The Fall We Saw Coming
A memory care charge nurse on the evening her unit’s fall pattern finally became visible — before the next fall happened.
What we knew, and where it lived
Everything I just said about Mr. K. was true and known by someone in this building. None of it was in one place. The shoes were a hallway comment. The sertraline was in the chart, on a page nobody opens at shift change. The earlier sundowning was in my head and in the aide’s head and nowhere else. The trips toward the courtyard were in the night shift’s rounding notes, which I don’t read because I’m gone by then, and they don’t read mine, because they come on after I leave.
That is how falls happen on a memory care unit. Not because nobody saw it. Because six people saw a sixth of it.
I’ve been to fall huddles. I’ve filled out the post-fall form 174 times in nine years. I can recite the contributing factors from memory. Every fall huddle I’ve ever been in has been about a fall that already happened. I have never been in a meeting about a fall that didn’t.
The Tuesday it lined up
It was a Tuesday around 4:30 p.m. I sat down at the station to start my pass. There was a card on the screen I’d never seen. It had Mr. K.’s name on it and a short list underneath. New SSRI — day 14. Three unwitnessed ambulations toward courtyard door, last 7 nights. Sundowning onset earlier by ~90 min vs baseline. Footwear flagged by aide on 11/4. Suggested: review with NP today; consider non-slip socks; consider visual cue at courtyard door.
I read it twice. Then I read it a third time, because I wanted to be sure I wasn’t imagining a sentence I’d been trying to say out loud for ten days.
Nothing on that card was new. It was the same six pieces I already knew, and the aide already knew, and the night shift already knew, and the chart already knew. What was new was that the six pieces were on the same card, with his name on top, in front of me, before anyone fell.
What we did
I walked down to his room. I switched his slippers. I put a sock-and-grip pair on that the OT had ordered months ago and we’d never put on him. I paged the NP and she actually called back in eleven minutes, which is a sentence I have never written before, because the card had gone to her too, and she had read it, and she knew why I was paging.
We tapered the SSRI by half that night. I told the night shift at handoff — not in passing, on the card, with a box they had to check. I asked maintenance to put a dark mat in front of the courtyard door, because for someone with Lewy body, a dark mat reads as a hole, and people with dementia do not step into holes. I learned that from a CNA, not from school.
Mr. K. did not fall that night. He did not fall the next night. He has not fallen. I’m not going to tell you he won’t. He’s 84 and he has Lewy body. He will fall eventually. What I will tell you is that for the first time in nine years on this unit, the conversation about Mr. K.’s fall happened before the fall, and not after.
What that feels like
There is a particular kind of tired you get from being the person who knew. You sit in your car after the shift where someone fell and you replay the ten days before it, and you find the moments where you said something and nobody had time, and the moments where you didn’t say something because you were saving it for a meeting that wasn’t scheduled. That tired is the one I came into this job with and the one I assumed I’d leave with.
I’m not less tired now. I want to be honest about that. The unit is still the unit. But I’m a different kind of tired. I’m the tired of someone who got heard in time, instead of the tired of someone who was right too late. Those are not the same tired.
A fall huddle for a fall that didn’t happen. I didn’t know we were allowed to have those. We are now.
The card on Yvette’s screen
The fall-risk card Yvette describes is one surface of the SeniorCRE ® clinical platform — correlating medication changes, behavior notes, ambulation patterns, and aide observations across shifts into a single pre-fall view, so the conversation can happen before the fall, not after.
https://seniorcre.com/voices-from-the-floor/the-fall-we-saw-coming