In many Indiana facilities, risk is highest in predictable places and moments—hallways during shift change, bathroom and shower routes, common areas where residents gather, and transfer routines around meals and medication rounds. In Vincennes, families also see the same pattern: when residents are temporarily more active (or less stable) after appointments or medication adjustments, supervision and fall-prevention plans sometimes lag behind.
That’s why we focus early on the details that explain how the fall happened:
- Where the resident was when they fell (hallway, bathroom, common area, room)
- What the resident was doing right before the incident
- Staffing levels and staff assignments during that shift
- Whether assistive devices and transfer steps matched the resident’s documented needs
- How quickly staff recognized the injury and escalated care


