The steps you take early can strongly affect what can be proven later. If the fall just occurred (or you just learned about it), focus on:
- Get the medical record trail started immediately: ask for the ER/urgent care visit summary (if applicable), discharge paperwork, and imaging reports.
- Request the facility’s incident documentation: incident report, shift notes, fall risk assessment updates, and the resident’s care plan around the time of the fall.
- Ask what changed after the fall: staffing adjustments, new supervision orders, new mobility/transfer instructions, alarm use, or environmental changes.
- Preserve video and logs: if the facility has cameras, ask them to preserve relevant footage. Also ask whether alarms were triggered and what staff documented.
California has strict expectations around record handling and resident care. Even when the facility says the fall was unavoidable, the documentation often reveals whether risk precautions were in place.


