After a fall, evidence can disappear quickly—sometimes because of normal document turnover or because facilities move on to the next shift. Your next steps can help preserve what matters.
- Get medical care immediately (and make sure the record reflects what happened).
- Ask for the incident report and post-fall documentation while the facts are fresh.
- Request the resident’s fall risk assessment and care plan updates around the time of the fall.
- Ask whether surveillance exists for the area where the fall occurred and request preservation if applicable.
- Write down the timeline: time of day, unit location, what the resident was doing, whether alarms were used, and what staff said afterward.
If you’re in Lodi and the resident is transferred to an outside hospital, keep copies of discharge paperwork and follow-up instructions—those documents often become central to how the injury is described and linked to the fall.


