Time matters after a fall because documentation can get incomplete, delayed, or inconsistently updated.
Within the first few days, gather and preserve:
- The incident report (and any addenda)
- Fall risk assessments created before the fall and any updates afterward
- The care plan section related to mobility, toileting, transfers, and supervision
- Medication records around the time of the fall (especially changes in sedatives, sleep aids, or pain medication)
- Names of staff on shift and whether anyone witnessed the event
- Photos you’re allowed to take of the area (bathrooms, hallways, lighting, flooring, grab bars)
- Any statements made by staff about what caused the fall and what precautions were added
If you can, write down what you remember immediately—how your loved one was walking, whether they used a walker or cane, and whether they had recent dizziness, weakness, or confusion.


