In the hours and days after a resident fall, the details matter—especially because facilities often rely on their internal documentation to explain away risk. Start building your own record while you’re receiving care and updates.
Collect or request the basics:
- The incident report (including time, location, and who was present)
- The resident’s fall risk assessment and any updates around the time of the fall
- The care plan in place before and after the incident
- Staff notes for the shift when the fall occurred
- Medication records for the relevant timeframe
- Any post-fall observations (confusion, dizziness, pain, mobility changes)
If video may exist: ask whether there is surveillance covering the area and request preservation.
Write down what you can: the resident’s baseline mobility, whether alarms were in use, whether staff assisted with transfers, and what staff said about the cause.


