If there were a car accident at an intersection and there were 4 witnesses, one on a bike, one standing at the crosswalk, one with screaming kids at her side and one old guy, you would get a total of 4 Different stories on how that accident occurred. Privacy Statement They are: The resident's footwear and foot care as well as environmental and equipment safety concerns should also be assessed. How to use this tool: Staff nurses and physicians should follow this protocol, in combination with clinical judgment, with patients who have just fallen. The one thing I try most intensely to include any explanatory statement by the pt, verbatim, if poss. This is basic standard operating procedure in all LTC facilities I know. Analysis. The unwitnessed ratio increased during the night. 4 0 obj A frequently occurring job during on-call and out-of-hours shifts is reviewing a patient following a fall with this often being the responsibility of the most junior and inexperienced doctors. 3 0 obj This training includes graphics demonstrating various aspects of the scale. 0000001636 00000 n Resident response must also be monitored to determine if an intervention is successful. Forms and Training Materials (Appendix Contents), Appendix C. Case Study and Program Examples, U.S. Department of Health & Human Services. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. 4 0 obj Falls can be a serious problem in the hospital. Arrange further tests as indicated, such as blood sugar levels, x rays, ECG, and CT scan. I work LTC in Connecticut. A copy of this 3-page fax is in Appendix B. Healthcare professionals check older people who fall in hospital for signs or symptoms of fracture and potential for spinal injury before moving them. 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. 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. 3. If I found the patient I write " Writer found patient on the floor beside bedetc ". Assess circulation, airway, and breathing according to your hospital's protocol. 0000013935 00000 n | Specializes in Geriatric/Sub Acute, Home Care. Notify the physician and a family member, if required by your facility's policy. Physiotherapy post fall documentation proforma 29 How the physician is notified depends on the severity of the injury. No, unless you should have already known better. If fall circumstances are not investigated at the time of the incident, it is very difficult later to piece together the event and to determine what risk factors were present. Example Documentation for Nursing Associate Scenario Below is an example of an OSCE which is based in the community setting. Doc is also notified. 3 0 obj . More information on step 6 appears in Chapter 4. This includes creating monthly incident reports to ensure quality governance. %PDF-1.5 Immediate evaluation by the nurse after a resident falls should include a review of the resident systems and description of injuries. I was just giving the quickie answer with my first post :). The post-fall protocol should be easily accessible (for example, laminated versions at nursing stations). Service providers (NHS organisations with inpatient beds, such as district hospitals, mental health trusts and specialist hospitals) ensure that staff have access to and follow 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. 0000014271 00000 n Specializes in Acute Care, Rehab, Palliative. This study guide will help you focus your time on what's most important. Is the fall considered accidental (extrinsic), anticipated physiologic (intrinsic), or unanticipated physiologic (unpredictable)? 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. Revolutionise patient and elderly care with AI. The purpose of this chapter is to present the FMP Fall Response process in outline form. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> If a resident rolled off a bed or mattress that was close to the floor, this is a fall. Rockville, MD 20857 Rapid response report: Essential care after an inpatient fall (2011), recommendation 1, A fall is defined as an event which causes a person to, unintentionally, rest on the ground or other lower level. 4) If they are from a nursing home/SNF, we make sure they know about the fall before they go back home. Denominator the number of falls in older people during a hospital stay. [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. Has 17 years experience. Patient found sitting on floor near left side of bed when this nurse entered room. This includes factors related to the environment, equipment and staff activity. MD and family updated? * Check the skin for pallor, trauma, circulation, abrasion, bruising, and sensation. Record neurologic observations, including Glasgow Coma Scale. By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. Follow up assessments of the patient at facility specified intervals (q shift x 72 hours) addressing none or any specific injuries the patient might have sustained. I have gotten reprimanded INTENSELY for writing a nursing note in regard to a patients fall. 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. SmartPeeps trusty AI caregiver automatically monitors all of the elderlies in your aged care facility for you to generate an accurate monthly incident report. 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. How do you implement the fall prevention program in your organization? No Spam. He eased himself easily onto the floor when he knew he couldnt support his own weight. Or better yet, what happens if an elderly is unable to accurately explain the causes of their fall due to diseases such as dementia? . Activate appropriate emergency response team if required. The exact time and cause of traumatic falls among senior residents might not be easy to document without error if they were unwitnessed. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input. Specializes in Med nurse in med-surg., float, HH, and PDN. I'm trying to find out what your employers policy on documenting falls are and who gets notified. Published May 18, 2012. Evaluate and monitor resident for 72 hours after the fall. Since 1997, allnurses is trusted by nurses around the globe. <> Sit back, let us do the work for you, and allow your residential care facility to become the leading care provider of the nation. Content last reviewed December 2017. It's so detailed, which is good in a way, but confusing in another, making nurses so paranoid about writing something they saw and then thinking they will get fired for it. If its past a certain time of night (9:30PM), unless its a major injury, I think it is, we just leave the info on the nursing supervisiors desk and she/he calls the family and the doc 1st thing in the morning. Internet Citation: Chapter 2. 0000015185 00000 n | Data source: Local data collection. As of 1 July 2019, participating in Australias National Aged Care Mandatory Quality Indicator Program has become a requirement for all approved providers of residential care services. 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. Protective clothing (helmets, wrist guards, hip protectors). 0000015427 00000 n Specializes in LTC/SNF, Psychiatric, Pharmaceutical. All Rights Reserved. Since 1997, allnurses is trusted by nurses around the globe. Early signs of deterioration are fluctuating behaviours (increased agitation, . Implement immediate intervention within first 24 hours. This level of detail only comes with frontline staff involvement to individualize the care plan. The Primary Care Provider FAX Report and Orders introduces the FMP, presents results of the resident's Falls Assessment and provides a form to fax back orders. 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. . 0000005718 00000 n A practical scale. A response of "unknown" should rarely if ever be accepted by the nurse manager during the investigation of a fall. Most times the patient is sent out to hospital for X-rays if there is even a slight chance of injury. The number of falls that occurred every 3 h decreased between 15.01 hours and 18.00 hours and increased around 0.00 hours. Before moving the patient, ask him what he thinks caused the fall and assess any associated symptoms. These symptoms suggest spinal cord injury, leg or pelvic fracture, or head injury. 1-612-816-8773. Has 2 years experience. Rapid response report: Essential care after an inpatient fall, NICE's clinical knowledge summary on falls risk assessment, National Patient Safety Agency's rapid response report on essential care after an inpatient fall. Thanks everyone for your responses..however I did proceed to follow through on what I did FIND out or OBSERVE from this patients incident. I don't understand your reprimand altho this was an unwitnessed fall, did you NOT proceed as a 'fall' and only charted in your nsg notes??? But a reprimand? Numerator the number in the denominator where the person is checked for signs or symptoms of fracture and potential for spinal injury before they are moved. Document all people you have contacted such as case manager, doctor, family etc. 2017-2020 SmartPeep. unwitnessed fall documentationlist of alberta feedlots. Rolled or fell out of low bed onto mat or floor. 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. ?W+]\WWNCgaXV}}gUrcSE&=t&+sP? Typical fall documentation at a nursing home in my area (Central OK): Nurse assesses fallen resident for injury and provides appropriate care. It is designed to assist nursing facilities in providing individualized, person-centered care, and improving their fall care processes and outcomes through educational and quality improvement tools. Of course all you LTC nurses out there have been in this scenario..you are walking into a patients room and wa lathere they are ON THE FLOOR. allnurses is a Nursing Career & Support site for Nurses and Students. 1-612-816-8773. The total score is the sum of the scores in three categories. Now, that I was interviewed for another nursing job recently, I ASKED them what word is proper documentation when writing on a fall. Specializes in Acute Care, Rehab, Palliative. View Document4.docx from VN 152 at Concorde Career Colleges. Content last reviewed January 2013. | * Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain. The interventions listed on this form are grouped in the same five risk areas used for the Falls Assessment. Be aware of the following warning signs: numbness or tingling in the extremities, back pain, rib pain, or an externally rotated or shortened leg. In addition, there may be late manifestations of head injury after 24 hours. Failed to communicate to the appropriate stakeholders of HY's fall; c. Failed to complete the required post-fall documentation. Investigate fall circumstances. While the word 'observed' sounds better to me, I doubt that I would have reprimanded you over your use of the word 'found'. Review current care plan and implement additional fall prevention strategies. Examine cervical spine and if there is any indication of injury do not move the patient; instead, immobilize cervical spine, and call treating medical provider. 1 0 obj I also chart any observable cues (or clues) that could explain the situation. If this rate continues, the CDC anticipates seven fall deaths every hour by 2030. Our supervisor always receives a copy of the incident report via computer system. What I usually do is start like this "observed resident on the floor on his/her left side." and describe exactly what I saw when I entered the room. The distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred. Agency for Healthcare Research and Quality, Rockville, MD. Gone are the days of manually monitoring each incident, or even conducting tedious investigations! Step two: notification and communication. SmartPeeps intelligent AI system will act as a solution for nursing shortages while reducing each caregivers workload. Reference: Adapted from the South Australia Health Fall Prevention Toolkit. Important Communications In the medical record, document the incident, outcome, and initial and ongoing observations, and update fall risk assessment and care plan. Was that the issue here for the reprimand? To sign up for updates or to access your subscriberpreferences, please enter your email address below. Contributing factors to the fall included the following: - The fall risk assessment was not completed on admission as per policy. Classification. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. When a pt falls, we have to, 3 Articles; - Documentation was not sufficient; the post fall documentation was missing from the health record and there was no . Thought it was very strange. Assist patient to move using safe handling practices. You Are Here: unblocked sticky ninja east london walking tour self guided unwitnessed fall documentation example. An immediate response should help to reduce fall risk until more comprehensive care planning occurs. 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. In both these instances, a neurological assessment should . FAX Alert to primary care provider. (Full citation: Jevon P. Neurological assessment part 4Glasgow Coma Scale 2. What was done to prevent it? 2023 Wolters Kluwer Health, Inc. and/or its subsidiaries. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. Assess immediate danger to all involved. Physiotherapy post fall documentation proforma 29 Create well-written care plans that meets your patient's health goals. Notify treating medical provider immediately if any change in observations. Available at: www.sahealth.sa.gov.au/wps/wcm/connect/5a7adb80464f6640a604fe2e504170d4/Post+fall+management+protocol-SaQ-20110330.pdf?MOD=AJPERES&CACHEID=5a7adb80464f6640a604fe2e504170d4. 0000001165 00000 n Specializes in Gerontology, Med surg, Home Health. It includes the following eight steps: The first five steps comprise an immediate response that occurs within the first 24 hours after a fall. Medicationsantidepressants, antipsychotics, benzodiazepines, sedative/hypnotics and digoxin. endobj Fall victims who appear fine have been found dead in their beds a few hours after a fall. Record circumstances, resident outcome and staff response. % Has 8 years experience. I spied with my little eye..Sounds like they are kooky. Last updated: By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. Due by A nurse's note is documented describing the known facts regarding the resident's fall and any interventions. Failure to complete a thorough assessment can lead to missed . Increased toileting with specified frequency of assistance from staff. AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Near fall (resident stabilized or lowered to floor by staff or other). %PDF-1.5 Increased staff supervision targeted for specific high-risk times. %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz 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 . I am a first year nursing student and I have a learning issue that I need to get some information on. Often the primary care plan does not include specific enough detail to effectively reduce fall risk. Internet Citation: Tool 3N: Postfall Assessment, Clinical Review. (D3$Qjk{yUflvCchZ]7+q'*ze9)k-r$oDI# 6SU-- dT ,p3s5~JyMGHc 6:SI%-c-$$dmnK-R?0wyuu4)_EVQ@TI4H * +&8h\#:nM+&78=hT~l~owiLP=5a$r$7=APs''wPF^hbR]n`e%fB87(]T1][b7#4Q)&x~dQs_p,QH#4 ['U}` j8n`umlT unyM4a XfwXs w4s EC "`i:F.pEE gv4;&'Sp9yI .(r@OEB. Risk factors related to medical conditions or medication use may be reflected in abnormal values for any of the following: When indicated by the resident's condition and history, laboratory tests such as CBC, urinalysis, pulse oximetry, electrolytes and EKG should be performed. The Falls Management Program (FMP) is an interdisciplinary quality improvement initiative. Has 17 years experience. Record circumstances, resident outcome and staff response. Therefore, an immediate intervention should be put in place by the nurse during the same shift that the fall occurred. unwitnessed fall documentation example. Sign in, November 2007, Volume :107 Number 11 , page - [Free], Join NursingCenter to get uninterrupted access to this Article. Being weak from illness or surgery. Your subscription has been received! The resident's responsible party is notified. Do not move the patient until he/she has been assessed for safety to be moved. However, if the resident is found on the floor between the bed and the bathroom and staff do not look for clues such as urine or footwear or ask the resident questions, immediate care planning is much more difficult. I would also put in a notice to therapy to screen them for safety or positioning devices. Background: This protocol explains how to assess and follow injury risk in a patient who has fallen. Step one: assessment. Death from falls is a serious and endemic problem among older people. This means that aged care facilities must now provide error-free data to measure incidents across the 5 quality indicators - pressure injuries, physical restraint, unexplained weight loss, falls and major injuries, and medication management. 4 Articles; Specializes in SICU. Continue observations at least every 4 hours for 24 hours or as required. allnurses, LLC, 175 Pearl St Ste 355, Brooklyn NY 11201 The Fall Interventions Monitor provides a method to document staff implementation, effectiveness of selected interventions and any necessary revisions. The presence or absence of a resultant injury is not a factor in the definition of a fall. 5. 4. If we just stuck to the basics, plain and simple, all this wouldnt be necessary. At handover, inform all clinical team members about the incident, any changes to the care plan, and possible investigation process. I am trying to find out what your employers policy on documenting falls are and who gets notified. trailer<<0c87cf0cbbf7ae766c1a82591f1e61f4>] >> startxref 0 %%EOF 200 0 obj <> endobj 220 0 obj <. The following measures can be used to assess the quality of care or service provision specified in the statement. National Patient Safety Agency. 0000015732 00000 n This will help to inform decisions about safe handling and ensure that any injuries are treated in a timely manner. 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. ANY, ANY, ANY time, way, or how a pt is on the floor, it's treated as a fall incident, even if unwitnessed. How do we do it, you wonder? Developing the FMP team. Our members represent more than 60 professional nursing specialties. For adults, the scores follow: Teasdale G, Jennett B. 3. . %PDF-1.7 % 199 0 obj <> endobj xref 199 22 0000000016 00000 n the incident report and your nsg notes. An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall. As you review this chapter, it may be helpful to use the case study and materials presented in Appendix C to illustrate the Fall Response process. 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. 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. If injuries are minimal, by FAX, and if there's suspected head trauma or hip injury, the doctor is called (if the injuries are obviously severe, to the point where moving the resident may be dangerous, 911 will probably be called). 0000014676 00000 n In fact, 30-40% of those residents who fall will do so again. Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Quality standard [QS86] <> Specializes in psych. 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. Be sure to note the patient's thoughts about the cause of the fall and associated symptoms, and whether the patient lost consciousness. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake. Program Goal and Background. Communication and documentation: Following a fall, the patients care plan will need to be reviewed. Next, the caregiver should call for help. Resident #1 (R1) sustained a right orbital fracture from an unwitnessed fall. unwitnessed incidents. Monitor staff compliance and resident response. Develop plan of care. When a person falls, it is important that they are assessed and examined promptly to see if they are injured. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/postfall-assessment.html. 0000001288 00000 n The rest of the note is more important: what was your assessment of the resident? Immediate follow-up will help identify the cause and enable staff to initiate preventative measures. 4) If they are from a nursing home/SNF, we make sure they know about the fall before they go back home. `88SiZ*DrcmNd Jkyy =+ukhB~Ky%y 85NM3,B.eM"y_0RO9]-bKV5' PH2 0?ukw:Lm_z9T^XZRZowmt _]*I$HGRzWY5BCVwWwj?F} gR.Z9 gs1)r1^oHn [!8Q5V4)/x-QEF~3f!wzdMF. 0000000922 00000 n You follow your facility's P&P for falls, with all the ballyhoo assessments, notifications & paperwork, incl. stream Assessment of coma and impaired consciousness. 0000105028 00000 n 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 am in Canada as well. 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. Has 30 years experience. Notify the treating medical provider at the time of the incident, and schedule an interdisciplinary review of the patient's care. University of Nebraska Medical Center <> Nursing Simulation Scenario: Unwitnessed Fall Intake and Output Nursing Calculation Practice Problems NCLEX Review (CNA, LPN, RN) I and O Record vital signs and neurologic observations at least hourly for 4 hours and then review. Agency for Healthcare Research and Quality, Rockville, MD. Specializes in NICU, PICU, Transport, L&D, Hospice. 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. * Assess the current level of consciousness and determine whether the patient has had a loss of consciousness. 42nd and Emile, Omaha, NE 68198 "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 !)?". Thus, it is crucial for staff to respond quickly and effectively after a fall. At a nursing home in my area, if someone falls and gets injured, they just fill out an incident report and then they put it on the assistant DON's desk. Documenting on patient falls or what looks like one in LTC. However, what happens if a common human error arises in manually generating an incident report? Facilities have different policies regarding falls, incidents, etc and how its to be documented and who is to be notified. 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. Which fall prevention practices do you want to use? For example, if the resident falls on the way to the bathroom because of urgency and poor balance, interventions related to toileting and staff assistance would be appropriate. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake. Get baseline vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and hydration). Charting Disruptive Patient Behaviors: Are You Objective? It includes the following eight steps: Evaluate and monitor resident for 72 hours after the fall. Complete falls assessment. sorry for that big wind up there I wrote.but I just get peed off at the system..I completely followed through with all documentation, incident report, calling the md, family, taking vitals, monitering the patient, alerting the CNA, so.I did all that but it was not good enough..only that little word."found" thanks guys, you are all the best. Specializes in Med nurse in med-surg., float, HH, and PDN. 2 0 obj 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. Specializes in med/surg, telemetry, IV therapy, mgmt. Everyone sees an accident differently. 4. Fall Response. You seemed to start out OK in your notes (pretty much like #1 poster), but you need a whole lot more to it. 0000013709 00000 n x\moFn?-4fA`wC>$50WOU7aS5zjZ}j7w?ku&B_4)2Q:&Two~ aV_.gla2Ggq*,sAuR`?^I-0W4m?LF-Qcpq i0e33z13:] Source guidance. Create well-written care plans that meets your patient's health goals. Reference to the fall should be clearly documented in the nurse's note. Older people who fall in hospital are checked for fractures and possible injury to their spine before they are moved. Patient is either placed into bed or in wheelchair. * Check the central nervous system for sensation and movement in the lower extremities. Published: &`h,VI21s _/>\5WEgC:>/( 8j/8c0c=(3Ux1kw| ,BIPEKeEVt5 YeSDH9Df*X>XK '6O$t`;|vy%jzXnPXyu=Qww1}-jWuaOmN5%M2vx~GJfN{iam& # F|Cb)AT.yN0DV "/yA:;*,"VU xdm[w71 t\5'sS*~5hHI[@i+@z*;yPhEOfHa;PA~>]W,&sqy&-$X@0} fVbJ3T%_H]UB"wV|;a9 Q=meyp1(90+Zl ,qktA[(OSM?G7PL}BuuDWx(42!&&i^J>uh0>HO ,x(WJL0Xc o }|-qZZ0K , lUd28bC9}A~y9#0CP3$%X^g}:@8uW*kCmEx "PQIr@hsk]d &~=hA6+(uZAw1K>ja 9c)GgX