VIEW COMPLETED NOTE

Completed Date: 2021-12-10T22:13 Type of Event: Fall, Skin Tear, . Location of Event: Patient Room, . Just prior to Event the patient was doing: watching TV; Patient’s Explanation of Event: Due to the mental condition the patient unable to explain te event. Vital Signs: B/P: 120/80, Pulse: 60, Respiration rate: 18, Temperature: 98 °F. Was Event witnessed?: Yes (Maria (CNA)}. Description of the event: The patient was watching TV and got up to look for something and she lost her balance. Pain related to the Event: Yes; Pain location: right leg, Pain Intensity: 2/10. Injury: No injury noted, Injury location: , Character of Injury: Redness, Skin Tear, ROM X4 Without Pain/Limitations, No Rotation/Deformity/Shortening Noted. Neuro- checks Activated: Yes, If yes, explain: confuse; Mental Status: Some Confusion. Contributing factors: Neurological Disorder – e.g. Seizures, Parkinson’s Disease, Fragile skin, Sleeping medications, Anxiolytics, , . Measures taken: Rest, First Aid, . Physician was Notified: A Mora; 2021-12-10T22:22; Family/responsible party was notified: Peter (son); 2021-12-10T22:25.