After a fall, facilities may document the event as routine. Your priority is to make sure the record reflects what you can verify.
Do these steps early:
- Request the incident report and any “after the fall” documentation the same day (or as soon as possible).
- Ask for the resident’s fall risk assessment and the care plan in effect at the time of the fall.
- Get the medication administration record for the relevant shift(s) if there were recent changes.
- If video may exist, ask the facility to preserve surveillance and related logs.
- Write down details while they’re fresh: where the fall occurred (hallway, bathroom, common area), lighting conditions, whether assistive devices were used, and who was present.
This matters in Berkley because many residents live with mobility limitations in everyday settings—bathrooms, transfer areas, and hallways—where small failures (missed supervision, delayed response, or unsafe conditions) can quickly become serious injuries.


