the floor beside the bed, on apixaban. Completed a head-to-toe injury survey (no obvious deformity), initiated neuro checks q15min then per protocol, vital signs stable, no LOC reported but the fall was unwitnessed. SBAR to the provider 03:35; order for a head CT and continued neuro checks received; responsible party notified 03:40. New interventions added to the care plan (floor mat, hourly rounding); the fall coded on Section J; a root-cause review initiated. Skilled post-fall surveillance required because of the anticoagulant and the delayed-bleed risk — a daily SNF-level need.
Model abnormal 2
Fall with suspected injury: resident found after a fall with the right leg shortened and externally rotated, unable to bear weight, pain 8/10 — concerning for a hip fracture. Immobilized, did not move the limb, vital signs obtained; SBAR to the provider, transfer order received; responsible party notified; transfer packet (orders, meds, code status, baseline, reason for transfer) sent. Fall and injury coded on Section J; care plan revised on return; root-cause review initiated.
