On 15th February, 2021 at 8:45am, patient named Mrs Elsa Williams , a resident of

Mount Surrey hospital found on the floor of the hallway. Fall was witnessed by her
spouse Mr. James, who was with the patient at the time of fall. Mr. James informed
the incident to the nurses station.
On the scene at 8:46am Mrs Elsa Williams was found on the floor lying on
her back in the hallway and crying with pain. Patient was conscious and oriented.
On head to toe assessment, her right knee was swelled and bruised. No other injury
or bleeding was observed. She looked anxious after the fall. Vital signs were
monitored, BP- 130/80mmHg, Pulse- 78/bpm, Respiration-18bpm. Her pain score
was 9/10 on a numerical scale. When asked about what happened, she said “ I
couldn’t balance my body while I am walking in the hallway and suddenly fell
down”. Patient was given sedative 30minutes before the incident. Her spouse
reported that Elsa was very aggressive and tripped over when she tried to walk in
hurry.
Physician was informed at 9:00am. He ordered X-ray and Tylenol. Manager
was informed at the same time as well. Patient’s leg was elevated, and ice pack
applied as per the instruction of the physician. Patient was transferred to her room
with assistance. Mrs Elsa’s next of kin was informed over the phone about the fall
incident. Arrangements to transport the patient to Xray is done. Incident recorded in
the nursing report